RHINOPLASTY

Edited by Michael J. Brenner

Rhinoplasty
Edited by Michael J. Brenner

Published by InTech
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Rhinoplasty, Edited by Michael J. Brenner

p. cm.
ISBN 978-953-307-849-6
Contents

Preface IX

Part 1 Nasal Analysis 1

Chapter 1 Anthropometric Analysis of the Nose 3

Abdullah Etz

Chapter 2 Preoperative Planning for Rhinoplasty,

in Relation to the Gender and Ethnicity 11
Pawel Szychta, Ken J. Stewart and Jan Rykala

Chapter 3 Preoperative Assessment 19

Pawel Szychta, Ken J. Stewart and Jan Rykala

Part 2 Innovations in Delivery Approach 43

Chapter 4 Modified Delivery Approach A New Perspective 45

Rui Xavier

Part 3 Reconstructive Challenges 55

Chapter 5 Surgical Strategy for Secondary Correction of Unilateral and

Bilateral Cleft Lip-Nose Deformities 57
Norifumi Nakamura

Chapter 6 Thin Nasal Shell 71

Paul OKeeffe

Chapter 7 Surgical Management of Nasal Hemangiomas 83

Aleksandar Vlahovic

Part 4 Nasal Tip Refinement in Rhinoplasty 95

Chapter 8 Rhinoplasty The Difficult Nasal Tip Total Resection of

the Alar Cartilages and Temporal Fascia Technique
A 24 Year Experience 97
Salvador Rodrguez-Camps Devs
VI Contents

Part 5 Minimally Invasive Techniques 115

Chapter 9 Minimally Invasive Approach for Rhinoplasty 117

S. Cohen

Part 6 Complications 133

Chapter 10 Mucous Cysts as a Complication of Rhinoplasty 135

Aris Ntomouchtsis, Nikos Kechagias,
Persefoni Xirou, Georgios Christos Balis,
Katerina Xinou and Konstantinos Vahtsevanos
Preface

Rhinoplasty is one of the defining procedures of plastic and reconstructive surgery,

and it retains its stature as the most diverse and challenging of all plastic surgery
procedures. Its roots stem from early efforts in nasal reconstruction and contemporary
rhinoplasty reflects a rich history dating back to early descriptions of forehead
reconstruction thousands of years ago. The emergence of modern rhinoplasty as a
nuanced restorative and artistic procedure has allowed for an evolution of surgical
technique that continues to the present day. As the most central and prominent facial
features, the nose has distinct anatomic features that render it uniquely susceptible to
injury and to scrutiny. Success in rhinoplasty is predicated on an understanding of
structural and aesthetic considerations. The art and science of nasal surgery is truly a
marriage of form and function.

This book describes the most recent clinical and research perspectives in the field of
rhinoplasty. The contributing authors reach across specialty and international borders,
sharing ideas from their respective surgical fields; this work should have broad appeal
to an international readership. Over the years, rhinoplasty has matured into a field
that strikes a balance between structural correction and aesthetic refinement.
Contemporary thinking on rhinoplasty emphasizes a balance between preservation of
supporting structures and a wide variety of approaches to rebuilding natural contours
and structure through judicious resection and grafting. Surgical methods are
continuously refined and have been influenced by new approaches in tissue
engineering. The advent of open access publishing has afforded an unprecedented
opportunity for reaching rhinoplasty surgeons around the world with these vital
clinical and research innovations.

This book begins with a discussion of the rudiments of nasal analysis and planning,
discusses execution of surgical techniques, and concludes with consideration of
surgical complications. Opening chapters by Dr's Pawel Szychta and Abdullah Etoz
cover preoperative assessment of the rhinoplasty patient, anthropometric analysis of
the nose, and ethnic aspects of nasal anatomy. Dr Rui Xavier details experience with a
modified delivery approach that improves precision and preservation of support in
endonasal rhinoplasty. Dr Norifumi Nakamura elaborates on an elegant conceptual
and practical approach to correction of unilateral and bilateral cleft lip nasal
deformity. Dr Salvador Rodrguez-Camps Devs describes long term outcomes in
X Preface

combining temporalis fascia grafting with alar resection in tip rhinoplasty. Dr Paul
OKeeffe details progress in the use of a thin Medpor nasal shell for reconstituting
nasal structure, and Dr. Aleksandar Vlahovic provides background and practical
surgical approach to the challenging area of nasal hemangiomas. Closing chapters by
Dr Sarit Cohen and Aris Ntomouchtsis consider minimally invasive approaches and
mucous cysts as a complication of rhinoplasty.

This unique book thus provides invited treatises on the breadth of rhinoplasty from a
diverse set of leaders in the field. The contributors collectively present expertise from
the fields of plastic and reconstructive surgery, facial plastic surgery, and oral-
maxillofacial surgery. Their collective experience as thought leaders covers a broad
swath of cosmetic and reconstructive rhinoplasty specialists. Included herein are
critical analytic insights, a wealth of illustrations, and accompanying schematics and
clinical photographs. This volume serves as a resource for both students and for
experienced aesthetic and reconstructive surgeons wishing to expand their
understanding of rhinoplasty. Within this book is a wealth of proven and innovative
approaches ranging from minor refinement to major reconstruction. The diversity of
subjects covered reflects the inherent complexity of the art and science of rhinoplasty.

In tracing the development of rhinoplasty from early reconstructive efforts to the

sophisticated aesthetic and restorative techniques of modern day, one can appreciate
the rich history of this specialty. Within this volume are philosophies and approaches
intended to provide a balanced perspective on the ever changing field of rhinoplasty.
Discussion of structural grafting and approaches to augmentation are counterbalanced
by consideration of judicious resection and refinement. Correction of congenital
deformities is followed by consideration of acquired complications. The overarching
goal of this work is to instill an understanding of the subtleties of nasal structure and
how nasal anatomy can be adapted to maximize function and achieve a natural,
pleasing appearance. The dedicated rhinoplasty surgeon progressively grows in his or
her understanding of nasal anatomy, developing an armamentarium of skills over the
course of many years of dutiful study. It is the purpose of this book to serve the reader
as a trusted companion in this journey.

Michael J. Brenner
Southern Illinois University School of Medicine
USA
 Part 1

Nasal Analysis
 1

Anthropometric Analysis of the Nose

Abdullah Etz
Aesthetic, Plastic and Reconstructive Surgery, Bursa
Turkey

1. Introduction
Anthropometric analysis is a method, aiming to achieve the most reliable comparison of the
body forms by using specific landmarks determined in respect of anatomical prominences.
Owing to the previous anthropometric studies, it is getting easier to discuss about the
differences in between the ethnic and racial groups, and to compare the individual
variations in both sexes. A great body of work in craniofacial anthropometry is that of
Farkas who established a database of anthropometric norms by measuring and comparing
more than 100 dimensions (linear, angular and surface contours) (DeCarlo, 1998).
Today, anthropometric methods and surgical practice intersected at the point to treat
congenital or post-traumatic facial disfigurements in various racial or ethnic groups
successfully (Farkas et al 2005). The nose is a persons most defining feature because it is at
the center of the face. The shape of the nose is a signature indicating the ethnicity, race, age
and sex (Ofodile, 1995; Milgrim et al 1996; Mishima et al 2002; Ochi, 2002; Romo, 2003;
Ferrario et al 1997; Bozkir et al 2004; Leong, 2004; Uzun et al 2006). Nasoplasty surgeons
require access to facial databases based on accurate anthropometric measurements to
perform optimum correction in both sexes.
There are several anthropometric studies related with the nose, which are bringing forward
other different methods. However we decide to review a landmark-based geometric
morphometric technique which can be easily used to analyze the nasal shapes in any
population.
The shape differences in nasal anatomy between male and female are important thus,
feminization of a male nose is an undesirable result. A successful outcome in rhinoplasty
requires a thorough and accurate preoperative planning, and awareness of the
morphological differences. Anthropometric analysis of nose is showing us a way to provide
data which should contribute to satisfactory results of the cosmetic nasal surgery.
List of abbreviations used in the manuscript:
NHP: Natural head position
EDMA: Euclidean Distance Matrix Analysis

2. Anthropometric measurements
Anthropometric analysis of nasal anatomy is based on the comparison of measurements
which are obtained separately from the anterior, lateral and inferior aspects. These
measurements can be performed both by direct and indirect methods. Direct methods are
4 Rhinoplasty

time-consuming and have several other disadvantages such as difficulty of patient

adaptation (especially in children and infants), problems concerning repeatability of
measurements and archiving of data. Therefore, indirect measurement methods including
photograph, cephalogram, stereophotograph, laser scanning, and computerized
tomography have increasingly become popular in recent years. The most frequent methods
used clinically are photogrammetry and cephalometry. Photogrammetry is a fast and
inexpensive method with superior patient compliance. The most important disadvantage of
two-dimensional photogrammetry is its inability to assess facial depth. Three-dimensional
photogrammetry appears to be a more appropriate technique in this respect.
The following issues are crucial in anthropometric analysis of the nose:
1. Standardization of the method
2. Landmark identification

2.1 Standardization of the method

Details of standardization of the methods used in anthropometric analysis have previously
been defined by several investigators and are beyond the scope of this review. It is
important to note that a standard head position is essential for any facial measurement.
Natural head position (NHP) is the most appropriate since it is the most reproducible and
provides a natural face orientation for treatment planning.

2.2 Landmark identification

The accurate identification and reliability of the landmarks are the most important
indicators of the accuracy of the anthropometric measurements. One way to increase
accuracy is to mark the landmarks before measuring. Many soft tissue landmarks reflect
underlying bony structure. The bony points must be palpated with a finger to find the soft
tissue equivalent. While some soft tissue points can be marked with a dermographic pen,
some soft tissue landmarks such as endocanthion, exocanthion, cheilion, and crista philtre
can be clearly identified without palpation. In photogrammetry, meticulous identification of
soft tissue landmarks and marking of the landmarks determined by inspection and
palpation before the acquisition of photographs will certainly improve the reliability of
measurements. Nasal landmarks are presented in Figure-1 and Table 1.

1-2: al, Alare, the point where the nasal blade (ala nasi) extends farthest out
3: sn, Subnasale, the midpoint of the columella base
4-5: c, Columella apex, the most anterior, or the highest point on the columella crest at
the apex of the nostril
6: prn, Pronasale, the most prominent point on the nasal tip
* 7-8: The estimated junction of upper and lower lateral cartilages
9-10: mf, Maxilloanteriorale, where the maxilloanterioral and nasoanterioral sutures
meet
11: n, Nasion, the point in the midline of both the anatomic nose and the nasoanterioral
suture

Table 1. Anthropometric landmarks of nose from the anterior aspect. The numbers,
abbreviations and definitions of the examined landmarks. The constructed landmarks are
indicated by * sign
Anthropometric Analysis of the Nose 5

* 1: the junction of nasolabial crease and nasal blade (ala nasi)

2: prn, Pronasale, the most prominent point on the nasal tip
3: sn, Subnasale, the midpoint of the columella base
4: al, Alare, the point where the nasal blade (ala nasi) extends farthest out
* 5: the most prominent point of medial cruris of alar cartilage
* 6: the most prominent point of lateral cruris of alar cartilage
7: c, Columella apex, the most anterior, or the highest point on the columella crest at
the apex of the nostril
* 8: The ending point of the nasolabial fold
* 9: The estimated junction of nasal and maxillary bones
* 10: The most prominent point of nasal dorsum (nasal hump)
* 11: The estimated insertion point of medial cantus
12: n, Nasion, the point in the midline of both the anatomic nose and the nasoanterioral
suture
Table 2. Anthropometric landmarks of nose from the lateral aspect. The numbers,
abbreviations and definitions of the examined landmarks. The constructed landmarks are
indicated by * sign

1-2: al, Alare, the point where the nasal blade (ala nasi) extends farthest out
3: sn, Subnasale, the midpoint of the columella base
* 4-5: The most convex point of lateral cruris of alar cartilage
6: prn, Pronasale, the most prominent point on the nasal tip
Table 3. Anthropometric landmarks of nose from the inferior aspect. The numbers,
abbreviations and definitions of the examined landmarks. The constructed landmarks are
indicated by * sign

Fig. 1. Anthropometric (anterior 1-6, 9-11; lateral 2-4 and 12; inferior 1-3, 6) and constructed
(anterior 7, 8; lateral 1, 5-11; inferior 4, 5) landmarks which were used in the anthropometric
analysis of the nose
6 Rhinoplasty

Key Point:
Photogrammetry is an easier and more effective method for anthropometric analysis of the nose.

Anterior Aspect Lateral Aspect Inferior Aspect

The greater interlandmark 2Y6, 7Y8, 2Y7, 1Y3, 4Y10, 6Y10, 8Y10, 2Y3, 3Y5, 3Y4,
distances in males (P < 0.05) 1Y6, 2Y3, 7Y9, 3Y9, 5Y11, 2Y4,
1Y8, 4Y5, 1Y5, 2Y4, 5Y12, 3Y10, 7Y10, 1Y3, 1Y2, 1Y5,
9Y10, 1Y2 2Y11, 4Y6, 2Y12, 4Y5
3Y5, 4Y7, 5Y10, 5Y9,
6Y7, 2Y4,
6Y8, 2Y9, 2Y10, 2Y6,
2Y7, 3Y8,
1Y2, 7Y8, 9Y10, 4Y5,
1Y7, 2Y8,
1Y6, 5Y8, 1Y5, 3Y6,
5Y6, 1Y4,
3Y4, 1Y3, 5Y7,

The greater interlandmark 4Y9, 3Y9, 1Y9, 1Y9, 1Y11, 8Y9, 3Y6, 2Y5, 2Y6,
distances in females (P < 2Y10, 6Y9, 5Y10, 1Y6, 1Y4
0.05) 3Y10, 6Y10, 7Y9,
3Y11, 6Y11,
8Y10, 4Y11, 5Y11,
4Y7, 5Y8

Table 4. The Inter-landmark Distances Found to be Significantly Different Between Males

and Females. In figure 2 these interlandmark distances were shown by bold and thin lines

Total length of nasal bridge (n-prn)

Morphological width of nose (al-al)

Nasal root width (mf-mf)

Anatomical width of nose (ac-ac)

Tip protrusion (prn-sn)

Table 5. The common names for interlanmark distances of the nose

Anthropometric Analysis of the Nose 7

Males Females
r p r p
MorphologicNasal Width / Nasal Root Width .616 <0.001 .345 0.001
MorphologicNasal Width / Length of nasal bridge .651 <0.001 .409 <0.001
Morphologic Nasal Width / Anatomical width of nose .612 <0.001 .317 0.003
MorphologicNasal Width / Tip protrusion .299 0.007 .286 0.008
Nasal Root Width / Length of nasal bridge .492 <0.001 .439 <0.001
Nasal Root Width / Anatomical width of nose .392 <0.001 - p>0.05
Nasal Root Width / Tip protrusion .351 0.001 - p>0.05
Length of nasal bridge / Anatomical width of nose .410 <0.001 .223 0.039
Length of nasal bridge / Tip protrusion .405 <0.001 .378 <0.001
Anatomical width of nose/ Tip protrusion .527 <0.001 .761 <0.001

Table 6. For example, the data showing us the statistical correlations of the interlandmark
distances of nose in both sex
Landmark reliability
It is important to understand the various sources of error that can affect anthropometric
measurements during location of landmarks. Lack of precision results in variability among
repeated measurements of the same specimen and has two components:
Observer error in locating landmarks
Instrument error in identifying landmark coordinates (Lele, 1991 and 1993).
It is crucial to analyze the reliability of the landmarks. Optimal standard to achieve
reliability is that all landmarks should be marked by the same investigator on all subjects.
Instrumental errors should be avoided by using a standardized digital photographic
imaging taken from anterior, lateral and inferior aspects by using a constantly stable digital
camera (Hwang, 2003; Uzun et al 2006).
Collection of two-dimensional craniofacial landmarks of nose
The data collection procedure should take place in two separate steps, and followed by off-
line calculations. At first, for each subject, digital photographic images should be taken by
the same investigator using an at least 2.0 mega pixel digital camera. At the second stage,
the examined landmarks are marked on these digital images. Anthropometric landmarks
are defined in Figure-1. The landmarks shown in the figure are also accepted in previous
anthropometric studies (Farkas et al 1998). For enrichment of nasal anthropometric analysis,
some constructed landmarks are also used. These landmarks are determined by
constructing a line tangent to another landmark or a bony edge. The descriptions of the
examined landmarks are done in Table 1 and shown in Figure 1.
For each subject, eleven landmarks (five anthropometric and two constructed) in the
anterior aspect, twelve landmarks (four anthropometric and eight constructed) in the lateral
aspect and six landmarks (four anthropometric and two constructed) in the inferior aspect of
8 Rhinoplasty

nose are defined. The landmarks were marked on the digital photographs by using TPSDIG
2.04 software. This software was developed by F. James Rohlf and it is one of the most
frequently used software both for the marking the landmarks (however, what is
recommended is to take photos after marking the landmarks on the person) and for
determining the inter-landmark distances in pixels. A ruler is used in the shooting for the
measurement of the distances between the landmarks in digital images and later on the unit
distance (1 cm) is calibrated with its equivalent in pixel in order to obtain measurement
values separately.

Fig. 2. The inter-landmark distances, viewed from anterior, lateral and inferior aspects.
These distances could be measured by computer scales in photogrammetric computer
programs and the results should be proportionate to each other. For example in this figure,
the thin lines indicate the inter-landmark distances which were found to be greater in
females; the bold lines indicate the inter-landmark distances which were found to be greater
in males
It was proven to be reliable in studies including facial landmarks by Nechala (1999) and
Ferrario et al (2003) which compared photogrammetry with direct measurements, and
showed that sharp facial profile contours could eliminate the differences between the direct
and indirect measurements of the nose. The strengths and limitations of photogrammetry
must be appreciated. However, it is ideally suited to the evaluation of proportions, as the
magnification factor is eliminated (Weigberg, 2005).
Statistical studies of anatomical shape variations in population are important in
understanding anatomical effects of diseases or biological processes. Several procedures for
obtaining shape information from landmark data have been proposed. Euclidean Distance
Matrix Analysis (EDMA) is used to calculate all possible linear distances among landmarks
by creating matrixes for each subject. EDMA results are actually related to the coordinate-
system-invariant properties that make EDMA biologically and statistically advantageous
(Theodore, 1998).
Ethnic influences can result in different appearances of the nose, as follows: Caucasian,
leptorrhine; African American, platyrrhine; Hispanic, paraleptorrhine; and Asian,
subplatyrrine. For example, there are three types of African American noses are described:
Anthropometric Analysis of the Nose 9

African, Afro-Caucasian, and Afro-Indian (Ofodile, 1995). There are also variations of nasal
shape related to sex in both ethnic groups. Nose shape gives information about race,
ethnicity, age and sex. The size, shape, and proportions of the nose provide a visual basis
suggesting the character of the person. Moreover, it is an important key for a natural and
aesthetically pleasing human face (Aung et al, 2000). Accordingly, concern about the nasal
shape has recently increased; lots of people want to have rhinoplasty operations. Any
surgeon who performs rhinoplasty must be keenly aware of the morphological differences
in nasal anatomy between male and female. The planning of the cosmetic nasal surgery
must take into consideration psychological aspects, differences in skin conditions, and
anthropometric measurements.
There have been many methods on the anatomic evaluation of the nose and variations in
different racial and ethnic groups however there is an easy and reliable way to analysis nose
shape: Photogrammetric nasal analysis which is based on framework and thought to be a
better way to examine the differences of nose according to conventional methods.

3. Applications to other areas of health and disease

Today, the anthropometric methods and surgical practice intersected at a point to treat the
congenital or post-traumatic facial disfigurements in various racial or ethnic groups
successfully. Rhinoplasty surgeons require access to facial databases based on accurate
anthropometric measurements to perform optimum correction in both sexes. There should
be some points to be brought to mind during the cosmetic nasal surgery for men because of
different expectations, which is not technically different from the one for women.
Anthropometric analysis is a step to clarify these important points and basement for
enhancing the plans of the corrective surgery.

4. Practical guidelines
The subjects have to be recruited from a population who has no noticeable nasal, facial
disfigurement and no history of previous nasal or facial surgery .
Demographic data obtained included age, place of birth, and parental heritage.
The subjects are rested for 10 minutes before the photography.
A constant, stable three-leg camera holder is used and all the subjects are positioned at
the same distance from the camera.
All data was obtained from standardized digital photographic images taken from
anterior, lateral and inferior aspects by using a digital camera.
Anthropometric landmarks were defined regarding a previous report of Farkas et al.
For enrichment of shape analysis, some constructed landmarks can be used, meaning
that the definition of the landmark is determined by constructing a line to another
landmark or bony edge.
The landmarks should be marked by the same investigator on the digital photographs
by using a digital imaging software.

5. Summary points
Statistical studies of anatomical shape variations in population are important in
understanding anatomical effects of diseases or biological processes.
10 Rhinoplasty

Anthropometric analysis of facial asymmetry is based on the comparison of homolog

measurements that are obtained separately from the anterior, lateral and inferior
aspects.
Standardization of method, accurate identification of landmarks to be used in the
measurements in nasal anthropometric analysis.
Anthropometric analysis is a step to clarify these important points and basement for
enhancing the plans of the corrective surgery.

6. References
Aung S.C. (2000) Br J Plast Surg 53: 109116
Bozkir M.G. (2004) Surg Radiol Anat 26:212-219
DeCarlo D. (1998) An Anthropometric face model using variational techniques. 25th Annual
Conference on Computer Graphics and Interactive Techniques. Appeared in
Proceedings SIGGRAPH 98, pp 67-74
Farkas L.G. (2005) J Craniofacial Surg 16: 615-646
Ferrario V.F. (1997) Cleft Palate Craniofac J 34:309-317
Ferrario V.F. (2003) Clin Anat 16:420-443
Hwang T-S, Kang H-S. (2003) Ann Anat 185:189-193
Lele S, Richtsmeier J.T. (1991) Am J Phys Anthropol 86:415428
Lele S (1993) Math. Geol. 25:573602
Leong S.C.L., White P.S. (2004) Clin Otolaryngol 29:672-676
Milgrim L.M. (1996) Arch Otolaryngol Head Neck Surg 122:1079-1086
Mishima K. (2002) Cell Tissues Organs 170: 198-206
Nechala P. (1999) Plast Reconstr Surg 103:1819-1825
Ochi K, Ohashi T (2002) Otolaryngol Head Neck Surg 126:160-163
Ofodile F.A., Bokhari F (1995) Ann Plast Surg 34:123-129
Romo T, Abraham M.T. (2003) Fac Plast Surg 19:269-277
Rohlf FJ. http://life.bio.sunysb.edu/ee/rohlf/software.html
Theodore M.C. III, Richtsmeier J.T. (1998) Am J Phys Anthropol 107:273283
Uzun A. (2006) Auris Nasus Larynx 33:31-35
Weinberg S.M., Kolar J.C. (2005) J Craniofac Surg 16(5):847-51
 2

Preoperative Planning for Rhinoplasty,

in Relation to the Gender and Ethnicity
Pawel Szychta1,2, Ken J. Stewart2 and Jan Rykala2
1Plasticand Reconstructive Surgery Department, St Johns Hospital, Livingston
2Plastic, Reconstructive and Aesthetic Surgery Department, 1st University Hospital, Lodz
1Great Britain
2Poland

1. Introduction
The nose plays an important role in the respiratory tract and is one of the most visible
organs on the face due to its central position. It emphasizes the shape of the eyes, is an
integral part of the face, and co-decides for its aesthetics as a whole. In clinical practice, there
is no universal concept of the perfect face, nor is there a specific shape of the nose,
considered a model of beauty. Normal range of the values describing nasal shape varies
depending on race and gender. In order to achieve a very good result of aesthetic surgery
for an each individual patient, surgeon must include to the preoperative planning of
rhinoplasty the differences of nasal shape in relation to gender and ethnicity.

2. Anthropometry for individual analysis of the nasal shape

Precise preoperative planning is essential in obtaining good results after rhinoplasty, judged
subjectively by the patient and surgeon. Anthropometric measurements of the nose can be
helpful in preoperative objective analysis. They serve both to highlight the parameters that
require correction, as well as pointing to some of the correct proportions, which should be
preserved during surgery (Szychta et al. 2010).

2.1 Devices for measuring the nasal shape

Until recently, anthropometric measurements were carried out directly on the patient using
rulers and anthropometric calipers or indirectly on standardized photographs. These methods
cannot be used in routine clinical practice as they are time-consuming and inaccurate.
An innovative method for measuring the surface of the human body is three-dimensional
imaging. It involves taking standardized pictures of the analyzed region using specialized
equipment connected to the computer, and then analyzing the three-dimensional digital
model. The advantages of this method include accuracy, speed and automation of the
calculations. Analysis with a 3D scanner was developed with relevant analytical software by
one of the authors adds an additional 2 minutes to the time spent with patient (Szychta et al,
2010a). The invested time is minimal, taking into account the possibility of obtaining
relevant, objective clinical data that may provide significant help in planning rhinoplasty.
Reliability of measurements with a 3D scanner using the anatomical points has already
12 Rhinoplasty

been confirmed in the previous studies. The drawbacks of the currently available 3D
scanners are their high, one-time cost and very low availability of the equipment adapted
for clinical use.

2.2 Outline of the analytical method of the nasal shape assessment

The authors propose an algorithm including linear measurements, angles and indices,
which allow to depict the differences among people of both sexes and of different races
(Szychta et al, 2010b). Assessment is based on 18 anthropometric nasal points (7 separate for
left and right side of the body), including points describing the nostrils: anterior (naL, naR),
posterior (npL, npR), lateral (nlL, nlR) and medial (nmL, nmR), as well as subalare (sbalL,
sbalR) and alare (alL, alR), and also 7 single points of the nose: pronasale (prn), subnasale
(sn), nasion (n), glabella (gl), rhinion (rh), labiale superius (ls) and columellar point (cp)
(Figure 1).

Fig. 1. Anatomical points used in the study together with indices of proportions (solid lines)
and angles (dashed lines), shown on a sample three-dimensional model of the face in a
patient after posttraumatic rhinoplasty. Views: a) front, b) profile, c) from below
By using selected anatomical points, the following 8 linear measurements are carried out:
length and width for both nostrils (naR-npR, naL-npL, nlR-nmR and nlL-nmL, respectively),
nasal height (n-sn), nasal length (n-prn), nasal width (al-al) and the nasal prominence (sn-
prn). On the basis of linear measurements, two ratios of nasal proportions are determined:
index of the prominence to the nasal width (sn-prn/al-al * 100) and nasal index (al-al/n-sn *
100).
The survey consists of 4 angles defining the shape of the nose: interaxial (sbalR-cp-sbalL),
nasofrontal (gl-n-prn), nasolabial (cp-sn-ls) and nasofacial (prn-n-sn).

3. Ethnic differences in parameters describing facial and nasal shape

The aesthetic beauty of a nose is subjective and varies according to specific cultural and
ethnic population (Table 1). A characteristics of the proper nasal shape depends on the race:
the Caucasian nose (called leptorrhine - 'long and narrow'), the African nose (platyrrhine - 'a
wide and flat') and the Asian nose (called mesorrhine borderline) (Krzeski, 2005).
The Caucasian nose is characteristic of people of European descent, and its features are often
used as a model for comparison with other races. The Caucasian nose is narrower than the
 Mongoloid race
Caucasian Negroid race
Our study, Caucasian Koreans
race (Leong (Ofodile & Chinese (Farkas Singaporeans
(Caucasian race (Farkas, (Hwang &
Parameter of the et al., 2006), Bokhari, et al., 1994b), (Aung et al., 1995),
Sex race) n=54 1994a), n=50 Kang, 2003),
nose n=50 1995), n=69 n=60 n=90
n=265
mea mea mea
mean SD SD SD SD mean SD mean SD mean SD
n n n
F 32.15 3.73 31.40 1.90 36 40.00 0.4 37.20 2.10 37.63 3.47 37.2 2.3
Width (mm)

(Szychta et al. 2011)

M 34.89 4.35 34.70 2.60 36 43.50 0.39 39.20 2.90 39.49 2.95 40.7 2.4
F 55.81 4.36 48.90 2.60 49.30 0.42 51.70 2.30 46.93 3.30
Height (mm)
M 60.02 4.23 53.00 3.50 52.40 0.44 53.50 2.80 50.15 4.16
F 45.66 5.58 44.30 3.70 40.04 3.62
Length (mm)
M 49.02 6.60 46.20 2.80 43.65 4.50
F 19.29 3.96 19.30 1.90 20.40 0.32 15.40 1.80 16.69 2.01 20.2 1.9
Prominence (mm)
M 20.66 2.95 20.60 2.20 23.10 0.36 16.10 1.50 17.68 1.66 21.7 1.8

Width F 9.63 1.96 6 1

Right (mm) M 10.47 2.09 6.6 1.1
nostril Length F 15.61 2.14 10.8 1.2
(mm) M 16.25 1.92 12 1.4
Width F 9.49 1.81 6 1
(mm) M 10.25 1.94 6.5 1.1
Left
nostril Length F 15.92 2.48 10.8 1.2
(mm) M 16.71 1.93 12.1 1.4
Nasofrontal angle F 132.95 5.99 134 7.40 137.5 4.8 131.9 6.8 135.6 4.40 139.09 7.65
() M 131.05 5.10 130.5 8.10 129.3 12.1 135.6 5.4 134.5 7.00 137.43 8.10
Nasolabial angle F 104.23 11.21 99.1 8.70 101.1 8.6 91 9.3 88.5 11.20 97.71 12.65
Preoperative Planning for Rhinoplasty, in Relation to the Gender and Ethnicity

() M 103.67 10.31 98.9 8.00 95.6 10.2 83.5 10.5 86.9 12.20 99.91 7.39
F 69.02 11.89 80.67 10.96 76.9 18.3
Interaxial angle ()
M 66.32 13.21 75.07 10.65 84.8 24.5
Nasofacial angle F 33.06 4.16 37.2 5.4
() M 31.64 3.01 36.7 7.8
F 57.72 5.93 64.21 81.70 79 7.00
Nasal index (%)

black and Asian race, compared with our results of rhinoplasty in group of Europeans
M 58.25 6.92 64.85 83.80 81 9.00
Index of F 60.49 13.95 61.46 51.5 45 6.00 53.9 5.6
prominence to

Table 1. Parameters describing the shape of the nose in relation to gender in healthy white,
M 59.56 7.89 59.36 53.8 45.77 4.00 52.9 5.8
have larger nostrils, compared with those of Mongoidal race (Table 1) (Rohrich & Bolden, 2010).

width (%)
13

African and the Asian. It is also longer compared with other ethnic groups. Caucasians also
14 Rhinoplasty

The African nose is characterized by a wide base, short and concave bridge and nasofrontal
angle of 130-140 degrees. It is said to be pear-shape. Relatively short tip projection is often
encountered, as well as posteriorly extended alae and round nostrils. Very thick skin of the
nose is observed. Black people have the widest and most prominent nose compared with
other ethnic groups. Within Europe of course interracial nasal differences are recognized by
all (Patrocinio LG & Patrocinio JA, 2007).
The Asian nose has intermediate characteristics between representatives of Caucasian and
African. The skin of the nose is quite thick and the bridge is wide. Analyzing cartilaginous-
osseous skeleton, nasal bones are usually short. Nasal tip is rounded off with an insufficient
projection, rotation and recessed columella. Typically, the nostrils are slightly rounded. The
shape of the nose is similar in representatives of the Mongoidal race: Chinese, Singaporeans
and Koreans, with clearly more prominent nose in the last group (Table 1) (Farkas et al.,
1994b; Aung et al., 1995; Hwang & Kang, 2003; Lam, 2009).
Additionally, patients can sometimes seek to conform to culturally accepted perceptions of
an attractive nose. For example, Black or Asian patients living in predominantly Caucasian
societies not uncommonly seek surgery to enhance nasal projection (Niechajev &
Haraldsson, 1997).

4. Differences in normal values of the nasal shape in relation to gender

The range of values of the anthropometric parameters defining the 'ideal aesthetic face' and
ideal aesthetic nose' is different for male and female (Table 2). These differences must be

Anatomic Anthropometric nasal Women Men

nasal parameter
parameter
Height Height Smaller Larger
Dorsum Nasal index Narrower Wider
width
Alae width Nasal width Narrower Wider
Nostrils Length and width of Smaller Larger
both nostrils
Projection Fronto-nasal angle, Smaller Larger
Naso-facial angle
Nasal tip Naso-labial angle More cranial rotation More caudal
rotation
Nasal root Nasion-glabella lenght Superior eyelid crease or Superior eyelid
just below crease or just above
Line of the Angle of deviation Straight or a bit concave; Straight or a bit
nasal dorsum between cartilaginous acceptable small depression convex; acceptable
and osseous vault of the nasal dorsum small nasal hump
Soft tissues Thinner Thicker
layer
Table 2. Overall, comparative characteristics of the normal nasal shape in women and men
(Krzeski, 2005)
Preoperative Planning for Rhinoplasty, in Relation to the Gender and Ethnicity 15

taken into account when planning the surgery. During each preoperative evaluation of the
nose, the proportions of the nose must create harmony with the rest of the individual face. It
is commonly held view that women have larger eyes, smaller noses, fuller lips, a smaller
distance between lips and chin, a smaller lower lip and a gently outlined maxilla. In
contrast, an attractive man has close and deep placement of eyes, bigger nose, pronounced
cheekbones and jaw, as well as clearly outlined non-prominent ears (Gunter et al., 2007).
Rhinoplasty techniques for men and women are identical, differing only within the scope of
the resection. Lack of understanding of differences in the shape of the nose in relation to
gender may lead to adverse aesthetic outcome (e.g. feminization of the male nose), which is
not a rare complication of rhinoplasty.

4.1 Our study

The authors examined the usefulness of the proposed method of anthropometric assessment
of the nose, evaluating 43 patients treated in the Plastic, Reconstructive and Aesthetic
Surgery Department (Medical University of Lodz, Poland) (33 men and 10 women) aged 18
to 45 years (mean 27 years) for the aesthetic results of posttraumatic rhinoplasty (Szychta et
al. 2011). The results were compared with previously described values of anthropometric
parameters for the healthy population. In order to standardize the study group, only
Caucasians of both genders have been included to the research. All patients underwent
partial resection and reposition of the nasal septum, placing it in the median plane of the
body. Simultaneously, the osteotomy of the nasal skeleton was performed. Three-
dimensional images using 3D scanner were performed at 6 months after surgery.
Subsequently, the anthropometric measurements of the three-dimensional facial model were
carried out with a computer program. Linear measurements were performed with an
accuracy of about 0.1 millimeter.
The shape of the nose in men and women showed significant differences (Table 1).
According to the results obtained in previous studies, women had narrower and shorter
nose (width: 32.15 3.73 mm and 34.89 4.35 mm, height: 55.81 4.36mm and 60.02
4.23mm, respectively). In women, the nostrils were rounder, with similar width and shorter
length in comparison to men (width of the nostrils: p> 0.05, length of the right and left
nostril: p = 0.0457, p = 0.0207, respectively). For both sexes we observed the same ratio
between width and height of the nose as well as between its prominence and width. We did
not notice differences in the position of the nasal tip in relation to the whole face.
In conclusion, the nose was usually smaller in women. We obtained good results of
rhinoplasty, which were similar to healthy Caucasian population in majority of the linear
parameters. However, the nasal index was lower compared with the control group due to
the surgical narrowing of nasal tip. Moreover, in the present study, slightly more obtuse
nasolabial angle than in the healthy population was associated with the surgical shortening
of the nasal tip. Increased nasofrontal angle and the associated reduced nasofacial angle
versus the comparison group resulted from osteotomy and the related shift of the nasal root
(nasion).
Further studies are planned to determine whether the introduction of the presented method
to clinical practice improves the aesthetic outcome of rhinoplasty. The comparative
assessment of pre- and postoperative results after posttraumatic rhinoplasty with use of 3D
scanner has been reported elsewhere (Szychta et al. 2010).
16 Rhinoplasty

5. The individual aspect of rhinoplasty

Individualized nasal analysis should into account normative values based on patient's
gender and race, as well as consideration of the individual shape of the face. The nose is
an integral part of the face and must be adjusted in size and shape to the whole.
Therefore, it is essential to obtain harmony between the parameters of the nose during
posttraumatic rhinoplasty (Gunter et al., 2007). Even in healthy people with an
aesthetically attractive appearance of the face, a number of parameters differ from the
usual aesthetic standards. A long or oval face looks attractive with a longer and narrower
nose. Similarly, a round or square face is more harmonious with the shorter and broader
nose (Figure 2). During the preoperative assessment the surgeon should show
understanding for the individual nasal proportions for each patient, treating the so called
aesthetic proportions only as a guideline and not seeking to achieve standard aesthetic
ideal (Tebbetts, 2008).

Fig. 2. Differently shaped faces with harmonious noses; a) and b) long face with long thin
nose, c) round face with harmonious short, wide nose
Almost every human face among the healthy population has a significant asymmetry
between the two sides of the body. Asymmetrical shape of the face can be interesting. It is
also important that before the posttraumatic rhinoplasty the surgeon supports the patient
with information regarding risks of postoperative deviations from perfect symmetry (Tardy,
1997).
In our opinion, knowledge of the normal range of values of parameters for a given gender
and ethnicity is important to better understand the general principles of the correct nasal
shape, along with the desire to obtain a perfect postoperative result, individually tailored by
the operation.

6. Conclusions
The aesthetic characteristic of the nasal shape in a healthy Caucasian population is
significantly different compared with the noses of other races. In the preoperative planning
Preoperative Planning for Rhinoplasty, in Relation to the Gender and Ethnicity 17

and evaluation of treatment results, knowledge of anthropometric differences between

people of different races and both sexes appears equally important as the individual
differences in relation to the whole face. Following the above mentioned guidelines in the
study, we achieved similar aesthetic results of posttraumatic rhinoplasty to the relevant
population with normal parameter values of the nasal shape.

7. References
Aung, S.C.; Ngim, R.C.K. & Lee, S.T. (1995). Evaluation of the laser scanner as a surface
measuring tool and its accuracy compared with direct facial anthropometric
measurements. British Journal of Plastic Surgery, (December 1995), Vol.48, No.8,
pp.551558, ISSN 0007-1226
Farkas, L.G. (Ed.). (1994a). Anthropometry of the head and face in medicine, 2nd edn.,
Raven, ISBN-13 9780781701594, New York, USA
Farkas, L.G.,; Ngim, R.C.K & Lee, S.T. (1994b). Craniofacial norms in 6-, 12-, and 18-year-
old Chinese subjects. In: Leslie, G. & Farkas, L.G. (Eds.). Anthropometry of the
head and face, 2nd edn., Raven, ISBN-13 978-0781701594, New York, USA,
pp.201218
Gunter, J.P.; Rohrich, R.J. & Adams, W.P. (Eds.). (2007). Dallas Rhinoplasty Nasal Surgery
by the Masters, 2nd edn., Quality Medical Publishing Inc., ISBN-13 978-1-57626-
223-8, St. Louis, USA
Hwang, T.S. & Kang, H.S. (2003). Morphometry of nasal bases and nostrils in Koreans.
Annals of Anatomy, Vol.185, No.2, (April 2003), pp.189193, ISSN 0940-9602
Krzeski, A. (Ed.). (2005). [Wyklady z chirurgii nosa]. In Polish. 1st ed., Via Medica, ISBN 83-
89861-29-1, Gdansk, Poland
Lam, S.M. (2009). Asian rhinoplasty. Seminars in Plastic Surgery, Vol.23, No.3, (August
2009), pp.215-22, ISSN 1535-2188
Leong, S.C.L. & White, P.S. (2006). A comparison of aesthetic proportions between the
healthy Caucasian nose and the aesthetic ideal. Journal of Plastic, Reconstrive and
Aesthetic Surgery, Vol.59, No.3, (March 2006), pp.248252, ISSN 1748-6815
Niechajev, I. & Haraldsson, P.O. (1997). Ethnic progile of patients undergoing aesthetic
rhinoplasty in Stockholm. Aesthetic Plastic Surgery, Vol.21, No.3, (May-June 1997),
pp.139-145, ISSN 0364-216X
Ofodile, F.A. & Bokhari, F. (1995). The African-American nose: part II. Annals of Plastic
Surgery, Vol.34, No.2, (February 1995), pp.123129, ISSN 0148-7043
Patrocinio, L.G.; Patrocinio, J.A. (2007). Open rhinoplasty for African-American noses.
British Journal of Oral and Maxillofacial Surgery, Vol.45, No.7, (October 2007),
pp.561-566, ISSN 0940-9602
Rohrich, R.J. & Bolden, K. (2010). Ethnic rhinoplasty. Clinics in Plastic Surgery, Vol.37, No.2,
(April 2010), pp.352-370, ISSN 0094-1298
Szychta, P.; Rykala, J. & Kruk-Jeromin, J. (2010). Assessment of 3D scanner usefulness in
aesthetic evaluation of posttraumatic rhinoplasty. The 33rd European Academy of
Facial Plastic Surgery Meeting, (September 2010), Belek, Turkey
Szychta, P.; Rykala, J. & Kruk-Jeromin, J. (2011). Individual and ethnic aspects of
preoperative planning for posttraumatic rhinoplasty. European Journal of Plastic
Surgery, Vol.34, No.8, (August 2011), pp.245-249, ISSN 1435-0130
18 Rhinoplasty

Tardy, M.E. (Ed.). (1997). Rhinoplasty The Art and the Science, 1st edn., W.B. Saunders
Co., ISBN 0-7216-8755-5, Philadelphia, USA
Tebbetts, J.B. (Ed.). (2008). Primary Rhinoplasty Redefining the Logic and Techniques, 2nd
edn., Mosby Elsevier Inc., ISBN 978-0-323-04111-9, Philadelphia, USA
 3

Preoperative Assessment
Pawel Szychta1,2, Ken J. Stewart1 and Jan Rykala2
1Plastic and Reconstructive Surgery Department, St Johns Hospital, Livingston
2Plastic, Reconstructive and Aesthetic Surgery Department, 1st University Hospital, Lodz
1Great Britain
2Poland

1. Introduction
Rhinoplasty offers a substantial customization of the parameters of the operated area in
comparison with most cosmetic procedures. At the same time, the surgeon faces a
challenging task of matching the complex shape of the nose to the rest of the face. The face is
a three-dimensional structure of highly-integrated anatomical components, gently
intersecting one another. Therefore, detailed preoperative planning, based on accurate
knowledge of the construction of the nose, can significantly contribute to achieve pleasing
result after rhinoplasty.

2. Nasal aesthetics
The nose occupies a central position on the face, dictating, to a large extent, general facial
aesthetics. There is no single model of ideal proportions of the face, or nose. Moreover, a
slight facial asymmetry is considered an attractive trait. In practice, therefore, the concept of
the normal range should be used instead of determining the 'ideal' values of parameters
describing the proportions of the face and nose.
The result of rhinoplasty should be an attractive nose, harmonious with the rest of the face
and emphasizing the beauty of the eyes (Tardy, 1997). The most favourable evaluation of
patient before rhinoplasty is based on the proportions of nose with the whole face.

2.1 Nose as an integral part of the face

Examination of the patient prior to rhinoplasty should include assessment of all the facial
components as complementary elements. Knowledge of normal proportions allows for
accurate detection of deviations from existing standards and precise targeting of surgical
correction in the establishment of an aesthetic shape of the nose, which is proportionate to
the rest of the face.
Leonardo da Vinci's facial model is split into three equal horizontal parts, bounded by the
lines intersecting four topographic points: trichion (hairline in the midline), glabella,
subnasale (nasal spine) and menton (lower edge of the chin) (Figure 1) (Gunter et al., 2007).
The upper third is the least important in the estimation of the proportion of the nose and
face. The nose is in the middle third of the face. The lower third of the face (between
subnasale and menton) is further divided by a horizontal line intersecting the commissure of
the lips (stomion) into two parts: 1/3 upper and 2/3 lower.
20 Rhinoplasty

In addition, Powell and Humphreys divided face into 5 vertical areas of equal width,
bounded by six vertical lines: both, a) and b) lines passing through the inner canthi, which
includes the medial part of the face with nose, both, c) and d) lines crossing the lateral
canthi, denoting the lateral edge of the neck, both, e) and f) lines through the most
outwardly situated point of the pinna (Powell & Humphreys, 1984).

Fig. 1. a) Face divided into three equal horizontal parts by Leonardo da Vinci, b) face
divided into 5 vertical areas of equal width
The correct proportions of the face vary depending on gender, race, and individual
anatomical features. According to a beautiful face in relation to gender, attractive women
have less marked jaw, bigger eyes and complementary smaller noses, as compared to men
(Perrett et al., 1994). Aesthetically pleasing lips are fuller, with a smaller upper lip. Women
also have a smaller distance between lips and chin. In contrast, men usually have a bigger
nose than women, coupled with a deep placement of eyes, located close to each other.
Attractive males have visible cheekbones and jaw. It is important that the ears in men are
not prominent.
For educational purposes, the commonly used facial proportions relate to white women,
who are the most common group of patients undergoing rhinoplasty (Talakoub & Wesley,
2009). It should be noted, however, that surgeons have to maintain the different
relationships between the nose and face in individuals of both sexes and different races.

2.2 Nasal aesthetic subunits

The facial surface is divided into so-called aesthetic units, which are areas of skin with
identical properties such as colour, texture, elasticity and thickness, and are often limited by
the curvature of the surface of the body. They serve as guidelines for reconstruction in the
event of loss of tissue. One of the units is the skin covering the nose. Its surface is divided
into subunits, the knowledge of which can be helpful in understanding the nasal shape.
There are nine aesthetic subunits of the nose: tip, columella, alar bases, alar side walls,
dorsum and dorsal side walls (Figure 2) (Rahman et al., 2010). Any surgical incision placed
between the subunits produces the least visible scars.

2.3 Characteristics of the correct shape of the nose

Preoperative evaluation is based largely on a conversation with a patient, observation of the
nose and palpation. However, standardised photographs are a valuable addition in the
preoperative analysis of the nasal shape, often highlighting the anatomical details, which are
difficult to see during the examination. Regardless of the method of analysis, the surgeon
should recognize the anatomical abnormalities of the nose, based on knowledge of the
Preoperative Assessment 21

correct proportions of the face and nose. The characteristics of the aesthetic face and nose are
described below.

Fig. 2. Aesthetic subunits of the nose: 1 tip subunit, 2 columellar subunit, 3 and 6 alar side
wall subunits, 4 and 5 alar base subunits, 7 dorsal subunit, 8 and 9 dorsal side wall
subunits
From the anterior view (on examination/in the photograph), the nasal bridge changes
gradually over its entire length, being narrowest in the area around the root (at the height of
the medial supraorbital edge, nasion), while the broadest at the base (at the tip of the nose -
pronasale) (Krzeski, 2005). Lines running along its side edges should be slightly diverging
caudally (Figure 3a). These are commonly described as the dorsal aesthetic lines.
Ideally, the nasal width at nasion should be equal to the palpebral fissure; while at the level
of pronasale (width of the nasal base) should be similar to the distance between the inner
commissures of the eyes. The width of the base of the nasal osseous pyramid should be 70-
80% of the nasal base (Mathes & Hentz, 2006).
The shape of the nasal base and columella should resemble the outline of seagull in flight
(gull-wing appearance) (Figure 3b) (Gunter et al., 2007). Its shape is attributable to the
columella position, which protrudes slightly below the edges of the nasal alae. The trunk of
the gull is the lowest portion of the columella, and the wings of the gull are the outlines of
the lower edges of alae. The edges of alae are shaped like a dome, convex in caudal-lateral
direction.

Fig. 3. a) Outline of the edges of the nasal bridge b) gull-wing appearance of the nasal base
and columella
22 Rhinoplasty

In addition, the proportions between the nose and mouth should be considered. The length
of the columella should be equal to height of the upper lip (Simons, 1982). Similarly, the
upper lip height (distance between subnasale and labiale superius) should be equal to 1/3 of
the lower face (1/9 of the whole face, according to the Leonardo da Vincis canon of beauty)
(Trenite, 2005). From the profile, the alar edge should have the shape of the letter 'S', starting
at the front of the columella, and ending posteriorly and laterally at the transition between
the nasal ala and cheek (Figure 4) (Tardy, 1997).

Fig. 4. S-shaped alar edge of the nose

The most attractive nasal profile is straight, as compared to convex or concave. The nasal
length and the columella should be proportional, without local irregularities. The nasal
profile is well described by the frontonasal angle. The frontonasal angle starts at around
eyebrows area and creates a gentle concave arc ending at the bridge of the nose. The top of
the frontonasal angle is positioned at level between the free edges of eyelids and supratarsal
folds, with eyes opened freely. In women, the nasal profile is straight or slightly concave, in
males straight or slightly convex (Tezel & Durmus, 2009).
The nasal tip has two points that define it in the horizontal plane, which are the points on
the domes of the nasal alae. Another two points, defining the tip in the profile view, are
supratip and columellar breakpoints. Supratip breakpoint is the the stepoff from the the
plane of the nasal dorsum on profile view at the cephalic aspect of the nasal tip. Columellar
breakpoint forms about 2mm anterior part of the columella (Figure 5 a). All four points that
define the nasal tip form two equilateral triangles (Figure 5 b) (Daniel, 2009).

Fig. 5. a) Points defining the nasal tip in the vertical plane, visible from the profile; b) Two
equilateral triangles formed by the points defining the nasal tip and the domes of the nasal
alae
Preoperative Assessment 23

Projection of the nasal tip is determined by the distance from the junction of the upper lip
with alae (subnasale) to the most anterior edge of the nose (pronasale) (Elsahy, 2000). Given
the normal projection of the upper lip, 50-60% of this line is located anterior from the most
prominent point of the upper lip (Mathes & Hentz, 2006).
Recession of the supratip area is beneficial for women, but does not occur commonly in
men. Nasal tip shows more cranial rotation in women (described as supratip break) and
therefore is more apparent in females, in contrast to the nasal bridge, which is more
prominent in men (Begg & Harkness, 1995).
The worm eye view shows the nasal base. Its external outline in the ideal conditions should
create an equilateral triangle (Figure 6). The height of the triangle, measured from the nasal
tip (pronasale) to the back of the nose (subnasale) consists of three parts. Its anterior 1/3
passes only through the infratip lobule, whilst the posterior two thirds are located along the
columella and nostrils. In another division, its length is divided into two halves at the
division of the medial edge of nostrils from the columella. The nostrils have the shape of
falling drops, and their widths are similar to the width of the columella. The long axis of the
nostrils faces anteriorly and medially about 45 degrees in comparison to the axis of the
columella. The width of the columella is narrow in its central part, and widens posteriorly,
which reflects the anatomy of the medial crura of alar cartilages. Anteriorly the columella
changes into the infratip lobule, whilst posteriorly it connects to the upper lip (Elsahy, 2000).

Fig. 6. Base of the nose; 1 columella, 2 infratip lobule, 3 nostrils, 4 alae, 5 nasal tip,
6 upper lip

2.4 Anthropometric measurements of the face and nose

The shape of the cartilaginous-osseous skeleton is relatively well depicted on the skin
surface due to the closely fitting skin envelope, especially in patients with thin skin.
Therefore, it is possible to designate relatively fixed points of surgical anatomy, which are
used for preoperative and intraoperative evaluation. After determining points on the face,
anthropometric parameters can be taken, which consist of linear measurements with the
resulting indicators, angles and spatial parameters (Szychta et al., 2010).
On the face we suggest determination of 24 anthropometrical points (7 separate for left L
and right R sides), including points describing the nostrils: anterior (naL, naR), posterior
(npL, npR), lateral (nlL, nlR) and medial (nmL, nmR), as well as: subalare (sbalL, sbalR),
24 Rhinoplasty

alare (alL, alR), alar curvature point (acL, acR). Nine single points are also determined:
pronasale (prn), infratip lobule (il), subnasale (sn), nasion (n), glabella (gl), labiale superius
(ls), rhinion (rh), columellar point (cp), stomion (s) and menton (m) (Figure 7).

Fig. 7. Anatomical anthropometric points of the face shown on the three-dimensional model
of the face; views: a) from the front, b) from the bottom
The nasion (n) is defined in the place of the greatest concavity of the upper pole of the nasal
bridge (nasal root). The rhinion (rh) is located at transition of cartilage into osseous pyramid.
The pronasale (prn) is described as the most projecting point at the nasal profile. The
subnasale (sn) is defined by the base of columella. The subalare (sbal) is located at transition
of the ala into the inferior wall of nostril. The alar curvature point (ac) is located in the far
lateral basal part of the ala. The alare (al) is the most laterally situated point of the nose. The
columellar point (cp) is determined at the intersection of both axes of nostrils, usually being
the lowest point of the nasal tip. The stomion (s) is located at the level of the lips fissure,
whilst the menton (m) is the lowest point of the chin. The reliability of measurements using
the anatomical points has been confirmed in the previous studies. The above mentioned
anthropometric points can be used to obtain: 9 linear measurements, 7 indicators of nasal
proportions, 7 angles, 2 indicators of spatial asymmetry of the skin surface and the total
volume of the operated area.
The linear measurements include: length and width of both nostrils (naR-npR, naL-npL,
nlR-nmR and nlL-nmL, respectively), nasal height (n-sn), nasal length (n-prn), nasal width
(alL-alR), length of the nasal base (acL-acR) and the nasal prominence (sn-prn). Nasal length
(n-prn) should be equal to the distance between stomion and menton (s-m). Nasal height is
equal to the length of the upper lip or up to 50% longer. Nasal prominence (sn-prn) is about
2/3 of the nasal length (n-prn). The degree of projection of the nasal tip, determined by the
distance sn-prn, should be equal to the upper lip height.
The calculated linear indices are: the index of the nasal base (sn-prn/ac-ac * 100), the index
of the prominence to the nasal width (sn-prn/al-al * 100), indicators of the shape of both
nostrils (nl-nm/na-np * 100), nasal index (al-al/n-sn * 100) and index of the nasal length (n-
prn/n-sn * 100). Asymmetry in the shape of the nostrils is given by [2 * ((nlL-nmL/naL-npL)
- (nlR-nmR/naR-npR)) / ((nlL-nmL/naL-npL) + (nlR-nmR/naR-npR)) * 100]. The nasal
index is normally 55%-60%.
Preoperative Assessment 25

The analysed angles are: interaxial angle (sbalR-cp-sbalL), angle of deviation between
cutaneous septum and midline (cp-sn-median line), angle of deviation between osseous
pyramid and midline (rh-n-median line), angle of deviation between osseous and
cartilaginous pyramid (n-rh-prn), nasofrontal (gl-n-prn), nasolabial (cp-sn-ls) and nasofacial
(n-prn-sn) (Figure 8).

Fig. 8. Angles of the nose, shown on the three-dimensional model of the face; views: a) from
the front, b) lateral profile, c) from the bottom
The nasofrontal angle is normally 125-135 degrees. However, the following features of the
nasofrontal angle are important for the whole aesthetics of the nose, apart from its value:
position of its tip in the frontal and sagittal plane, and its slope. In fact, the nasofrontal angle
does not contain a clearly identified vertex, but describes a mild change in the nasal profile.
The nasolabial angle in women is 95-105 degrees, while in men it varies from 90 to 95
degrees (Gruber & Peck, 1993). The nasolabial angle directly sets the rotation of the nose. It
may be different from the columella-lip angle, e.g. the prominent edge of the caudal nasal
septum can cause an illusion of increased cranial rotation of the nose, although the
nasolabial angle may remain within normal limits. The nasofacial angle, determining the
slope of the nasal bridge of the nose, sets the deviation of the nasal bridge from the facial
plane and varies correctly from 34 to 35 degrees (Daniel & Farkas, 1988). An excessively
obtuse nasofacial angle indicates excessive projection of the nose, and a very sharp
nasofacial angle is often found e.g. in boxers.
Spatial measurements are only possible by using three-dimensional imaging, which has
increasing clinical application. Asymmetry of the side surfaces of the nose is described as: [2
* (left side skin surface area area right) / (area left + area right) * 100], while the
asymmetry of cross-sectional areas of the nostrils is equal to [2 * (left cross-section area area
right) / (area left + area right) * 100]. Automated measurement of the total volume of the
nose can also be performed (Szychta et al., 2010).
Certainly not all patients will require undergoing the whole abovementioned extensive
formal analysis. Such exhaustive measurements are usually important in revision or
cosmetic cases with a high degree of precision required. That said, it is important for
surgeons to have a working understanding of all of these parameters.

3. The functionality of the nose

3.1 The nasal valve
Internal nasal valve is defined as that area of maximal narrowing that is bounded by the
nasal septum, caudal aspect of the upper lateral cartilage, the anterior face of the inferior
26 Rhinoplasty

turvinate and the nasal floor. It is located at a distance of about 1.3 cm posterior to the
nostrils (Trenite, 2005). A narrowed nasal valve is the most common cause of reduced
patency of the nasal airway, caused by the distortion of the nasal anatomy. Air resistance in
the nasal passages may also be caused by incorrect construction of the nasal vestibule or the
pathology of the nasal cavity valve.
The external nasal valve, formed by the nasal vestibule caudal to the internal nasal valve, is
defined by the alar and lower lateral cartilage tissues, which create the lateral and anterior
walls, as well as by the caudal septum and piriform aperture.
Cottles test is used to detect internal nasal valve pathology (Trenite, 2005). The surgeon
places his hand on the patients cheek near the nasal bridge and then pulls the skin in the
lateral direction. In case of valve failure, the patient feels immediate relief on breathing after
previous breathing difficulties (positive result). A negative result usually indicates either
lack of any pathology in the absence of nasal resistance or a correct nasal valve with
pathology of the other area of the nose. A false positive result is found in case of nasal alae
collapse. False negative results occur in cases of stenosis or adhesions of the valve or medial
displacement of the frontal process of maxilla as a result of mechanical trauma or surgery
(Krzeski, 2005).
Another way to evaluate the nasal valve is the introduction of the blunt instrument (e.g.
speculum) to the vestibule, moving away the nasal side wall from the septum. Improved
function of the nose on inspiration demonstrates pathology of the valve (Krzeski, 2005).
Nasal valve collapse is corrected with cartilage grafts. Nasoscopy and cross-sectional
imaging have value in illustrating the cause of airway obstruction.

3.2 The mechanism supporting the nose

The cartilaginous-osseous skeleton provides the nasal scaffolding and supports the covering
soft tissue (Figure 9). Understanding the mechanisms supporting the nose contributes to an
optimal range of surgical manipulation, including the ability to predict correctly the
postoperative appearance of the nose after wound healing.

Fig. 9. The cartilaginous-osseous skeleton acting as a support mechanism of the nose: a)

cadaveric dissection b) scheme depicting the anatomical details: 1 skin septum, 2 medial
crus of nasal ala, 3 lateral crus of nasal ala, 4 nasal septum, 5 upper lateral cartilage, 6
pisiform cartilage, 7 nasal bone, 8 frontal process of maxilla, 9 nasal muscle, 10 nasal
part of frontal bone
There are several mechanisms to support the nose with different significance for individual
patients. However, there are three relatively stable mechanisms, which have the greatest
impact on the stability of the nasal tip: a) Medial and lateral alar crura (size, shape and
structure), b) Ligamentous attachment between the upper lateral nasal cartilages and the
Preoperative Assessment 27

alae, and c) Connections between the medial crura of alae and the septum. The less
important six elements supporting the nose include: a) ligamentous connection of the alar
domes, b) the nasal septum, c) the pisiform cartilages, extending a support function of the
lateral crura of alae to the pyriform aperture, d) adhesions of the alae to the covering muscle
and skin, e) the nasal spine and f), the membranous septum (Figure 9) (Tardy, 1997). It
should be noted that the classic three major support mechanisms are not always the major
contributors in all patients. For example, in patients with a tension nose, the nasal septum
usurps much of the supporting role of the tip, and may be the single most important
support mechanism.
The mechanism for support for the nose can be assessed by checking the reversing
mechanism. The nasal tip is squeezed by the thumb and after a rapid withdrawal of the
finger the tissue is observed to return to baseline. A slow or incomplete return to the original
shape may indicate a weak support apparatus.
Operations, which maintain the structural integrity, result in controlled postoperative
outcome. A skeleton of sufficient strength maintains its functional support of the skin,
subcutaneous tissue, and SMAS. Moreover, larger noses after subtle correction may be more
aesthetically pleasing than small noses after radical reduction. Favourable outcome of nasal
correction can be achieved in most cases with conservative reorientation of the anatomical
elements.

4. Nasal deformities
4.1 Deviation of the nasal septum
Deviation of the nasal septum should be assessed in the context of the whole nasal skeleton
(Figure 10). It often coexists with distortion of the nasal pyramid. The surgeon assesses the
visible distortion and examines for fractures using the speculum.

Fig. 10. Twisted nasal septum

4.2 Distortion of the nasal pyramid

Distortion of the nasal pyramid, resulting in impaired function, is a frequent clinical
problem, both functionally and aesthetically. In case of deformation of the nasal skeleton,
the primary aim is improved breathing. A second aim is correction of nasal aesthetics. A
28 Rhinoplasty

crooked nose is often difficult to repair due to the distorted and scarred skeletal elements
and necessitates bilateral surgical manoeuvres to restore symmetry. The importance of the
nasal septum in the pathogenesis and the subsequent persistence of crooked nose deformity
after surgery should be emphasized. The septum is much like the rudder of a boat. If it is
deviated and not corrected, it will steer the nose back to a crooked position even after
corrective osteotomies are performed.

Diagnosed type of Distortion of the cartilaginous- Shape of Position/s of the

distortion of nasal osseous skeleton in relation to the nasal nasal bridge
pyramid the median facial line bridge bend/s
The cartilaginous and osseous Straight
Oblique nose Nasion
arch veers in the same direction line
Distortion of the The osseous pyramid is Singly
cartilaginous straight, the cartilaginous twisted Rhinion
pyramid pyramid distorted laterally curve
The cartilaginous vault is
C-shaped distortion Rhinion and
shifted in the opposite direction Arch
of the nose nasion
to the osseous pyramid
Nasion, rhinion
The cartilaginous vault shifted Double-
S-shaped distortion and area of
in the opposite direction to the twisted
of the nose weakened
osseous pyramid curve
triangle
Table 1. Division of nasal pyramid deformation, depending on the distortion of the nasal
bridge from the midline

Fig. 11. Division of nasal pyramid deformation, depending on the distortion of the nasal
bridge from the midline; a) oblique nose, b) nose with distorted cartilaginous vault, c) C-
shaped nose, d) S-shaped nose
Post-traumatic deformity reflects the type and direction of injury. In terms of the extent of
cartilaginous and/or osseous damage this may include: a) distortion of the nasal
cartilaginous vault by a deviated nasal septum, b) distortion of the entire cartilaginous-
osseous skeleton, or c) displacement of the osseous nasal pyramid. Distortion of the external
Preoperative Assessment 29

nose, depending on the type of deviation of the nasal bridge from the midline, is described
as: a) an oblique nose, b) a hooked nose, c) a saddle nose, or d) and e) C or S shaped nose
(Table 1, Figure 11) (Krzeski, 2004). Assessment of the extent of injury helps in planning the
appropriate surgical technique. Preoperative evaluation and the subsequent surgical
correction should consider separately the three parts of the nose: cranial, middle, caudal.

4.3 The hooked nose

The nasal bridge is built of bone and cartilage. The osseous part is formed by the paired
nasal bones, and the cartilaginous is built of lateral nasal cartilages attached to the nasal
septum. Their correct proportions define the aesthetics of the nasal bridge. In women this is
a straight or slightly concave, whilst in men forms a straight or gently curved line. The nasal
hump is an excessive bulge which creates a hooked appearance (Figure 12). The aim of
resection of the hump is aesthetic correction that will reconstruct the optimal nasal
proportions (Sevin A et al., 2006).

Fig. 12. Hooked nose (nasal hump)

Various anatomical structures may contribute to the nasal hump. These include the osseous
pyramid and the cartilaginous vault. However, a genuinely pronounced nose may also give
the illusion of a hump. Alleged hump (also called pseudo hump, usually resembling a hump
of the osseous pyramid) results from the reduced projection of the upper cartilaginous vault
or ptotic tip, giving the impression of excessive convexity of the caudal edge of the nasal
bones. The prominent nose includes hypertrophy of the septum cartilage in the sagittal
plane and the accompanying hypertrophy of the lateral cartilages of the nose (Krzeski,
2004).

4.4 Saddle nose

The saddle nose is determined by collapse of the nasal bridge, often colloquially described
as a boxer's nose or puggy nose (Figure 13).
The saddle nose can be congenital but it is more often acquired. Aetiologies include:
iatrogenic cause, certain types of cleft lip and palate, genetic syndromes, congenital syphilis,
recurrent cartilaginous inflammation, Wegener's granulomatosis, cocaine use or leprosy.
30 Rhinoplasty

Fig. 13. Saddle nose

A practical method of classification described by Tardy divides severity of the saddle nose
deformity into three categories:
a. Minimal recession of tip supratip area is larger than the ideal 1-2mm, no retraction of
the columella, the nose is not widened.
b. Moderate - loss of the nasal projection is mostly due to the damage to nasal septum
cartilage. Damage to the cartilage of the nasal septum is a direct cause of weakening of
two of the support mechanisms of the nose: the attachment of the medial alar crura to
the caudal edge of the septal cartilage and the upper lateral cartilage attachment to the
nasal alae. This is the reason for the reduced projection of the nose. The columella is
retracted. The pyramid of the nose is too broad and flattened. The nasolabial angle is
usually less than 90 degrees. In contrast, the nasal valve angle is often found increased,
in rare cases up to 90 degrees.
c. Significant - significant loss of cartilage and loss of projection of the nasal bridge. In
cases of a high degree of distortion, the following coexisting distortions are found: a
lowered nasal bridge, a shortened columella, loss of support of the nasal tip, shortened
nasal length, excessive cranial rotation of the nasal tip, widened nasal tip, alae too
prominent and slender, atrophy of the nasal spine and the caudal edge of nasal septum.
A decreased nasal tip projection together with a shortened columella is the cause of a
disproportionately widened nasal base (Tardy, 1997).

4.5 Distorted nasal tip

The nasal tip is the most prominent area of the nose. Distorted proportions significantly
aesthetically influence the facial aesthetics. A larger nose, harmonious with the face is often
regarded as more acceptable than the insufficiently prominent one.

Fig. 14. Rotated nasal tip in women and men; a) snub nose b) droopy nose
Preoperative Assessment 31

In addition to the position, the tip is also determined by caudal or cranial rotation. Excessive
cranial rotation, providing a 'snub nose' is acceptable for women and unacceptable in men
(Figure 14). On the contrary, 'hanging nose', caused by excessive caudal rotation, is more
acceptable in men (Begg & Harkness, 1995). It is often referred to in women as a witch
nose.
The supratip area is located between alae and the lateral cartilages. It is filled with adipose
tissue. Insufficient volume of this structure can contribute to increased cranial rotation.

5. Consultation of the patient

Rhinoplasty is performed to obtain a functional nose of the correct proportions. Surgeons
should acquire the ability to assess the executable range of corrections of the nose, having
imposed the pre-established limits. These include anatomical features, such as the
characteristics of the covering skin (thickness, elasticity, existing scar tissue), and the
cartilaginous-osseous skeleton. In addition, the surgeon should note the areas of the well-
proportioned nose, avoiding the changes during the operation (Tardy, 1997).

5.1 Taking a history

On the first visit, the surgeon evaluates the preoperative indication for rhinoplasty, faces the
patients expectations and confronts them with limited operational capability because of the
individual anatomical conditions. In the meantime, the surgeon performs the initial analysis
of the face and its proportions.

5.1.1 Assessment of patients motivation

It is essential that the patient himself/herself is convinced of the need for surgery, without
pressure from third parties. Recent traumatic experiences in the patients private or
professional life should be regarded as contraindications to surgery. Any signs of body
dysmorphic disorder should be also identified. Patient with body dysmorphic disorder
focuses usually on one part of the body, most commonly on the nose. His/her
preoccupation with an imagined defect in the physical appearance often is expressed as
require for surgical correction. The aesthetic outcome of the rhinoplasty is usually not
satisfying for these patients with underlying psychiatric disorder (Alavi et al., 2011). The
patient qualified for rhinoplasty should be emotionally mature, have realistic expectations
about correction and understand his/her contribution to the healing process. With the
above conditions of selection, the patients in most cases are happy with a good
postoperative result.
By contrast, patients who survived a major injury to the nose are a distinct group of people.
For the most patients, they never have considered undergoing surgery without the
emergence of posttraumatic deformities to the nose and the related disorder of nasal
patency. They want to breathe without difficulty and to have the shape of their nose
reconstructed from period before injury. Their motivation is high and usually results in a
positive reaction to rhinoplasty (Dziewulski et al., 1995).
The surgeon should be able to identify patients who may pose significant potential
problems. These include patients: with unrealistic expectations, hyperaesthetic, obsessive-
compulsive, depressive, fickle, hesitant, rude, overly flattering, chummy, sloppy, non-
cooperating, 'VIP', overly talkative or haggling over the price of treatment (Tardy, 1997). It
32 Rhinoplasty

should be emphasized that most patients have realistic expectations and understand limited
possibilities of correction.

5.1.2 Taking a history nose

At the beginning of the interview, the surgeon obtains information on conditions that may
interfere with nasal function, taking into account: the patency of both nostrils, nasal trauma,
seasonal allergies causing nasal obstruction, purulent sinusitis requiring antibiotics, snoring,
epistaxis, asthma, headache caused by sinus, bronchitis, history of rhinoplasty or
septoplasty, hypertension, tendency to keloids, drugs (aspirin, steroid sprays,
decongestants), environmental conditions - work, addictions: cigarettes, alcohol and cocaine
(Krzeski, 2004). There is potential of exacerbation of some of these diseases after the surgery.
The above mentioned drugs should be discontinued at least one week prior to surgical
treatment. Stimulants significantly impair wound healing and can lead to increased
incidence of complications. Allergic rhinitis, causing obstruction of the nose, may be due to
the hypertrophic inferior nasal turbinates. On this account, the history of headache should
not be ignored, as it can exist due to insufficient warming of air inhaled by the inferior nasal
turbinates.
Secondly, the surgeon asks questions about patients concerns in relation to nasal
deformations, allowing him/her to answer freely in order to understand the expectations
and to assess of executable potential of the requests.
Preliminary analysis of the major complaints gradually shall turn into an assessment of less
significant problems. Sometimes patients can not accurately identify problems. Then the
surgeon acts as a guide, helping the patient for self-analysis of irregularities by using his
experience and artistic sense. Useful descriptors include the words 'harmony' and
'proportion'. To better explain the operative plan to the patient, the surgeon demonstrates
certain existing distortions of the individual nose, such as asymmetry, deformities of the
nasal tip, distortion of the supratip area, irregularities of the nasal pyramid and nasal septal
perforations. It is emphasized that rhinoplasty does not improve the facial symmetry.
Sometimes it may become even more apparent after creating a symmetrical nose (Figure 15).

Fig. 15. Asymmetrical faces where rhinoplasty is contraindicated

The first visit should be completed by a thorough understanding between the surgeon and
the patient of the aesthetic concerns and opportunities. It is followed by depiction of the
Preoperative Assessment 33

operational plan, based on the realistic possibilities of correction of the distorted anatomical
components, but also maintaining some of the existing pre-operative characteristics of a
desirable nasal shape. In patients without respiratory distress, the surgeon should have in
mind the need to maintain the functionality of the nose after surgery.

5.1.3 Preoperative information

Most patients are highly motivated and, after giving the relevant information, do not require
a second preoperative interview. Before being asked for the formal consent, they should be
informed about possible complications: bleeding, infection, distortion of results from the
negative healing, the potential need for reoperation, which may not be possible until 1 year
after the first procedure. However, the surgeon should reassure patients that rhinoplasty is
usually a relatively safe operation, and that some minor irregularities may disappear in the
process of healing.
In the event of the patient deciding to proceed, the surgeon should obtain written consent
and photographic documentation. The patient receives a written recommendation
concerning the necessary laboratory tests and guidance prior to surgery. Patients often want
information about anaesthesia, operative time, length of hospital stay and early
postoperative period. They should be informed about the possibility of postoperative pain,
swelling of the face, bruising around the eyelids, difficulty in breathing through the nose
due to anterior packing and the dressing left for up to seven days. In the case of the planned
osteotomy patients should be warned about the need to swap glasses for contact lenses for 6
weeks after surgery.

5.2 The physical examination of the external nose

The surgeon examines the external nose and nasal cavity. At the beginning, an overall
evaluation of nasofacial harmony is conducted. Examination of the external nose includes
observation and palpation. Firstly, the skin covering the nose is assessed. Then, a systematic
analysis of the nose is performed, including the following areas in the caudal direction: the
nasofrontal angle, osseous pyramid, the upper lateral cartilage and nasal tip (the supratip
area, nasal tip, alae, columella).

5.2.1 Evaluation of nasal skin and subcutaneous tissue

The surgeon can relatively easily modify the nasal cartilage and bone, but the nature of the
covering skin must be accepted and included in the technique used for correction.
Individual characteristics of each patient's skin have a huge impact on the scope of
executable operations and the final result. Nasal skin is resistant to varying degrees to
changes in cartilaginous-osseous skeletal, depending on its thickness, texture and elasticity.
The elasticity of the skin is reduced in the elderly. The constraints due to the volume of
preoperative skin with reduced elasticity must be taken into account during preoperative
planning. For example, the skin over a broad nasal base may not contract adequately to
cover a small, narrow base of the nose, and the postoperative result rather turns into a
distorted wide base of the nose.
The skin is assessed by observation and palpation, checking the extent of the possible
surgical correction. Gently lifting the nasal skin allows for an evaluation of its mobility in
relation to the nasal skeleton and for the indirect analysis of its elasticity and contractility.
34 Rhinoplasty

The thickness of the skin is the single most important parameter of the skin. Nasal skin is
generally thinner, more mobile, easier shifting in the cranial area, while being relatively
devoid of subcutaneous tissue and sebaceous glands. The caudal part of the nose contains a
thicker skin more strongly attached to the substrate, with a higher content of the sebaceous
glands. Skin is thickest in the following areas: the nasal root (nasion), supratip area, whiles
the thinnest at the rhinion (Krzeski, 2005). This should be taken into account when
considering nasal reduction. Nasal tip contains additional subcutaneous tissue.
The best skin for the perfect result of rhinoplasty is of moderate thickness. It consists of the
epidermis that includes minimum number of sebaceous glands and pores. Sufficient
quantity of fibrous tissue and fat protects the skin from underlying skeletal structures, while
hiding minor irregularities in the nasal cartilages. It adheres well to the bed after the
surgery, so that changes made to the skeleton translate into the desired changes in the
appearance of soft tissue.
In patients with thin, delicate skin, less postoperative swelling and fast wound healing are
observed (Figure 16 a). However, it does not disguise small irregularities in the skeleton,
making the shape of the nose edgy and unnatural. In most patients, the skin is medium thick
or thin, so the surgeon should make every effort to save the subcutaneous tissue during
operation (Tardy, 1997).
Thicker nasal skin is un-aesthetic (Figure 16 b). For those with thicker skin, a higher
postoperative swelling is observed, together with slower healing and more pronounced
contraction. The creation of scar tissue under the skin is more pronounced, especially for a
nasal reduction. This leads to a parrot nose (pollybeak), a shapeless nose. It is difficult to
obtain the accentuated definition of the nose in patients with thick nasal skin. After the
operation is adheres poorly to the nasal skeleton. Care should also be taken not to resect
excessively the cartilaginous skeleton due to the danger of weakening the support of the
nose (Mathes & Hentz, 2006).

Fig. 16. Noses with a) thin, b) thick nasal skin

5.2.2 Examination of the cartilaginous-osseous nasal skeleton

Ability to assess the external shape of the nose during the physical examination is largely
dependent on knowledge of the topographical points of the face and nose, as well as classic
proportions described by Leonardo da Vinci. However, often the practical usefulness of
these aesthetic purposes is limited by the anatomy of skeleton and the surrounding skin.
Preoperative Assessment 35

The examination is performed in an orderly manner, in caudal direction (Elsahy, 2000). The
surgeon evaluates the location and slope of the frontonasal and nasolabial angles.
Frontonasal angle can be improperly shifted cranially or caudally, so the nose is elongated
or abnormally short. Too mild frontonasal angle is an indication for resection of bone or
longitudinal muscle. If too sharp, it forms a clearly visible vertex of the frontonasal angle,
which is an indication for the cartilage graft (Figure 17).

Fig. 17. Frontonasal angle; a) obtuse, b) normal, c) acute

Nasal bones are examined for symmetry, the occurrence of irregularities and their length. It
is important to determine the ratio between the width of the base of the nose and the length
of the bridge (Elsahy, 2000). Simultaneously, visual illusion must be taken into account on
the inverse relation between the projection of the nasal bridge and the size of the nasal base
(Figure 18). The aim is to select the optimum reduction of osseous pyramid or augmentation
of the area.

Fig. 18. Two noses with the similar length and a) wider b) narrower nasal base visual
illusion of the shorter nose in the picture on the left because of the wider nasal base
The surgeon assesses the lateral cartilages in terms of their symmetry and strength. Lateral
nasal cartilages are compared with nasal bones and nasal septum cartilage in order to assess
their supportive function. For shorter nasal bone, the weaker support of the nasal valve is
experienced. In these cases, only conserving hump removal can be performed in order to
avoid the collapse of the lateral cartilages (Gunter et al., 2007).
Assessment of stiffness and support to the lower third of the nose is of crucial importance in
the multivariate analysis of the nose. In order to assess valve pathology, the patient is asked
36 Rhinoplasty

to breathe intensively. The surgeon observes collapsing or asymmetry in the nasal side
walls, the distortion of the columella, protrusion of the caudal part of nasal septum or
collapse of the alae. Reliable screening test (evaluation of reversing mechanism) to denote
the support of mobile bottom third of the nose consists of strong pressing of the nasal tip to
the upper lip using your finger tip, and subsequent sudden release. Then the ability of the
nasal tip return to baseline is observed (Krzeski, 2005).
Nasal base is a more complex structure compared to the simple structure of the osseous and
upper cartilaginous vaults. In addition, the skin in the caudal pole of the nose is thicker and
thus less adapted to surgical manipulation.
Supratip area is evaluated in terms of its position (height, width and recession) and
symmetry. In normal conditions it should be flat.
The nasal tip is examined in terms of its projection, rotation, symmetry and position of
defining points. Identification of poorly defined tip, a low point of greatest projection tip,
convex supratip area, infratip lobule lying above the point of greatest projection helps in
planning a thorough correction of this complex anatomical structure.
Nasal alae are examined in terms of width, retraction, and place of connection to columella.
The abnormal curvature or asymmetry can be observed. Visual inspections on a peaceful
and forceful breathing allow to depict collapse, flaccidity of the cartilage or narrowing of the
nasal valve. Palpation determines their size, mobility, shape and strength. The increased
distance between the domes of the alae is an indication for correcting the forked nasal tip
(Elsahy, 2000).
Infratip lobule is assessed in terms of shape, harmony with the surrounding structures,
width, thickness and the ratio of the nasal length and the nasal base width.
Nostrils are assessed in terms of shape and symmetry (Figure 19). At the same time, shape
of columella is observed. Examination of columellar width and length allows to assess its
supportive function. In case of too short medial crura of alae, there is a need of longitudinal,
narrow cartilage graft. Correction of excessive tip projection may include reducing the
width and length of too long or widening medial crura of nasal alae (Gunter et al., 2007).

Fig. 19. Shape of nostrils: a) symmetrical teardrop-shaped, b) symmetrical narrow,

c) asymmetrical in width, d) asymmetrical in length
The nasolabial angle is examined by observation. Excessively acute angle (less than 80
degrees) indicates a drooping nasal tip - on the assumption that there is no evidence of
hanging columella (Figure 20). Excessively acute or retracted nasolabial angle is an
indication for tip reduction or transplantation thickening grafts (called plumping grafts) at
intersection of columella and the upper lip (subnasale). Excessively obtuse angle is more
challenging to repair and requires usually cartilage or bone graft (Krzeski, 2005).
Preoperative Assessment 37

Fig. 20. Nasolabial angle; a) excessively acute, b) normal, c) excessively obtuse

Septal cartilage is examined from the outside in terms of its relation to columella. Palpation
is performed with thumb and index finger, allowing to check twisted caudal edge of nasal
septum, hypertrophic cartilage septum, caudal distortion of the medial alar crura and
columella or structural abnormalities of the anterior nasal spine (Figure 21).

Fig. 21. Distortion of the nasal septum from the midline

Fig. 22. a) Hanging columella, b) recessed columella

38 Rhinoplasty

Excessively protruding columella in the lower pole of the nose, or too big alae, resulting in
excessive outline of 'gull in flight', are called hanging columella (Figure 22). In contrast, a
flat line is called recessed columella. An important point in nasal analysis is differentiating
alar retraction from a hanging columella.
The infratip lobule should be localized below the top of the alar domes. Uncommonly
observed hanging infratip lobule occurs when infratip lobule has a too low position
relative to the junction of alae.

5.3 Examination of the internal nose

Intranasal examination allows to assess the functionality of the nose. It is performed using a
speculum, after applying vascular contractile factor in the aerosol (oxymetazoline). The
following structures can be assessed: mucosa, nasal turbinates, nasal septum, nasal valve,
valve of nasal cavity and nasal ala. The review of the nasal duct confirms nasal patency or
indicates the anatomical abnormalities (Tebbetts, 2008).
Assessment of the appearance of mucosa is in consideration of the appearance, atrophic
changes, oedema, presence of polyps and anatomical abnormalities in the lateral wall of the
nasal cavity.
Nasal turbinates are assessed visually in terms of their size, shape and appearance. Their
hypertrophy is common in people with allergies. Because of their functions, the
conserving resection should be carried out and only when absolutely necessary (Krzeski,
2004).
Septum is examined to assess its size, shape, coverage of the mucosa, perforation or
adhesions. Curvature of the nasal septum posterior from the nasal valve can be detected.
Excessive size of septum is noted for its potential use as a graft. Identification of high
distortion of the septum (anterior edge) is important to avoid formation of high curvature of
the septum after removal of the nasal hump. It is important to detect the curved horizontal
cribriform plate because it can cause impaired nasal patency after the lateral osteotomy
(Mathes & Hentz, 2006).
Nasal valve can be easily visualized due to its relatively superficial location. Angle of the
valve is formed by the nasal septum and lateral nasal cartilage, amounting normally from 10
to 15 degrees (Trenite, 2005). In order to evaluate the nasal valve, the patient's head is tilted
back and the surgeon uses a point light source to observe the presence of a narrow valve, or
its collapse on inhalation.
Alae are examined to detect the protrusion of their lateral crura to the vestibule and to
assess their support function of the lateral nasal wall.

6. Photographic documentation
Pre- and postoperative photographic documentation is a valuable addition to the daily
practice of surgeon involved in the rhinoplasty for the following purposes: diagnostic,
teaching, self-criticism, as well as medico-legal. Surgeon should obtain written consent from
the patient for the photographs to be taken.

6.1 Two-dimensional photographs

Routine photographic documentation on a preoperative visit involves an additional 2
minutes, and provides invaluable information on the nasal shape.
Preoperative Assessment 39

Quality images are obtained using the 105 mm portrait lens (Mathes & Hentz, 2006). Patient
should be placed approximately 150 cm from the photographer. Proper lighting provides a
set of two lamps directed at an angle of 45 degrees to the camera and the patient. The
greatest depth of focus will be provided by optics lens with aperture F-11 to F-22. The
background colour should be pale pastel in order to avoid reflection or absorption of an
excessive light rays, as well as to be a good complement to the colour of the skin (Tardy,
1997).
Face of the patient should be placed along the Frankfort line. From the front, head and neck
should be included. From the side profile, ear and nose should be taken into account. In
order to standardize the oblique profile, the lateral border of the face should be adjusted
with the tip of the nose. From the bottom, tip of the nose should be positioned between the
eyebrows. The patient is placed no closer than 50 cm from the background in order to avoid
the shadows.
Normally, six photographs are carried out in the following projections: front (lens at eye
level), lateral (left and right profile - invisible opposite eyebrow), oblique (left and right) and
the base of the nose (Figure 23).

Fig. 23. Routine photographic documentation of the patient prior to rhinoplasty

6.2 Three-dimensional imaging

Three-dimensional imaging method allows to determine the shape of a three-dimensional
object (e.g. face). Scanning requires set of devices, which transform the image from analog to
digital form and include: an optical system, digital communication network and computer
with the calculation program. Image captured by an optical system is subjected to computer
analysis in the process of digitization. Body surface area is written in the form of points with
coordinates in three dimensions. Points are combined with one another to form triangles on
poligonisation. The collection of all triangles in a three-dimensional model forms the surface
of analysed part of the body, which contains information concerning its actual size (Figure
24). 3D scanner should be configured to allow an accurate assessment of the linear
measurements, proportion, area and volume.
40 Rhinoplasty

With three-dimensional imaging all currently designated line parameters can be achieved in
a repeatable and precise way, as well as additional spatial data describing the shape of the
nose, which could be useful for preoperative planning. The postoperative data allow for
accurate long-term follow-up. Three-dimensional imaging can also provide invaluable
assistance to the surgeon through the preoperative calculation of the needed degree of
resection of the nasal cartilages during surgery. Confirmation of usefulness of this method
of preoperative planning, however, requires further study.

Fig. 24. Three-dimensional model of the face

7. Additional studies
Labolatory tests should be performed two weeks prior to rhinoplasty, these may include:
blood group, full blood count, ESR, urea + electrolytes, coagulation tests (INR, APTT), HBV
antigen, HCV antibodies.
The following tests may be additionally recommended: WR, total protein, urinalysis, chest
X-ray and ECG.

8. Conclusions
Proper selection of patients together with detailed preoperative planning, based on accurate
knowledge of the nasal anatomy, is essential to achieve good result of rhinoplasty. The
relatively fixed points of the nasal surgical anatomy, designated using our protocol of
anthropometrical assessment with 3D imaging, can be used for accurate preoperative and
intraoperative evaluation. However, ideal proportions of the nose to the whole face act only
as guidelines in individualized planning of the surgery.

9. References
Alavi, M.; Kalafi, Y.; Dehbozorgi, G.R. & Javadpour, A. (2011). Body dysmorphic disorder
and other psychiatric morbidity in aesthetic rhinoplasty candidates. Journal of
Preoperative Assessment 41

Plastic, Reconstructive and Aeshtetic Surgery, Vol.64, No.6, (June 2011), pp.738-41,
ISSN 1748-6815
Begg, R.J. & Harkness, M. (1995). A lateral cephalometric analysis of the adult nose. Journal
of Oral and Maxillofacial Surgery, Vol.53, No.11, (November 1995), pp.1268-1274,
ISSN 0278-2391
Daniel, R.K. & Farkas, L.G. (1988). Rhinoplasty: image and reality. Clinics in Plastic Surgery,
Vol.15, No.1, (January 1988), pp.1-10, ISSN 0094-1298
Daniel, R.K. (2009). Tip Refinement Grafts: The Designer Tip. Aesthetic Surgery Journal,
Vol.29, No.6, (November - December 2009), pp.528-537, ISSN 1084-0761
Dziewulski, P.; Dujon, D.; Spyriounis, P.; Griffiths, R.W. & Shaw J.D. (1995). A retrospective
analysis of the results of 218 consecutive rhinoplasties. British Journal of Plastic
Surgery, Vol.48, No.7, (October 1995), pp.451-454, ISSN 0007-1226
Elsahy, N. (Ed.). (2000). Plastic and Reconstructive Surgery of the Nose, 1st edn., W.B.
Saunders Co., ISBN: 0-7216-7722-3, Philadelphia, USA
Gruber, R.P. & Peck, G.C. (Eds.). (1993). Rhinoplasty: State of the Art, 1st edn., Mosby, ISBN-
13 978-0801662775, St. Louis, USA
Gunter, J.P.; Rohrich, R.J. & Adams, W.P. (Eds.). (2007). Dallas Rhinoplasty Nasal Surgery
by the Masters, 2nd edn., Quality Medical Publishing Inc., ISBN-13 978-1-57626-
223-8, St. Louis, USA
Krzeski, A. (Ed.). (2004). [Podstawy chirurgii nosa], In Polish. 1st edn., Via Medica, ISBN 83-
89861-10-0, Gdansk, Poland
Krzeski, A. (Ed.). (2005). [Wyklady z chirurgii nosa]. In Polish. 1st ed., Via Medica, ISBN 83-
89861-29-1, Gdansk, Poland
Mathes, S.J. & Hentz, V.R. (Eds.). (2006). Plastic Surgery. Volume II The Head and Neck,
Part 1, 2nd edn., Saunders Elsevier Inc., ISBN-13 978-0-7216-8811-4, Philadelphia,
USA
Perrett, D.I.; May, K.A. & Yoshikawa, S. (1994). Facial shape and judgements of female
attractiveness. Nature, Vol.368, No.6468, (March 1994), pp:239-242
Powell, N. & Humphreys, B. (Eds.). (1984). Proportions of the aesthetic face, 1st edn.,
Thieme-Stratton, ISBN 0865771170, New York, USA
Rahman, M.; Jefferson, N.; Stewart, D.A.; Oliver, R.; Walsh, W.R. & Gianoutsos, M.P. (2010).
The histology of facial aesthetic subunits: Implications for common nasal
reconstructive procedures. Journal of Plastic, Reconstructive and Aesthetic Surgery,
Vol.63, No.5, (May 2010), pp.753-756, ISSN 1748-6815
Sevin, A.; Sevin, K.; Erdogan, B.; Adanali, G. & Deren, O. (2006). A Useful Method for
Planning Hump Resection of Deviated Nose. Aesthetic Plastic Surgery, Vol.30,
No.4, (August 2006), pp.433-436, ISSN 0364-216X
Simons, R.L. (1982). Nasal tip projection, ptosis, and supratip thickening. ENT Ear, Nose,
& Throat Journal, Vol.61, No.8, (August 1982), pp.452-455, ISSN 0145-5613
Szychta, P.; Rykala, J. & Kruk-Jeromin, J. (2010). Assessment of 3D scanner usefulness in
aesthetic evaluation of posttraumatic rhinoplasty. The 33rd European Academy of
Facial Plastic Surgery Meeting, (September 2010), Belek, Turkey
Talakoub, L. & Wesley, N.O. (2009). Differences in Perceptions of Beauty and Cosmetic
Procedures Performed in Ethnic Patients. Seminars in Cutaneous Medicine and
Surgery, Vol.28, No.2, (June 2009), pp.115-129, ISSN 1085-5629
42 Rhinoplasty

Tardy, M.E. (Ed.). (1997). Rhinoplasty The Art and the Science, 1st edn., W.B. Saunders
Co., ISBN 0-7216-8755-5, Philadelphia, USA
Tebbetts, J.B. (Ed.). (2008). Primary Rhinoplasty Redefining the Logic and Techniques, 2nd
edn., Mosby Elsevier Inc., ISBN 978-0-323-04111-9, Philadelphia, USA
Tezel, E. & Durmus, F.N. (2009). A new instrument for achieving a natural nasofrontal
angle. Journal of Plastic, Reconstructive & Aesthetic Surgery, Vol.62, No.12,
(December 2009), pp.e617-e619, ISSN 1748-6815
Trenite, G.J.N. (Ed.). (2005). Rhinoplasty: a practical guide to functional and aesthetic
surgery, 3rd edn., Kugler Publication, ISBN 90-6299-208-0, Hague, Netherlands
 Part 2

Innovations in Delivery Approach

 4

Modified Delivery Approach

A New Perspective
Rui Xavier
Hospital da Arrbida, Porto
Portugal

1. Introduction
Every rhinoplasty begins with the analysis of the patient. For this analysis it is very
important to carefully assess not only the nose, but also the facial features and the
morphological characteristics of the patients body. After this evaluation a list of the surgical
techniques necessary to achieve the desired nose is drawn and, according to this surgical
planning, the surgical approach is selected.
The surgical approach should provide adequate exposure of the nasal structures that are to
be addressed by surgery, and should allow the various surgical techniques to be executed
without difficulty and without jeopardizing the nasal structures. For providing adequate
exposure, however, every approach has to divide or to elevate nasal cartilaginous and soft
tissues structures, and this may interfere, to a certain degree, with the natural mechanisms
of tip support and strength. Several nasal structures are unanimously recognised as
contributing to the tip support. The factors influencing this support are usually classified as
the major and the minor tip support mechanisms. The major tip support mechanisms are: the
size, shape, thickness and resilience of the alar cartilages; the upper lateral cartilages
attachment to the cephalic margin of the alar cartilages; the attachment of the medial crura
footplates to the caudal septum. The minor tip support mechanisms are: the ligamentous
sling spanning the domes of the alar cartilages; the membranous septum; the cartilaginous
septal dorsum; the nasal spine; the sesamoid complex extending the support of the lateral
crura to the piriform aperture; the attachment of the alar cartilages to the overlying skin and
musculature. (3,4).
Recent studies have underscored the role of the upper lateral cartilages attachment to
the cephalic margin of the alar cartilages to maintain a strong tip support (5,6). It has
been demonstrated that this attachment is made of fibrous tissue consisting of dense
collagen fibers, all orientated in a single direction, thus fulfilling the criteria of a true
ligament (5).
Another study demonstrated that the most efficient way to release the tip as to be freely
moved is severing these fibrous attachments between the upper lateral and the alar
cartilages (6), thus highlighting the role of this ligament to the tip support. Every effort
should be made, therefore, to preserve these collagen fibres during rhinoplasty, in order not
to weaken the support of the nasal tip. This should be kept in mind while performing
rhinoplasty, as well as while choosing the approach for surgery.
46 Rhinoplasty

The three standard approaches for rhinoplasty are the non-delivery approach, the delivery
approach and the open approach (7).
The non-delivery or cartilage-splitting approach is very suitable to achieve minor
modifications of the nasal tip, such as a moderate increase in tip rotation or an improvement
in tip definition (3,8,9) and also provides good access to the upper two thirds of the nose,
particularly when reduction techniques to the dorsum are being planned. This approach
involves only one incision, a transcartilaginous incision.
The non-delivery approach is particularly suitable for patients with reasonable tip
symmetry, normal domal angles and normal or almost normal interdomal distance (3). The
great advantage of this approach is its simplicity and easiness to perform, with good and
predictable results (8), as it causes almost no interference to the natural mechanisms of tip
support (7,10).
The delivery approach is an elegant approach that allows more delicate tip work than the
non-delivery approach. Two incisions are usually made for this approach: an
intercartilaginous incision and a marginal incision.
This intercartilaginous incision may cause scarring at the valve area, if not made slightly
caudally to the caudal border of the upper lateral cartilages (9). It may also promote
weakening of one of the major support mechanisms of the nasal tip, the upper lateral
cartilage attachment to the cephalic margin of the alar cartilage (10,11).
Nevertheless, besides providing access to the upper two thirds of the nose, the delivery
approach is often used to correct bifidity or asymmetry of the tip, to achieve extra tip
rotation or to change tip projection (7,9). With the delivery approach, precise excision of
cartilage is possible, as well as it is possible to introduce and fixate cartilaginous grafts. It
is also possible to interrupt the continuity of the alar cartilages in order to change nasal tip
projection and rotation, or to enhance tip projection with a lateral crura steal (9). The
delivery approach allows an excellent exposition of the alar cartilages that may, thus, be
remodelled as necessary. This approach is particularly useful in patients with a non
triangular tip (on basal view), with wide domal angles and large interdomal distance
(3,8).
The open approach uses a marginal incision and an external (columelar) incision. The great
advantage of this approach is the superb visual control of every structure of the nasal
framework that it allows (7,12,13). Another advantage of the open approach is affording
an enhanced surgical exposure, facilitating nasal sculpturing by suturing or by the
introduction and fixation of different kind of grafts. Any modification of the cartilages can
be performed and the result may be easily assessed. The open approach allows maximal
exposure of the tip, improving diagnosis and facilitating correction of gross deformities
(11,14,15).
The extra time necessary for the approach and for carefully closing the incisions cannot be
considered a drawback of the open approach, and the interference that the open approach
causes to the mechanisms of tip support (3,10,13), although relevant, may be overcome by
using surgical techniques that reinforce this support at some stage of the procedure (10).
The open approach, however, does leave an extensive submucous wound area, leading to a
prolonged edema and to longer healing time (3); there may be sensory disturbances at the
tip area and there will be an external scar, which may be of concern for some patients and
that, eventually, may not be completely undistinguishable.
Modified Delivery Approach A New Perspective 47

Due to its maximal surgical exposure, improved diagnosis and facilitated correction of
deformities, the open approach is particularly useful for patients with marked asymmetry of
the tip, patients undergoing major reconstruction of the tip or of the upper two thirds of the
nose and patients whose complete diagnosis is still unclear after a careful preoperative
analysis of the nose (3,9).
The non-delivery approach, the delivery approach and the open approach are the three
standard approaches for rhinoplasty. Some surgeons always perform rhinoplasty by using
an open approach, others always use an endonasal approach; we believe that every facial
plastic surgeon should be familiar with all approaches, as the choice of the approach should
not be dictated by the preferences of the surgeon but, mainly, by the nasal deformities of the
patient and by the surgical techniques that have been planned in order to achieve an
improvement in nasal functioning and aesthetics.
The simplest approach that allows the planned surgical techniques to be performed without
difficulty should be selected, to cause the least disturbance to the tip support (3,7,13). The
surgeon must always weigh the surgical trauma caused by the approach against the surgical
exposure afforded by the approach. In other words, the approach should be as invasive as
necessary, but, at the same time, as non invasive as possible.
A frequent goal of rhinoplasty is achieving an improvement in tip definition; for this
purpose it is often advisable to resect the cephalic margin of the lateral crura of the alar
cartilages, sometimes combining this procedure with other techniques, such as single
dome or double dome sutures, or scoring or morselization of the cartilages. The
delivery approach is very appropriate to accomplish these manoeuvres, and is widely
used (3,9).
If the patient has long alar cartilages (in the cranial-caudal direction), it is particularly
important to resect a cephalic piece of the lateral crura to improve tip definition. In this
kind of cartilages, however, it may be difficult to deliver the alar cartilages without
twisting or tearing the most lateral part of the lateral crura and the intermediate crura or
even the dome area. The dome segment is usually the thinnest and most delicate portion
of the entire alar cartilage (16) and any weakening of this portion may endanger the
resilience of the cartilage, which could compromise the support of the nasal tip. When
planning surgery, the open approach may be chosen to overcome this; however, a
modified delivery approach may also be used, turning the exposure of the tip cartilages
easier and safer, and avoiding using an intercartilaginous incision, which could interfere
with the tip support.

2. Surgical technique
For the modified delivery approach a transcartilaginous incision is first used in each side of
the nose. The position of this incision must take into account that the exact amount of
cartilage to be resected may be difficult to assess at this stage, so care must be taken to leave
an appropriated sized cartilage caudal to the incision (figure 1). The cephalic piece of the
alar cartilage is dissected free in the vestibular and in the non-vestibular sides and resected
(figure 2). This procedure is repeated in the opposite side of the nose.
Then a marginal incision is made (figure 3), and the remaining alar cartilage is dissected in
the non-vestibular side and easily delivered (figure 4). After the same procedure is
48 Rhinoplasty

performed in the opposite side, both alar cartilages are delivered. At this stage of the
procedure the size of the remaining alar cartilages is assessed; if necessary, further cephalic
resection is done in order to achieve perfect symmetry or to achieve the desired size of the
alar cartilages (figure 5).
The rhinoplasty may then proceed with other surgical techniques to the alar cartilages,
which may be grafted, sutured or modified as considered necessary to achieve a good
functional and aesthetic result (figure 6). After addressing the upper two thirds of the nose,
at the end of surgery both the transcartilaginous and marginal incisions are closed with an
absorbable suture material.

Fig. 1. A transcartilaginous incision is first used, taking care to leave an appropriated sized
cartilage caudal to the incision

3. Comments
A large proportion of patients seeking rhinoplasty will benefit from surgery of the nasal tip.
This may involve major reconstruction for correction of gross asymmetry or deformity of the
tip cartilages, usually achieved by using an open approach. For most patients, however, the
nose will benefit from performing slight modifications in tip rotation or projection, from
correcting a bifid or boxy tip or from improving tip definition. These modifications can be
achieved by using an endonasal approach, usually a delivery approach.
Though very appropriate for performing these surgical manoeuvres, the delivery approach
has been criticized by some surgeons, and one of the reasons for this criticism is the
intercartilaginous incision usually used for this approach.
Modified Delivery Approach A New Perspective 49

If not placed slightly caudal to the caudal border of the upper lateral cartilages, the
intercartilaginous incision may lead to scarring of the valve area (9), which could
compromise the breathing capacity of the nasal cavity due to narrowing of the internal nasal
valve.
We have been using this modified delivery approach for several years without any
complications. Several clinical cases of patients operated on by using this approach have
previously been reported (1,2).
Another reason for criticizing the intercartilaginous incision is the damage produced by this
incision on the collagen fibers situated between the upper lateral cartilages and the cephalic
border of the alar cartilages. The importance of the attachment between these cartilages has
been well recognized for a long time and considered a major tip support mechanism.
Recently, this attachment has been described as a true ligament, due to the fact that it is
made of dense collagen fibers organised in a single direction (5).
The advantage of this modified approach over the traditional delivery approach is avoiding
the intercartilaginous incisions. The dense collagen tissue between the upper lateral and the
alar cartilages will not be severed by using a transcartilaginous incision, thus preventing
weakening of the tip support. It has been shown that dividing this fibrous tissue has much
more effect on releasing tip structures than dividing any other soft tissue important to the
tip support mechanisms (6), emphasising the importance of keeping this tissue to maintain a
strong tip support.

Fig. 2. The cephalic piece of the alar cartilage is dissected and resected
50 Rhinoplasty

Fig. 3. A marginal incision is made

Fig. 4. The remaining alar cartilage is dissected in the non-vestibular side and delivered
Modified Delivery Approach A New Perspective 51

Fig. 5. The remaining alar cartilages are delivered and compared; if necessary, further
resection is performed to achieve perfect symmetry or the desired size
We have been using this modification of the delivery approach for several years. In the
earlier cases, we used this modified delivery approach only for patients with long alar
cartilages (in the cranial-caudal direction) and a wide or bifid nasal tip. We felt that this kind
of tip required performing cephalic resection of the alar cartilages plus, if nothing else, a
double dome suture. We felt that this modification could make the delivery of long alar
cartilages easier and safer, as the cartilage would not be under tension or under a twisting
strength at any stage of the procedure. In more recent cases, we have been using this
approach for most cases of refinement of the nasal tip, as long as this involved more than
just cephalic resection of the alar cartilages. Thus, we have been using the modified delivery
approach in almost every case that we would, otherwise, be using the standard delivery
approach.
The purpose of this modification is combining the advantages of the non-delivery approach
with the advantages of the delivery approach in the same procedure, and avoiding an
intercartilaginous incision. Thus, the delivery of each alar cartilage is performed in two
stages: at the first stage a cephalic piece of the cartilage is resected; at the second stage the
remaining alar cartilage is delivered.
The exact amount of cartilage to be resected may be difficult to assess at the first stage, so it
is crucial to leave an appropriated sized cartilage caudal to the transcartilaginous incision.
At the second stage, after the delivery of the remaining alar cartilages on both sides, these
52 Rhinoplasty

are easily assessed and compared. Further cephalic resection of the alar cartilages may be
performed at this stage of the procedure, in order to achieve perfect symmetry or to achieve
the desired size of the cartilages.

Fig. 6. The other planned manoeuvres, such as domal suturing, are performed
By using first a transcartilaginous incision and then a marginal incision to deliver the
alar cartilages, this modified approach combines the reliability of the non-delivery
approach with the enhanced exposure of the more powerful delivery approach. By using
a transcartilaginous incision instead of an intercartilaginous incision, this modified
delivery approach does not promote weakening of one of the major tip support
mechanisms, the attachment of the upper lateral cartilages to the cephalic margin of the
alar cartilages.

4. Conclusion
In rhinoplasty it is often necessary to perform cephalic resection of the alar cartilages to
improve tip definition, sometimes combining this procedure with other surgical techniques
to the tip, such as single dome or double dome sutures.
The delivery approach may be appropriate to allow all these surgical techniques to be easily
executed. However, the intercartilaginous incision usually done for the standard delivery
approach may cause a weakening of the tip support by severing the dense collagen fibers at
the intercartilaginous region.
Modified Delivery Approach A New Perspective 53

A modified delivery approach may be a way to overcome these dangers, facilitating the
exposure of the tip cartilages. This modified approach, using a transcartilaginous and a
marginal incision, combines the reliability of the non-delivery approach with the enhanced
exposure of the delivery approach and avoids the dangers of the intercartilaginous
incision.
We have been using this modified delivery approach for several years, and found it
particularly useful for patients with long alar cartilages and a wide or bifid nasal tip. We
believe that, in this kind of tip, this modified approach is easier to perform and safer to the
tip support mechanisms.

5. References
[1] Xavier R. Tip rhinoplasty - a modified delivery approach. Rhinology 2009; 47:132-5.
[2] Xavier Rui. A modified delivery approach. In: Shiffman MA, Di Giuseppe A ed.
Advanced Rhinoplasty: Art, Science, and New Clinical Techniques. Berlin: Springer-
Verlag, in the press
[3] Tardy ME. Contemporary rhinoplasty: principles and philosophy. In: Behrbohm H,
Tardy ME ed. Essentials of Septorhinoplasty. Stuttgart-New York: Thieme, 2004: 37-
63
[4] Gassner HG, Sherris DA, Friedman O. Rhinology in rhinoplasty. In: Papel ID ed.
Facial Plastic and Reconstructive Surgery. Stuttgart-New York: Thieme, 2009: 489-
506
[5] Han SK, Lee DG, Kim JB, Kim WK. An anatomic study of nasal tip supporting
structures. Ann Plastic Surgery 2004; 52:134-9.
[6] Han SK, Ko HW, Lee DY, Kim WK. The effect of releasing tip-supporting structures in
short-nose correction. Ann Plastic Surgery 2005; 54:375-8.
[7] Nolst-Trenit GJ. Basic approaches and techniques in nasal tip surgery. In: Nolst-
Trenit GJ ed. Rhinoplasty 3rd Ed. The Hague: Kugler Publications, 2005: 87-96
[8] Tardy ME, Toriumi DM, Hecht DA. Philosophy and principles of rhinoplasty. In:
Papel ID ed. Facial Plastic and Reconstructive Surgery. Stuttgart-New York: Thieme,
2009: 507-528
[9] Nolst-Trenit GJ. Surgery of the nasal tip: intranasal approach. In: Papel ID ed. Facial
Plastic and Reconstructive Surgery. Stuttgart-New York: Thieme, 2009: 563-576
[10] Kim DW, Toriumi DM. Open structure rhinoplasty. In: Behrbohm H, Tardy ME ed.
Essentials of Septorhinoplasty. Stuttgart-New York: Thieme, 2004: 117-135
[11] Adamson PA, Litner JA. Open rhinoplasty. In: Papel ID ed. Facial Plastic and
Reconstructive Surgery. Stuttgart-New York: Thieme, 2009: 529-546
[12] Vuyk HD, Zijlker TD. Open-tip rhinoplasty. In: Nolst-Trenit GJ ed. Rhinoplasty 3rd
Ed. The Hague: Kugler Publications, 2005: 115-123
[13] Nolst-Trenit GJ, Vinayak BC. External rhinoplasty: the benefits and pitfalls. In:
Nolst-Trenit GJ ed. Rhinoplasty 3rd Ed. The Hague: Kugler Publications, 2005:
125-141
[14] Whitaker E, Johnson C Jr. The evolution of open structure rhinoplasty. Arch Facial
Plastic Surg. 2003; 5: 291-300
54 Rhinoplasty

[15] Farrior E. Dramatic refinement of the nasal tip. Otolaryngol Clinics of North America.
1999; 32: 621-636
[16] Oneal R, Beil R Jr, Schlesinger J. Surgical anatomy of the nose. Otolaryngol Clinics of
North America. 1999; 32: 145-181
 Part 3

Reconstructive Challenges
 5

Surgical Strategy for Secondary Correction

of Unilateral and Bilateral Cleft
Lip-Nose Deformities
Norifumi Nakamura
Department of Oral and Maxillofacial Surgery, Field of Maxillofacial Rehabilitation,
Kagoshima University Graduate School of Medical and Dental Sciences
Japan

1. Introduction
In the treatment of cleft deformities, restoring the symmetric and natural-shaped nose as
well as the symmetric and functional lip is important to allow patients to lead smooth social
lives. Recently primary rhinoplasty with presurgical orthopedic treatment for infants with
cleft lip and nose has been highlighted (Grayson, et al. 1999), and these techniques have
certainly improved nasal deformity and overall symmetry (Nakamura, et al. 2009).
However, definitive rhinoplasty may still be necessary as the child grows. Despite recent
developments in cleft surgery, the surgical modality for correction of cleft lip-nose
deformity that provides a desirable nasal form with long-term stability has not yet been
established. Surgeons have attempted cleft lip-nose correction, but they are often frustrated
by unsatisfactory results.
A considerable number of surgical modalities for definitive correction of unilateral and
bilateral cleft lip-nose deformities have been reported over the past half century. Generally,
it is argued that a clear understanding of the associated complex anatomical and
pathological abnormalities is required to obtain a desirable nasal form (Shih, et al. 2002). The
abnormalities of cleft lip-nose involve all components of the nose, including the facial
skeleton, cartilage, muscle, skin, subcutaneous tissue, and mucosal lining. To obtain
desirable and stable outcomes, secondary correction of the cleft lip-nose deformity should
approach each abnormality in each of the above components. Based on this concept, the
author has established the following strategy for secondary cleft lip-nose correction that
approaches each anatomical and pathological abnormality causing the main deformities of
unilateral and bilateral cleft lip-nose.

2. Treatment strategy for unilateral cleft lip-nose deformity

2.1 Anatomical and pathological characteristics of unilateral cleft lip-nose
Unilateral cleft lip (UCL)-nose deformity includes deviated columella, depressed nasal tip,
wide and snub nasal ala, and a flat and V-shaped nostril on the cleft side (Millard, 1976a).
The position of the nasal ala on the affected side often dislocates in a downward and distal
direction in relation to the inadequately unionized upper lip (Fig. 1A).
58 Rhinoplasty

A B

Fig. 1. Facial view (A) and three-dimensional CT finding (B) demonstrating characteristics of
UCL-nose deformity
When one considers the characteristics of unilateral cleft lip nose-deformities, the distal,
downward, and backward dislocation of the skeletal framework causes all components of
the lip and nasal tissue to be malpositioned three-dimensionally on the affected side (Fig. 1A
and Fig. 1B). Consequently, the upper and lower lateral cartilages dislocate distally and
downwardly, the attachment of the nasalis muscle is malpositioned and skin at the nostril
rim forms a web. Additionally, excessive stress over the nasal tip and dorsum causes growth
disturbances of the septal cartilage, resulting in a short columella and flared nasal tip on the
affected side.
To facilitate an understanding of these abnormalities, the unilateral cleft lip-nose can be
thought to be like a house built on a slope (Fig. 2). The center pole corresponds to the nasal
septum, the roof is the lower lateral cartilage and skin, the lateral pillar is the vestibule, and
the ground is the maxillary bone. In the normal nose, the ground is flat and the house can
stand upright (Fig. 2A), but in the unilateral cleft lip-nose, the house is on a slope and the
pole and roof incline toward the downward side (Fig. 2B). To create a straight house on a
slope, the center pole must stand upright in the center of the face, the pillar should be
expanded and roof should be lifted upward (Fig. 2C).

A) Normal nose B) UCL-nose C) Correction of UCL-nose

Fig. 2. Anatomical and pathologic abnormalities of UCL-nose; normal nose (A), UCL-nose
(B), and correction of UCL-nose (C) (Modified from Nakamura, Jpn J Oral Maxillofac Surg 2010)
Table 1 demonstrates the treatment strategy for unilateral cleft lip-nose, showing an
approach to each anatomical and pathological abnormality causing the main deformities of
Surgical Strategy for Secondary Correction of Unilateral and Bilateral Cleft Lip-Nose Deformities 59

unilateral cleft lip-nose: deviated columella, depressed and deviated nasal tip, wide and
snub nasal ala, and flat and V-shaped nonstril on the cleft side (Table 1). Therefore, the
authors secondary correction involves open rhinoplasty, septoplasty, repositioning of the
lower lateral cartilage, medial and upward advancement of the lip and nose components; the
nasal vestibular tissues, the nasal ala, nasalis muscle, and the upper part of the lip including
orbicular oris muscle, and nasal vestibular expansion with or without bone graft (Fig. 2C).

Table 1. Nasal deformity and treatment strategy for unilateral cleft lip-nose (Modified form
Nakamura, et al. J Oral Maxillofac Surg 2010)

2.2 Surgical procedures for correction of unilateral cleft lip-nose deformities (Fig. 3
and Fig. 4)
1. Open rhinoplasty is applied according to the bilateral reverse-U incision and
transcolumellar incision. A reverse-U incision is made on the outer skin slightly above
the nostril rim in order to lengthen the upper columella on the affected side (Fig. 3A and
Fig. 4A). The distal ends of the incision are extended into the nostril and connected to
the back cut incision along the nasal vestibule. The lower end of the back cut incision is
extended to the nasal floor and to the white lip along previous surgical scars, when
simultaneous correction of upper lip deformity is necessary.
2. Through the oral and nasal vestibular incision, supraperiosteal dissection surrounding
the piriform margin is performed on the affected side. This dissection provides 3D
movement of the nasal alar base and enables the medial-upward advancement of the
nasolabial components.
3. Deviation of the columellar base is corrected by supraperiosteal dissection around the
anterior nasal spine through the oral vestibular incision. When the base of the nasal
septum is severely deviated, the inferior edge of the septal cartilage is excised to allow
repositioning to the midline, and then it is secured to the small hole made at the
piriform bottom using a 4-0 Nylon thread (Fig. 4B and Fig. 5).
4. Reflecting the nose tip skin, the malpositioned lower lateral alar cartilage is exposed
from both the nasal skin and lining mucosa, and the distal ends of the lateral crura are
freed from the surrounding tissue (Fig. 3B and Fig. 4C). Since the corrected cartilage is
often insufficiently supported, a small, square cartilaginous strut approximately 8 - 10
mm x 15 mm is taken from the lower part of the nasal septum, and transferred to the
60 Rhinoplasty

anterior edge of the nasal septum; a caudal septal extension graft (Fig. 4D and Fig. 5).
When the growth of the nasal septum is too underdeveloped, free auricular cartilage is
used for a caudal septal extension graft. The medial crus of the lower lateral cartilage on
the affected side is repositioned in a slightly overlapped position on the upper lateral
cartilage and fixed symmetrically to the caudal septal extension graft using a 6-0 Nylon
thread (Fig. 4E and Fig. 5B).

Medial-upward
advancement

Mucosal graft

A B C
Fig. 3. Surgical procedures for correction of unilateral cleft lip-nose deformity (Nakamura, et
al. J Oral Maxillofac Surg 2010)

Fig. 4. Step-by-step procedures for correction of unilateral cleft lip-nose deformity

(Nakamura, et al. J Oral Maxillofac Surg 2010)
5. After the nasal tip skin is redraped, the nasal lining is advanced medially and upwardly
to cover the nostril dome (Fig. 3C). The excess skin at the nostril rim on the cleft side is
also reflected and pushbacked into the canopy of the nostril dome. The defect of lining
at the nasal vestibule caused by the above advancement is then covered by a free
Surgical Strategy for Secondary Correction of Unilateral and Bilateral Cleft Lip-Nose Deformities 61

mucosal graft donated from the buccal area or covered by the tissue advanced from the
bottom of the nasal floor (Fig. 3C)

A B
Fig. 5. Reposition of the lower lateral cartilage with a caudal septal extension graft
(Nakamura, et al. J Oral Maxillofac Surg 2010)
6. When simultaneous correction of upper lip deformity is carried out, the nasalis muscle
and the orbicularis oris muscle are separated along the previous scar. After dissecting
these muscles from the maxillary wall, the distal bundle of nasalis muscle is then
connected to the periosteum surrounding the anterior nasal spine, and the medial and
distal bundles of orbicularis oris muscle are connected in an overlapping manner using
a mattress suture technique (Fig. 3C). At the end of surgery, subcutaneous and
cutaneous suturing is carefully performed (Fig. 4F).

2.3 Pre- and postoperative views and three-dimensional observation of patients

treated for unilateral cleft lip-nose deformity
Pre- and postoperative photos and the three-dimensional (3D) color images of the patients
are demonstrated in figure 6 and figure 7. Preoperative views demonstrate the deviated
nasal tip, asymmetric and wide peak of the nasal hump and obviously small and flat nasal
ala on the affected side. The nostril on the affected side is flatter than that on the healthy side
in both patients. 3D color images indicate asymmetry of the alar groove and nasal tip more
visually. The top of the alar groove on the cleft side is dislocated distally and downwardly
resulting in a small snub ala.
Postoperative photos and 3D color images in the frontal and basal views demonstrate
symmetric nasal forms. The nasal tip projection is recovered in the center of the face and the
height and the appropriate contour of the nasal ala groove on the cleft side are improved
satisfactorily. The nostril demonstrates a symmetric and desirable form postoperatively. The
contour between the columella and the upper lip in the lateral view appears quite natural.
The author has performed secondary treatment of unilateral cleft lip-nose on more than 50
patients, and there have not been any serious complications such as necrosis of the skin flap,
infection, or airway obstruction, nor any obvious scars or deformities involving the upper
lip and/or columellar base in any patient.
62 Rhinoplasty

Fig. 6. Pre- and postoperative nasal views and 3D images of a female with UCLP whose
correction is shown in figure 4. (Nakamura, et al. J Oral Maxillofac Sug 2010)

Fig. 7. Pre- and postoperative nasal views and 3D images of a male with UCLP

3. Treatment of strategy for bilateral cleft lip-nose deformity

3.1 Anatomical and pathological characteristics of bilateral cleft lip-nose
Bilateral cleft lip (BCL)-nose deformity is characterized mainly by a columella with varying
degrees of shortness, a depressed nasal tip, bilateral dislocation of the alar cartilage, and
eversion of the alar bases (Fig. 8)(Millard, 1976b). When one considers the characteristics of
bilateral cleft lip-nose, the deformities might be basically considered the combined
characteristics of a unilateral cleft lip-nose on both sides, including varying degrees of
anterior overgrowth of the premaxilla. Due to the lateral, downward, and backward
dislocation of the bilateral skeletal framework, all components of the lip and nasal tissues
are also malpositioned three dimensionally. Consequently, the attachment of the nasal
muscle is malpositioned, bilateral major alar cartilages are separated distally and
downwardly, and nostril rim skin forms a web. Additionally, the excessive stress over the
nasal tip and dorsum causes growth disturbances of the septal cartilage, resulting in a short
Surgical Strategy for Secondary Correction of Unilateral and Bilateral Cleft Lip-Nose Deformities 63

columella and flared nasal tip. Therefore, it is more physiological to advance all nasal tip
components medially and upwardly after dissecting free from the dislocated anterior
maxillary wall, as in unilateral cleft lip-nose correction, and to supply lateral tissue to the
columella rather than the upper lip.

Fig. 8. Characteristics of BCL-nose deformity

The anatomical and pathological abnormality of the bilateral cleft lip-nose can also
explained by the metaphor of a house compressed by stress (Fig. 9). The basic principle is
the same as that for the unilateral cleft lip-nose. To create a normal form, the center pole in
the house should be extended at the center, and the roof advanced upwardly, and then the
pillar on each side should be extended. Most important, the stress should be removed,
which corresponds to pulling on the nasal tip due the shortage of columellar skin.

A) Normal nose B) BCL-nose C) Correction of BCL-nose

Fig. 9. Anatomical and pathologic abnormality of BCL-nose; normal nose (A), BCL-nose (B),
and correction of BCL-nose (C)
The author has established a surgical strategy based on the principle that the ideal technique
for secondary treatment of bilateral cleft lip-nose deformity should minimize damage to
either or both the upper and lower lip tissue as shown in Table 2. This strategy also
approaches each anatomical and pathological abnormality that causes the main deformities
of the bilateral cleft lip-nose: short columella, flat and flared nasal tip, wide and snub nasal
64 Rhinoplasty

alar, and flat and V-shaped nostril (Table 2). Therefore, the authors secondary correction
involves open rhinoplasty, repositioning of the lower lateral cartilages, a caudal septal
extension graft, medial and upward advancement of the lip and nose components, nasal
vestibular expansion, and columella lengthening using a nostril rim rotation flap, if
necessary.

Table 2. Nasal deformity and treatment strategy for bilateral cleft lip-nose (Modified from
Nakamura, et al. J Cranio-Maxillofac Surg 2011)

3.2 Surgical procedures for correction of bilateral cleft lip-nose deformities (Fig. 10
and Fig. 11)
1. Open rhinoplasty is applied according to the bilateral reverse U incision and
transcolumellar incision, but rim incisions on the bilateral side are made on the outer
skin slightly above the nostril rim in order to lengthen the upper columella. The distal
ends of the incision are extended into the nostril and connected to the back cut incision
along the posterior edge of the nasal vestibule (Fig. 10A and Fig. 11A).

free mucosal graft

A B
Fig. 10. Surgical procedures for correction of bilateral cleft lip-nose deformity (Nakamura, et
al. J Cranio-Maxillofac Surg 2011)
Surgical Strategy for Secondary Correction of Unilateral and Bilateral Cleft Lip-Nose Deformities 65

Fig. 11. Step-by-step procedures for correction of bilateral cleft lip-nose deformity
(Nakamura, et al. J Cranio-Maxillofac Surg 2011)
2. Through oral and nasal vestibular incision, supraperiosteal dissection surrounding the
piriform margin and lower border of the upper lateral cartilage is performed. These
dissections allow repositioning of the nasalis muscle at an adequate position on the
anterior maxillary wall and facilitate 3D medial-upward-frontal advancement of the
nasal alar base (Fig. 10B).
3. Reflecting the nose tip skin, the malpositioned lower lateral cartilages are exposed from
both the nasal skin and lining mucosa, and the distal ends of the lateral crura are freed
from the upper lateral cartilages (Fig. 11B). Cartilaginous strut is then transferred to the
anterior edge of the nasal septum to produce nasal tip projection. Medial crura of the
bilateral lower lateral cartilages are repositioned in a slightly overlapped position on the
upper lateral cartilage and fixed to the caudal septal extension graft symmetrically by a 6-0
Nylon thread (Fig. 11C). When the growth of the nasal septum is too underdeveloped to
use a cartilaginous graft, free auricular cartilage is transferred to the nasal tip.
4. To resolve the tightness of the skin envelope that often causes the collapse of the caudal
septal extension graft, subcutaneous fibrous tissue is widely dissected around the nasal
tip, and then elongated by the V-Y method at the columellar base. To produce the nasal
tip projection, the lateral parts of the subcutaneous fibrous tissue are dissected vertically
and molded on the nasal tip (Fig. 11D and E). When the nasal tip skin is redraped and skin
is insufficient to cover the base of columella due to the improved nasal projection,
inferiorly based small pedicle flaps (Ohishi, et al. 1996) are made from the rim skin below
the incision and rotated medially into the raw area of the columellar base (Fig. 12).
5. After repositioning the lower lateral cartilage, the nasal lining tissue is advanced
medially and upwardly to cover the nostril dome. The defects of lining at the nasal
vestibule caused by the upward advancement of the alar component are then covered
by a free mucosal graft donated from the buccal area (Fig. 10B and Fig. 12C).
6. At the end of the operation, subcutaneous and cutaneous suturing is carefully
performed (Fig. 11F), and sponge tube nasal stent is applied for 1 week postoperatively.
66 Rhinoplasty

A silicon nostril retainer (Koken Co., Tokyo, Japan) is then placed and kept in situ for at
least 3 months postoperatively.

Rim skin rotation flaps

mucosal graft
A B C
Fig. 12. Inferiorly based rim skin rotation flap for columella lengthening (Nakamura, et al. J
Cranio-Maxillofac Surg 2011)

3.3 Pre- and postoperative views and three-dimensional observation of patients

treated for bilateral cleft lip-nose deformity
Pre- and postoperative views and 3D color images of patients treated for bilateral cleft lip-
nose deformity are shown in figure 13 and figure 14. Preoperative photos and 3D images
demonstrate the short columella and flattened nasal tip in both patients. The frontal and
oblique 3D color images indicate wide peaked nasal tip demonstrating a pseudo nasal hump
visually. Bilateral nasal alas are almost symmetric but the nasal alar grooves on both sides
are small demonstrating snub forms.
Postoperative photos and 3D color images demonstrate symmetric nasal forms with
adequately projected nasal tip by successful columella lengthening in both patients. The
appropriate contours of the nasal ala groove on both sides are symmetrically expanded
resulting in a natural transition from nasal tip to ala.

Fig. 13. Pre- and postoperative nasal views and 3D images of a male with BCLP whose
correction is shown in figure 11 (Nakamura, et al. J Cranio-Maxillofac Surg 2011)
Surgical Strategy for Secondary Correction of Unilateral and Bilateral Cleft Lip-Nose Deformities 67

Fig. 14. Pre- and postoperative nasal views and 3D images of a male with BCLP (Modified
from Nakamura, et al. J Cranio-Maxillofac Surg 2011)
The author has performed secondary treatment of bilateral cleft lip-nose using these
techniques on more than 20 patients. There were no wide necroses of the skin flap, infection,
airway obstruction, nor any obvious scars or deformities in the upper lip and/or columellar
base in any patient. A small area of necrosis at the tip of the nostril rim rotation flap was
observed in some patients, and the most persistent postoperative problem was contraction
of large free mucosal graft in the vestibular lining.

4. Benefits and limitations of the authors correction for unilateral and

bilateral cleft lip-nose
Regarding the treatment of unilateral cleft lip-nose, several benefits have been demonstrated
from our previous data of pre- and postoperative 3D observations (Okawachi, et al. 2011).
First, repositioning of the open reduction of the lower lateral cartilage with slight
overlapping of the upper lateral cartilage with the caudal septal extension graft can provide
a symmetric and projected nasal tip form. Second, repositioning of the septal cartilage
through an oral vestibular incision recovers the nasal midline in half of the nose. Third,
medial-upward advancement of the nasolabial components with vestibular expansion
repositions the malattached nasalis muscles on the affected side and provides a symmetric
and expanded nasal alar form.
One of the most serious problems of the nose is a deviated and depressed nasal tip. There
are numerous modalities for unilateral nasal tip correction, and many previous reports
mainly focused on correction of the nasal repositioning, and molding (Spira, et al. 1970,
Millard, 1976a, Salyer, 1992). In the authors nose correction procedures, nasal tip correction
is achieved by repositioning of the lower lateral cartilage through open rhinoplasty and a
caudal septal extension graft, and these procedures are the same as those previously
reported (Byrd, et al. 1997, Shih, et al. 2002, Rettinger, et al. 2002). For a caudal septal
extension graft, the author favors septal cartilage donated from the lower part of the nasal
septum because of its straight form and hardness, but when the growth of the nasal septum
is too underdeveloped, free auricular cartilage is used. During surgery the affected lower
68 Rhinoplasty

lateral cartilage is carefully repositioned to a symmetric position to avoid an overprojected

nose by measuring the nasolabial angle during surgery. Since the nasolabial angle in Japanese
adults (95-100) is smaller than that of Caucasians (90-110) (Ozumi, 2006), excessive projection
of the nasal tip provides an undesirable nose form. Therefore, the author has prepared an
original metal scale to measure the nasolabial angle during the surgery. The metal scale had
sample corners with angles of 90, 100, 110, 120, and 130 (Fig. 15). When the angle was
greater than the Japanese average, the position of the strut graft can be changed during
surgery; consequently an undesirable overprojection of the nasal tip can be avoided.

Fig. 15. Original metal scale for measuring nasolabial angle intraoperatively (Nakamura, et
al. J Oral Maxillofac Surg 2010)
Another conspicuous deformity of unilateral cleft lip-nose is the small and deviated nasal
ala on the affected side. Even though correction of the nasal tip projection is fully achieved,
asymmetric and poorly expanded nasal ala is often persistent in patients with unilateral cleft
lip. It is considered that the nasal alar form is affected by not only alar cartilage but also
anomalies of the surrounding tissues, such as tightness of the skin envelope, dislocated
nasalis muscle, and insufficient vestibular lining. Therefore, it is essential to advance the
nasal components upwardly repositioning the nasalis muscles as well as reconstruct the
nasal cartilages for treatment of a small ala. Vestibular expansion also ensures prevention of
postoperative collapse of the support of the lower lateral cartilage. Additionally, the
improvement of the maxillary platform by bone graft is important to correct the dislocated
nasal ala. The author performs secondary bone graft in the alveolar cleft and anterior surface
of the piriform margin at approximately 9-11 years of age. Furthermore, when backward
dislocation of the nasal alar base is remarkable at the secondary correction of nose, a veneer
graft of cortical bone donated from the anterior edge of the mandibular ramus is used to
mold the area around the piriform margin. However, in the authors experience, a medial
and upward advancement of nasolabial components and reposition of the nasalis muscle is
more effective than bone graft to correct a small nasal ala on the affected nose.
Regarding secondary treatment of bilateral cleft lip-nose, there have been a considerable
number of surgical modalities reported for bilateral cleft lip-nose correction, and many of
Surgical Strategy for Secondary Correction of Unilateral and Bilateral Cleft Lip-Nose Deformities 69

these methods have focused on elongation of the short columella by a forked-flap technique
(Millard, 1976b), Cronins (1958) and Converses (1957) method, and advancement of the
prolabium into the columella in combination with an Abbe flap (Yonehara et al, 2008). For
correction of short columellar skin, we perform bilateral reverse-U incision when the skin
shortage is slight or mild, and a nostril rim skin rotation flap is combined when the
columella is extremely short (Ohishi, et al, 1996). V-Y elongation of the fibrous tissue in the
columellar base is also combined because tension from this often disturbs the nasal tip
projection. This technique has several advantages: 1) the flap utilizes the web skin below the
incision of the nostril rim; 2) there is no tissue supply needed and no additional scar on the
upper lip as a result; and 3) good color matching and the natural contour at the columella-
labial junction are possible and no conspicuous scar is observed on the columellar base.
Furthermore, 4) the surgical procedure for columella lengthening can be selected from
bilateral reverse-U incision alone or in combination with nostril rim skin flap, depending on
the severity of the shortage of columellar skin (Nakamura, et al. 2011). Disadvantages of this
technique include the fragility and relatively small size of the nostril skin flap. A small area
of necrosis at the tip of the nostril rim rotation flap resulting in postoperative scar
contraction of the flap tends to create an uneven contour of columella.
One of the challenges in augmentation rhinoplasty is the tissue contracture that has
occurred prior to framework surgery, especially in bilateral cleft lip-nose. Tightness of the
skin envelope often limits a space for repositioning the lower lateral cartilage and molding
the soft tissues around the nasal tip area, even the wide nasal undermining is carried out. To
resolve this problem, the author carefully performs nasal undermining along a single plane
beyond the lower part of the upper lateral cartilage and piriform margin that enables nasal
tissue advancement providing reattachment of the nasalis muscles in a higher position on
the anterior maxillary wall. When these procedures are completed, sufficient enlargement of
the skin envelop for nasal tip augmentation that is tolerated without inducing or attenuation
of the overlying skin can be achieved.
Complications resulting from our correction of bilateral cleft lip-nose deformity were not
serious, but the most persistent postoperative problem was postoperative contraction of
large free mucosal graft in the vestibular lining. Therefore, a sufficient supply for vestibular
lining is thought to be required, and when lip repair is accompanied, it is more reliable to
advance the tissue at the nostril floor upwardly to close the defects of the vestibular lining in
order to avoid the risk of scar contraction of the grafted tissue. Additionally, the use of
vasuclularized mucosal flaps that may be harvested from the nasal interior (e.g. from
septum, turbinates, nasal floor, etc.) might be less prone to contracture than the free mucosal
graft (Burget and Menick, 1989). Longer application of the nasal stent will be also useful to
maintain the nasal form.

5. Conclusion
Finally, the author concludes that our surgical strategy for secondary correction of unilateral
and bilateral cleft lip-nose is useful for providing satisfactory results, producing symmetric
and projected nasal tip and ala without damaging the upper lip tissue for Asian patients.
This approach may also be useful in Caucasian patients, when the columella is not too short.
Repositioning of the nasalis muscle and sufficient expansion of the nasal vestibule as well as
reconstruction of the nasal cartilage are important for correction of unilateral and bilateral
cleft lip-nose deformity.
70 Rhinoplasty

6. References
Burget GC and Menick FJ: Nasal support and lining: The marrige of beauty and blood
supply. Plast Reconstr Surg 84:189, 1989.
Byrd HS, Andochick S, Copit S, Waltom KG: Septal extension grafts: A method of
controlling tip projection shape. Plast Reconstr Surg 100:999, 1997.
Converse JM: Corrective surgery of the nasal tip. Laryngoscope 67:16, 1957.
Cronin TD: Lengthening columella by use of skin from nasal floor and alae. Plast Reconstr
Surg 21:417, 1958.
Grayson BH, Santiago PE, Brecht LE, Cutting CB: Presurgical nasoalveolar molding in
infants with cleft lip and palate. Cleft Palate-Craniofac J 36:486, 1999.
Millard DR Jr: The anatomy of the secondary deformity of the unilateral cleft lip nose. In:
Cleft Craft. The evolution of its surgery. Vol. I, The Unilateral Deformities. Boston,
Little, Brown and Company, 1976a, p629.
Millard DR Jr: The anatomy of the secondary bilateral nasal deformity. In: Cleft Craft. The
evolution of its surgery. Vol. II, The Bilateral and Rare Deformities. Boston: Little,
Brown and Company 1976b, P477.
Nakamura N, Sasaguri M, Nozoe E, Nishihara K, Hasegawa H, Nakamura S: Postoperative
nasal forms after presurgical nasoalveolar molding followed by medial-upward
advancement of the nasolabial components with vestibular expansion for children
with unilateral complete cleft lip and palate. J Oral Maxillofac Surg 67:2222, 2009.
Nakamura N, Okawachi T, Nishihara K, Hirahara N, Nozoe E: Surgical technique for
secondary correction of unilateral cleft lip nose deformity Clinical and three
dimensional observations of pre- and postoperative nasal forms-. J Oral Maxillofac
Surg 68:2248, 2010.
Nakamura N: Minimally invase treatment of unilateral cleft lip nose deformity by pesurgical
nasoalveolar molding followed by medial-upward advancement of nasolabial
components (in Japanese with English abstract). Jpn J Oral Maxillofac Surg 56:618, 2010.
Nakamura N, Sasaguri M, Okawachi T, Nishihara K, Nozoe E: Secondary correction of
bilateral cleft lip nose deformity clinical and three-dimensional observations on
pre- and postoperative outcomes-. J Cranio-Maxillofacial Surg 39:305, 2011.
Ohishi M, Nakamura N, Yoshikawa H, Goto K, Honda Y: A new method of columella
lengthening for correction of cleft lip nose deformity (Abstract). J Cranio-Maxillofac
Surg 24:84, 1996.
Okawachi T, Nozoe E, Nishihara K, Nakamura N: 3-Dimensinal analyses of outcomes
following secondary treatment of unilateral cleft lip nose deformity. J Oral
Maxillofac Surg 69:322, 2011.
Ozumi K: Aesthetic surgery of the nasal tip and columella (in Japanese with English abstract).
Keisei Geka 49:663, 2006.
Rettinger G, OConnell M: The nasal base in cleft lip rhinoplasty. Facial Plast Surg 18:165, 2002.
Salyer, KE: Early and late treatment of unilateral cleft nasal deformity. Cleft Palate-Craniofac J
29:556, 1992.
Shih CW, Sykes JM: Correction of the cleft-lip nasal deformity. Facial Plast Surg 18:253, 2002.
Spira M, Hardy SB, Gerow FJ: Correction of nasal deformities accompanying unilateral cleft
lip. Cleft Palate J 7:112, 1970.
Yonehara Y, Mori Y, Chikazu D, Saijo H, Takato T: Secondary correction of bilateral cleft lip
and nasal deformity by simultaneous placement of an Abbe flap, septal cartilage
graft and cantilevered iliac bone graft. J Oral Maxillofac Surg 66:581, 2008.
 6

Thin Nasal Shell

Paul OKeeffe
Paul J. O'Keeffe Pty Ltd, Brookvale, NSW
Australia

1. Introduction
The Medpor Nasal Shell, available from Porex Surgical, Inc., now a Stryker company, was
designed to reconstruct a saddle nose and produce an anatomically correct shape. The
breakdown of the nasal shape that was used is illustrated in Figure 1. The shell does not
extend into the tip in order to allow normal sideways movement of the tip.

Fig. 1. Analysis of nasal shape for implant mould manufacture

The original version was first implanted in March 1999. It was thicker than the current thin
shell as seen in Figure 2 and it came with Medpor inserts that could be used to fill the void
beneath the shell, Figure 3. Both thick and thin shells are provided with a blue silicone
template Figure 4 that can be inserted and then trimmed to a suitable dimension for the
particular case. The silicone template is removed and placed over the actual implant for
accurate trimming.
Eighty thick implants were placed between March 1999 and April 2005. The reconstructed
noses were excellent aesthetically, Figure 5, and the nose tips were naturally flexible.
Unfortunately, the movement between the reconstructed nasal pyramid and the nose tip
resulted in implant exposure in 3 cases. The hard edge of the implant eroded through the
underlying lining, Figure 6. Trimming the exposed Medpor initially corrected the problem
72 Rhinoplasty

but re-exposure and infection occurred months later. These infected implants were removed
and the nasal pyramids were reconstructed with cartilage grafts.

Fig. 2. Original thick Nasal Shell on left and new thin version on right

Fig. 3. Original Nasal Shell with inserts

Fig. 4. Blue silicone template on left and thin shell on right

Thin Nasal Shell 73

The thin Medpor Nasal Shell was designed to overcome the problems of the thicker and
stiffer original Nasal Shell. The Medpor is universally thin allowing for a greater trimming
of the implant, Figure 7. The implant is used now more as a cartilage graft forming device.
Cartilage fragments are placed in the void beneath the thin shell and are expected to
consolidate and grow to fill the void, Figure 8. If necessary, the Nasal Shell could then be
removed leaving the patient with a perfectly shaped nasal pyramid. To date, very few
implants have been removed but one was in response to recurrent sterile effusions. The shell
was removed 13 months after implantation leaving a well formed nose Figure 9.

a) b)

c) d)
Fig. 5. a and b show patient with a saddle nose, c and d show the post-operative result with
the original Nasal Shell
The Thin Nasal Shell was first implanted in April 2004 and, since then, 98 have been placed.
Every implant was trimmed, usually 25%, but sometimes more than this. The trimming is
done mostly at the caudal end of the implant where a cartilage extender graft is attached,
Figure 10. The implant composite is placed over the existing deformed nasal pyramid and
then cartilage fragments are placed in the void.
74 Rhinoplasty

Fig. 6. Red area depicts exposed edge of Nasal Shell

Fig. 7. A trimmed Thin Nasal Shell

Fig. 8. A Thin Nasal Shell in situ with a cartilage extender graft and diced cartilage in the
void
Thin Nasal Shell 75

a) b)

c) d)

e) f)
Fig. 9. a, b and c show a patient with a twisted costal cartilage graft in the nasal dorsum. d,
e and f show post-operative result after removal of the implant. The cartilage graft
associated with the implant has consolidated into a shape the patient is happy with
76 Rhinoplasty

Fig. 10. Cartilage extender graft attached to implant

2. Technique
Nasal reconstruction with the Thin Medpor Nasal Shell plus cartilage graft is usually
performed under general anaesthesia. The anaesthetist administers an intravenous dose of
antibiotic at the commencement of the procedure, usually cephalothin sodium, 1g.
Cartilage is harvested from the septum, ears or ribs, in that order of preference. The nose tip
is reconstructed by placement of cartilage graft as necessary before proceeding to
reconstruction of the pyramid.
A blue silicone template comes with the Thin Medpor Nasal Shell, Figure 4. It can be placed
over the nasal pyramid via intercartilaginous incisions. The template is trimmed to a
suitable size for the nasal reconstruction. The template is then removed and used as a guide
for trimming the Medpor implant.
The Medpor is trimmed in two stages, first to match the size of the template and second to
trim back the caudal edge of the implant to expose an attached cartilage graft. The initially
trimmed implant is soaked in antibiotic solution, 1g cephalothin sodium in 5ml normal
saline. The cartilage graft is then sutured beneath the distal portion of the implant using 6-0
Prolene sutures. The implant is then further trimmed to leave the cartilage graft projecting
beyond the implant edge as an extender graft, Figure 11.

Fig. 11. Cartilage extender sutured to implant with 6/0 Prolene sutures
Thin Nasal Shell 77

Fig. 12. Inserting diced cartilage into the void beneath the implant with a cut off 1ml syringe

a) b) c)

d) e) f)
Fig. 13. a, b and c show a patient with a saddle nose. d, e and f show post-operative result
following reconstruction with Thin Nasal Shell and cartilage grafts
78 Rhinoplasty

The blue silicone template is reinserted into the nose and then partially extracted. The Nasal
Shell and attached cartilage graft is then carefully inserted into the nose by sliding it over
the template. The template is then removed.
Cartilage fragments are placed beneath the implant to partially fill the void. Figure 12. It is
important to never overfill the void with cartilage fragments1 as they act like ball bearings
and the implant is likely to displace. The implant can be secured by suturing the cartilage
extender graft to the nasal septum. Some of the antibiotic solution used for soaking the
implant is drawn up and injected in the pocket over the implant.
Incisions are sutured with 4-0 plain catgut and a suitable nasal splint is applied. Post-
operative antibiotics are given intravenously while an intravenous line is in place and then
oral antibiotics are administered, usually Keflex 500mg three times a day for five days.

a) b)

c) d)
Fig. 14. a and b show a patient with a saddle nose and operative plan drawn on the photos.
c and d show post-operative result following reconstruction with Thin Nasal Shell and
cartilage grafts
Thin Nasal Shell 79

3. Results
There have been no exposures or infections of the 98 Thin Medpor Nasal Shells. Some
implants displaced presumably due to over packing cartilage fragments in the void beneath
the implant. Those implants were repositioned. The remaining implants have been stable
since restricting filling of the void to approximately 60% with fragmented cartilage.
One patient had recurrent sterile effusions, Figure 9. This implant was removed 13 months
after placement and the effusions disappeared. The resultant nasal shape was excellent and
has been maintained indicating consolidation of the graft beneath the implant.
Airways have been improved by placement of the Thin Medpor Nasal Shell. The implant
acts as an umbrella and maintains patency of the nasal valves.

a) b)

c) d)
Fig. 15. a and b show a patient with a saddle nose. c and d show post-operative result
following reconstruction with Thin Nasal Shell and cartilage grafts
Patients who had misgivings about placement of an implant in their nose were reassured
that their implant could be removed after consolidation of the graft beneath it. None of these
patients have come forth postoperatively to request removal of their implant. Should
removal ever become necessary it is possible because the outer surface of the implant,
80 Rhinoplasty

although perforated, is smooth. Separation from the overlying tissue is relatively easy. The
under surface is rougher but separation from deep tissue is easy enough after outer surface
separation because the shell is thin and very little tissue is entrapped into its structure.
A typical patient might have a saddle nose following trauma, Figures 13a, 13b, 13c. The
patient is obviously happy with the postoperative result, Figures 13d, 13e, 13f. Figures 14 to
16 show similarly satisfied patients. All have improved airways.

a) b)

c) d)
Fig. 16. a and b show a patient with a saddle nose and the detailed operative plan. c and d
show post-operative result following reconstruction with Thin Nasal Shell and cartilage
grafts

4. Discussion
A conventional approach to reconstruction of a saddle nose is to use the patient's own tissue
with preference for septal cartilage before ear cartilage, ear cartilage before costal cartilage
and costal cartilage before bone graft2. Bone graft is least preferred due to its tendency to
atrophy over time3,4,5,6. Foreign implants have been shunned for nasal reconstruction by
many surgeons in North America7,8 but their use in Asia is more accepted9,10. An
Thin Nasal Shell 81

explanation for this difference is the likelihood of trauma being involved in the case of a
Caucasian patient who has a saddle nose11. The scarred nasal tissue may allow easier ingress
of bacteria into the pocket containing the implant and result in a relatively high post-
operative infection rate. Bacteria in a pocket containing cartilage or bone graft are less likely
to result in clinical infection12,13.
Restricting the reconstruction options for a Caucasian patient may not always produce the
best result. Available cartilage graft may not perfectly match the ideal shape of a nasal
pyramid and bone grafts are often made too large cephalically and they are too hard
caudally. It is preferable to reconstruct the nasal pyramid with an object that matches
normal shape and which has bony consistency in its cephalic portion and cartilaginous
consistency in its caudal portion14. The Thin Nasal Shell with a cartilage extender attached
meets this need.
Previous nasal implants have been solid objects that rest on the nasal pyramid. Pressure
atrophy of the underlying bone15,16 can occur resulting in a flatter saddle nose than before
should the implant be removed to treat infection. The Thin Nasal Shell overcomes this
problem by being a shell under which cartilage fragments can be placed in order for them to
consolidate into an ideal shape. The nose will be a better shape than before should it be
necessary to remove this implant.
The Nasal Shell was specifically designed to reconstruct only the nasal pyramid, not the nose
tip. The purpose was to simulate a natural nose and allow natural movement of the tip. This
limits the possibility of changing the position of the tip but, of course, a long cartilage extender
can be attached in order to push the tip caudally and lengthen a short nose. In any case, more
cartilage will be available for grafting into the tip because less is used in the pyramid17.
Familiarity with the Nasal Shell advances its position on the surgeons preference list of
reconstruction options. Initially the shell will be on the bottom of the list but after rewarding
results are seen it will move up the list. The author places the thin Nasal Shell plus cartilage
graft after septal or auricular cartilage alone. It is far superior to bone grafts in the authors
experience over 40 years.
The elegance of results makes the shell suitable for patients with thin skin. Poorly shaped
bone or cartilage grafts can be obvious unless masked with dermis or fascia grafts18,19. It is
rarely necessary to place such masking grafts over a nasal shell.

5. Conclusion
The Thin Medpor Nasal Shell used in conjunction with cartilage grafts is an excellent means
for reconstruction of the nasal pyramid. The resultant nasal shape is anatomical and the
umbrella effect of the implant ensures an unobstructed airway. Less donor cartilage is
needed for nasal pyramid reconstruction thereby reducing donor site morbidity and leaving
more cartilage graft for associated tip reconstruction.

6. References
[1] Erol, . Onur. The Turkish Delight: A Pliable Graft for Rhinoplasty Plastic &
Reconstructive Surgery. 105(6):2229-2241, May 2000.
[2] Sajjadian, Ali; Rubinstein, Roee; Naghshineh, Nima. Current Status of Grafts and
Implants in Rhinoplasty: Part I. Autologous Grafts Plastic & Reconstructive
Surgery. 125(2):40e-49e, February 2010
82 Rhinoplasty

[3] Phillips, J. H., and Rahn, B. A. Fixation effects on membranous and endochondral onlay
bone-graft resorption. Plast. Reconstr. Surg. 82: 872, 1988.
[4] Holmstrm, Hans; Gewalli, Fredrik. Long-Term Behavior of Three Different Grafts in
Nasomaxillary Reconstruction of Binder Syndrome: An Analysis by Digitalized
Measurements Plastic & Reconstructive Surgery. 122(5):1524-1534, November 2008.
[5] Farina, R., and Villano, J. B. Follow-up of bone grafts to the nose. Plast. Reconstr. Surg.
48: 251, 1971
[6] Rune, B., and Aberg, M. Bone grafts to the nose in Binders syndrome (maxillonasal
dysplasia): A follow-up of eleven patients with the use of profile roentgenograms.
Plast. Reconstr. Surg. 101: 297, 1998
[7] Ziv M. Peled, Anne G. Warren, Patrick Johnston, Michael J. Yaremchuk. The Use of
Alloplastic Materials in Rhinoplasty Surgery: A Meta-Analysis. Plast. Reconstr.
Surg. 121: 85e, 2008.
[8] Daniel, R. K. The role of diced cartilage grafts in rhinoplasty. Aesthetic Surg. J. 26: 209,
2006
[9] Deva, A. K., Merten, S., and Chang, L. Silicone in nasal augmentation rhinoplasty: A
decade of clinical experience. Plast. Reconstr. Surg. 102: 1230, 1998.
[10] Lam, S. M., and Kim, Y. K. Augmentation rhinoplasty of the Asian nose with the bird
silicone implant. Ann. Plast. Surg. 51: 249, 2003.
[11] Herbst, Andrew. Extrusion of An Expanded Polytetrafluoroethylene Implant After
Rhinoplasty Plastic & Reconstructive Surgery. 104(1):295-296, July 1999.
[12] Maas CS, Monhian N, Shah SB. Implants in rhinoplasty. Facial Plast Surg. 1997;13:279
290.
[13] Sajjadian, Ali; Naghshineh, Nima; Rubinstein, Roee. Current Status of Grafts and
Implants in Rhinoplasty: Part II. Homologous Grafts and Allogenic Implants Plastic
& Reconstructive Surgery. 125(3):99e-109e, March 2010.
[14] Daniel, R. K. Rhinoplasty and rib grafts: Evolving a flexible operative technique. Plast.
Reconstr. Surg. 94: 597-609, 1994
[15] Yanagisawa, Akihiro; Nakamura, Toshitaka; Arakaki, Minoru; Yano, Hiroki; Yamashita,
Shunichi; Fujii, Tohru. Migration of Hydroxyapatite Onlays into the Mandible and
Nasal Bone and Local Bone Turnover in Growing Rabbits Plastic & Reconstructive
Surgery. 99(7):1972-1982, June 1997.
[16] Matarasso, Alan; Elias, Arthur C.; Elias, Richard L. Labial Incompetence: A Marker for
Progressive Bone Resorption in Silastic Chin Augmentation: An Update Plastic &
Reconstructive Surgery. 112(2):676-678, August 2003.
[17] Hodgkinson, Darryl J. Cranial Bone Grafts for Dorsal Nasal Augmentation Plastic &
Reconstructive Surgery. 104(5):1570, October 1999.
[18] Miller, Timothy A Temporalis Fascia Grafts for Facial and Nasal Contour
Augmentation. Plastic & Reconstructive Surgery. 81(4):524-533, April 1988.
[19] Guerrerosantos, J. Temporoparietal free fascia grafts in rhinoplasty. Plast. Reconstr.
Surg. 74: 465, 1984.
 7

Surgical Management of Nasal Hemangiomas

Aleksandar Vlahovic
Plastic, Aesthetic and Reconstructive Surgery, Belgrade
Serbia

1. Introduction
Vascular anomalies are seen in all branches of medicine and surgery. The term vascular
anomaly is necessarily broad, encompassing lesions of skin and viscera and excluding
abnormalities of the heart and large arteries and veins [1]. A biologic classification of
vascular anomalies described in 1982 by Mulliken and Glovacki, correlates the cellular
features of vascular anomalies with clinical characteristics and natural history [1,2]. Vascular
anomalies of infancy and childhood are divided into two major categories: 1) tumors (most
being hemangiomas) and 2) vascular malformations [1].
The typical infantile hemangiomas (IHs) appears postnataly and evolve through 3
predictable stages: a rapidly proliferating stage (generally lasting 8 to 12 months), followed
by prolonged involuting phase (1 to 7 years), entering the involuted phase characterized by
fibrofatty residuum [1,3]. Early proliferative-stage hemangiomas are composed of well-
defined, but noncapsulated, masses of plump endothelial cells and attendant pericytes that
form small lumina containing erythrocytes. Even in early lesional stage, endothelium posses
immunophenotypic and ultrastructural features of mature endothelium including
immunoreactivity for CD31, CD 34, factor VIII- related antigen Ulex europeaus lectin I, VE-
cadherin, HLA-DR, and vimentin. GLUT 1 is specific and useful immunohistochemical
marker for hemangiomas during all phases of these lesions [3]. The typical IHs appears
postnatally, grows rapidly, and regresses slowly. The term congenital hemangioma was
introduced to denote a vascular tumor that had grown to its maximum size at birth and
does not exhibit accelerated postnatal growth. There are at least two major subgroups:
rapidly involuting congenital hemangioma (RICH), and noninvoluting congenital
hemangioma (NICH) [4].
Infantile hemangiomas (IHs), are the most common benign, soft tissue tumors of infancy
which affect between 4 and 12% of all Caucasian [1,5,6]. The prevalence among Asians and
black infants is considerably less [5]. There is a 3:1 predilection for the female sex, and they
are weakly associated with prematurity [68]. The pathophysiologic mechanisms leading to
endothelial cells proliferation and involution are poorly understood [6,7]. Current theories
focus on progenitor cells, development field defects, placental involvement, derangement of
angiogenesis and mutations in the cytokine regulatory pathway [6,7]. Involution coincides
with increased apoptosis of endothelial and stromal cells [7].
Most IHs involve the head and neck (up to 60%) [1]. Facial IHs are associated with parental
reactions of disbelief and fear, particularly in the growth phase. Most parents expressed a
desire to have the hemangioma removed before the children entered school. The strangers
84 Rhinoplasty

often raised the question of child abuse, and some parents indicated that their children try to
hide their lesions from the other [8].
Clinical appearance allows differentiation between focal, indeterminate and segmental IHs.
Size, location and subtype were major factors that predicted complications and need for
treatment [9]. Focal type had a tumor-like appearance and a less common diffuse type had a
segmental distribution pattern and plaquelike appearance. Segmental IHs exhibit worse
prognosis with more complications (ulceration, airway obstruction) [5,9]. Although
subglottic hemangiomas are rare, they are extremely dangerous due to their location and
rapid growth during the proliferative phase. Beard distribution of hemangioma is highly
suspected for subglottic localization of hemangioma [5,6,23].
Most IHs are small, harmless tumors that should be allowed to involute without treatment.
Generally, treatment is instituted for complications within the IHs itself (such as ulceration,
bleeding, infection), or impairments caused by the hemangioma (amblyopia, impaired
breathing, feeding difficulties, heart failure), and the wait-and-see medical management
policy for these hemangioma should be replaced by a more active approach. [9,10]. More
than half of IHs will involute with a poor result and therefore required a corrective surgery
[11]. Haggstrom et al. stated that 43% patients with a facial hemangioma received treatment
of some kind [9].
The management of hemangioma is an area of great controversy [6]. Current options are
conservative treatment (corticosteroids, interferons, hemiotherapy, propranolol), laser
treatment, and surgical treatment [6,927]. Corticosteroids were generally accepted to be the
first-line therapy for hemangiomas [6]. They can be used orally, intralesionally,
intravenously or topically. Interferons were usually reserved for serious cases in which
steroids were contraindicated, have failed, or in severe complications [12]. Unfortunately,
severe neurotoxicity (spastic diplegia) was found to be severe adverse effect [6].
Antineoplastic agents were also successful in treatment of hemangioma, because of their
proliferative nature (bleomycin, cyclophosphamide, vinristine) but this treatment should be
reserved for infants with hemangioma demonstrating aggressive behavior characteristics
[6]. A wide variety of lasers have been used with a broad range of results (pulse-dye, CO2).
Externally-applied laser can penetrate only 1-2 mm into the dermis and therefore has a
limited value for the treatment of hemangioma [1,6]. Embolisation, cryotherapy and
compression had also been used [6,12,16,30].
Recently propranolol proved itself effective in inducing regression of growing hemangioma.
There are several reports confirming prompt response of hemangioma to propranolol with
no major side effects [23,25,28,29].
There are three questions regarding surgical intervention: 1) what are the indications, 2)
when it should be done (timing) and 3) how it should be done [30]. Surgical excision of
hemangioma has been usually performed by lenticular excision with a linear closure. This
technique is useful in the eyelid, lip and neck region [30]. An alternative technique that does
not have these disadvantages is the circular excision or by circular excision and with purse
string closure which is now considered the first line technique at any stage of the tumors life
cycle [11,30].
In some children with extremely large hemangiomas, the vascularity of the lesion is also a
significant anesthetic consideration. There is a need for particular attention to
hemodynamic consideration with anesthesia and potential need for transfusion.
Haemostatic squeezing suture around the hemangioma can be used prior to resection to
avoid blood loss [23].
Surgical Management of Nasal Hemangiomas 85

2. Nasal hemangiomas
Nasal hemangiomas are among the more distressing, if large, can cause a significant
residual damage to the shape of the nose [6]. Due to their location, nasal hemangiomas are
profoundly disturbing lesions both for patients and their families (Fig. 1). Hemangiomas
involving the nose occur approximately 15,8% of facial hemangiomas [13]. The nasal tip is
by far the most common site of nasal hemangiomas [11].

Fig. 1. Different types of nasal hemangioma from small no harming, involving nasal tip,
complicated with nasal obstruction and large superficial hemangioma
Nasal hemangiomas can cause functional problems (nasal obstruction, alteration of the nasal
valve, ulceration and destruction of the delicate growing cartilage of the nose) and severe
psychological sequelae to the children because of social redicule of their peers, and also
86 Rhinoplasty

from medical professionals who are using terms like Cyrano nose, Pinocchio nose.
During proliferative phase they can permanently distort nasal architecture (by displacing
lower lateral cartilages laterally) [13-15,17]. Parents anxiety is something that surgeon have
to deal with during the child growth. In most cases they are not satisfied with explanation
that hemangioma will regress spontaneously during childhood. Aesthetic problem is
usually obvious. Eivazi et al. classified nasal tip hemangiomas as limited or advanced
[25]. Hamou et al. identify three types of nasal hemangiomas that lead to three distinct
surgical approaches:
- Type A (mild cases): no cutaneous involvement, no misalignment of the cartilages an
mild nasal volume increase
- Type B (moderate cases): partial cutaneous infiltration, misalignment of the cartilages
and moderate nasal volume increase
- Type C (severe cases): cutaneous infiltration, misalignment of the cartilages and severe
nasal volume increase [31].
They are usually subcutaneous or mixed superficial and subcutaneous lesions that occupy
the space between the skin and the nasal tip and lower lateral cartilages [15]. Nasal
hemangioma are often slow to regress, leaving excess wrinkled nonelastic skin, residual
fibrofatty tissue with a permanently bulbous nasal tip, visible teleangiectases or contour
deficiencies [11,13,14,17,19,20,27].

3. Treatment options
The treatment of nasal hemangiomas is extremely difficult because of its location and
possible complications [31]. In most of these cases expectation is not a treatment option.
There is a pressure from the family to improve the childs appearance.
Numerous medical and surgical treatment approaches have been proposed for the
treatment of these tumors. The treatment choices of nasal hemangiomas are still
controversial considering use of preoperative medical treatment, timing of surgery, surgical
approach and necessity of skin resection [15, 27].
Pharmacological, surgical or laser interventions are current treatment options for nasal
hemangiomas [13-27].
A no-touch or conservative approach for the treatment of nasal hemangiomas was
previously advocated with frequent consultations with the parents to furnish psychological
support [26].
Advocates of conservative treatment claim that resection causes growth disturbances in
nasal architecture [14,16]. Denk et al. consider that conservative treatment should be
reserved for small hemangiomas on the nose that are not deforming and are without
complications [17]. Corticosteroids were, for the long period, the first line treatment for
nasal hemangioma with excellent results in 30% of cases [13,18]. Interferon was usually
reserved for life threatening lesions resistant to steroids [13]. Because of the possible
complications (skin atrophy) Hochman and Mascareno have moved away from using local
steroid injections for nasal hemangioma [22].
Because of convincing results, beta blockers are preferred as the first treatment option for
proliferating hemangioma [25,28,29,31]. Proponents of early surgery suggest that aesthetic
and functional improvement during a critical period in child development can be achieved
[13-17].
Surgical Management of Nasal Hemangiomas 87

Laser is indicated only for the treatment of the involuting hemangioma, and it is not helpful
for the deeper components [12,16].

4. Surgical treatment
Thomson et al. have been treated eleven patients with different surgical approaches. Several
procedures had been carried out on each patient (an average of 4 operations on one patient)
with 50% delayed primary healing, especially in earlier operated patients [26].
Van der Meulen et al. moved away from no touch approach, and they stated that there
is no need to wait with effective treatment until involution has stopped. They had 9
patients operated with low-flying bird incision (Rethi incision), and with so called L-
approach, which is Rethi incision extended in cranial direction along the alar fold and
nasomaxillary junction. They performed before school age without previous conservative
treatment [19].
Pitanguy advocated an elliptical midline incision over the dorsum of the nose that can give
good functional results but with obvious midline scar on the back of the nose, and the
excision of the dog ear may cause extensions of the incision up into the glabellar region,
which may lead to an unsatisfactory aesthetic result [20,24].
Jackson presented excision of a nasal tip hemangioma via open rhinoplasty procedure, with
step incision on columella, proceeding on both sides of columella, and continuing just inside
the alar rims. The resection of hemangioma and fibrofatty tissue begins between the medial
crura and continues upwards over the domes of lower lateral cartilages. The medial crura
and the domes of the lower lateral cartilages are approximated with nonapsorbable suture.
Intranasal incisions are closed with absorbable suture. A plaster cast was placed for seven
days. Care must be taken not to remove too much tissue because with the time and
continued involution, this may lead to loss of the nasal projection. The excess skin is allowed
to contract over the time (six months) [24].
Denk et al. used the incision made in midline, staring at the tip of the nose, extending the
incision superiorly or inferiorly as needed. The mean age at the first operation was 2,2 years
[17].
Warren et al. stated that the nose may be divided into topographic subunits (dorsum, tip,
alar lobules, side-walls, and soft triangles). There incision were placed along the the lines
that separate this subunits. The incision placement in this modified subunit approach to
nasal tip hemangiomas was at lateral aspect of the nasal dorsum and carried down around
the tip in the declivity medial to the alar lobule and medially into the infratip intercrucial
region [15].
Faguer et al. suggest for surgical treatment of nasal hemangiomas transcolumellar low-
flying bird (Rethi incision), combined with rim incision to expose alar cartilages [21]. With
this technique they manage to excise small and large hemangiomas. Waner at al. stated that
this approach is less appropriate for larger hemangioma, because the the incision cannot be
extended cranially [13].
McCarthy et al. performed surgical resection of nasal tip hemangioma when the patients
was over the age of 3 years for the treatment of lesions that showed no signs of regression
over at least a 6 month period. Open rhinoplasty approach was used similar to Faguer et
al. with transcolumellar incision and marginal rim incision. Before this haemostatic
88 Rhinoplasty

sutures around the lesion were placed. If there was marked skin excess after redraping, it
was resected, sometimes with central wedge excision [14].
Waner et al. proposed modified subunit approach along the contour lines of nasal subunits.
Their surgical approach is based on the principles of Burgett and Menick subunit surgery in
reconstructive surgery of the nose, but the incision line has been modified to allow better
access to all of nasal subunits, and to allow trimming of the excess skin after the
hemangioma has been removed. By this technique the lower lateral cartilages are
approximated, as well as the medial crura, narrowing the columella to achieve nasal
projection. These author avoid placement of in incision in an anterior location due to
aesthetic reasons, preserving if it is possible some part of the affected skin which can be
treated by laser [13].
Hochman and Mascareno proposed the combination of several treatment modalities. They
use classical surgical approach based on already accepted rules, extending the incisions into
the alar grooves or vertically along junction of the nasal tip and lobular subunits or even up
the midline of the tip [22].
Vlahovic and coworkers use the open rhinoplasty incision for nasal tip, columella and alar
subunits hemangioma and circular excision and purse string suture for large nasal
hemangioma localized on the nasal dorsum with predominant deep component with
previous medical (corticosteroid) treatment for large hemangiomas [23].
Eivazi et al. suggested that propranolol should be used as a treatment option for
hemangioma of the nasal tip, and if there is indication for surgical treatment (destructive,
highly proliferative or otherwise uncontrollable lesions) it should be conventional and made
on the basis of the affected regions [25].
Arneja et al. advocate combined medical and surgical approach to treat the Cyrano
nose. An open rhinoplasty approach with skin resection is the authors preferred technique
[27].
Hamou et al. advocate early surgery and the operative technique was chosen based on the
size of the lesion and the presence or absence of cutaneous infiltration. [31].

5. Conclusion
The optimal treatment approach for nasal hemangiomas remains controversial.
Management of nasal hemangiomas involves a combination of serial observation,
conservative treatment (propranolol), and surgical therapy.
Serial observation is indicated for small nasal hemangioma, which requires no treatment,
but in that way we can give support and counseling to the patient and family. As the results
after treatment of hemangioma with propranolol are encouraging, the beta blockers are
preferred as the first treatment option for proliferating IHs, and this includes nasal
hemangiomas also.
In a rapidly growing hemangioma (precisely the hemangiomas that one would prefer not to
operate upon due to increased vascularity and blood loss), the straightforward decision
should be to give a trial with propranolol, before embarking upon surgery. If propranolol
fails, then surgery becomes next option.
The treatment protocol for propranolol developed by Siegfried at al. to optimize the safety is
as follows: baseline echocardiography and 48-hour hospitalization or home nursing visits to
monitor vital signs and blood glucose levels, medication is given every 8 hours, with a
Surgical Management of Nasal Hemangiomas 89

initial dose of 0,16 mg per kilogram of body weight. If the vital signs and glucose levels
remain normal, the dose is incrementally doubled to maximum of 0,67 mg per kilogram
(to a maximum daily dose of 2.0 mg per kilogram). This therapy should be continued
through the proliferative phase of haemangioma growth or until no further improvement
occurs. Instead of abrupt discontinuation a gradual tapering of propranolol over 23
weeks is recommended. If a rebound effect occurs patients are placed back on propranolol
[29].
Different surgical procedures have been suggested for the treatment of nasal hemangiomas
depending on the size and location of hemangioma (Fig.2). Surgery had to be performed

Fig. 2. Preoperative nasal hemangioma and result two years after open rhinotomy excision
90 Rhinoplasty

under general anesthesia, with local infiltration of 1:100,000 adrenalin at the incision
place. The selection of the optimal surgical approach should be made carefully on the
basis of the affected regions. An open rhinoplasty approach, with or without skin
resection, should be preferred technique for the lesion that involved nasal tip, columella
and alar subunits, and in if wider approach is needed the nasal subunits had to be
respected (Fig.3).

Fig. 3. Intraoperativne result after excision of nasal hemangioma with open rhinoplasty
approach
Considering the timing of the surgery, early surgery at the end of the proliferative phase
and during second year of life with maximum preservation of the tissue is appropriate
because psychosocial, aesthetic and functional problems can be avoided. Surgical removal
of nasal hemangioma should be delayed until the hemangioma has stopped proliferating.
Surgical treatment during involutional phase is technically easier.
If there are no possibilities for total excision of hemangioma it can be reduced to an
acceptable level avoiding destruction of the nasal tissue.
Surgical Management of Nasal Hemangiomas 91

Subtotal excision for large hemangioma, without all of the affected skin, which will fade in
the involutive phase, avoiding visible scars, by placing the incision along the columellar
edge and parallel to the nostril is appropriate approach (Fig.4).

Fig. 4. Circular excision and purse string suture technique for large nasal hemangioma
If deep component of hemangioma is predominant, and hemangioma is mostly placed on
the nasal dorsum, a circular excision and purse string suture technique will be
appropriate because of tissue expander effect of hemangioma (Fig.5). The scar by this
technique is more acceptable comparing to lenticular excision especially for large
hemangiomas.
Surgery will retain its importance in cases of non responders to beta blockers, or the
theoretical remaining deformity caused by the residual hemangioma or remnant fibrous
fatty tissue after hemangiomas regression.
92 Rhinoplasty

Fig. 5. Excision of large nasal hemangioma with open rhinoplasty approach, minimal tissue
removing, result after two years

6. References
[1] SJ Fishman, JB Mulliken. Vascular anomalies. Ped Clin N Am 1998;45(6):1455-1477.
Surgical Management of Nasal Hemangiomas 93

[2] JB Mlliken, J Glowacki. Hemangiomas and vascular malfomations in infants and

children:a classification based on endothelial characteristics. Plast Reconstr Surg
1982; 69(3):412-422.
[3] PE North, M Waner, A Mizeracki, MC Mihm. GLUT 1:a newly discovered
immunohistochemical marker for juvenile hemangiomas. Hum Pathol
2000;31(1):11-22.
[4] JB Mulliken, O Enjolras. Congenital hemangiomas and infantile hemangioma:missing
links. J Am Acad Dermatol 2004;50(6):875-882.
[5] M Waner, PE North, KA Scherer, IJ Frieden, A Waner MC Mihm Jr.The nonrandom
distribution of facial hemangimas. Arch Dermatol 2003;139:869-875.
[6] AL Bruckner, IJ Frieden. Infantile hemangiomas. J A Acad Dermatol 2006; 55(4):671-682.
[7] CG Bauland, MA. van Steensel, PM Steijlen, PNMA Rieu, PHM Spauwen. The
pathogenesis of hemangiomas:review. Plast Reconstr Surg 2006;117(2):29-35.
[8] JL Tanner, MP Dechert, IJ Frieden. Growing up with a facial hemangioma: parent and
child coping and adaptation. Pediatr 1998; 101(3):446-52.
[9] AN Haggstrom, BA Drolet, E Baselga, SL Chamlin, MC Garzon, KA Horii, AW Lucky,
AJ Mancini, DW Metry, B Newell AJ Nopper, IJ Frieden. Prospective study of
infantile hemangiomas: Clinical characteristics predicting complications and
treatment. Pediatr 2006;118(3):882-87.
[10] CG Bauland, JM Smit, R Ketelaars, PNMA Rieu, PHM Spauwen. Management of
hemangiomas of infancy: a retrospective analysis and treatment protocol. Scand. J
Plast Reconstr Surg Hand Surg. 2008;42:86-91.
[11] M Waner, L Buckmiller, JY Suen. Surgical management of hemangiomas of the head
and neck. Oper Tech Otolar-Head Neck Surg 2002;13(1):77-84.
[12] A Vlahovic, R Simic, Dj Kravljanac. Circular excision and purse string suture technique
in the management of facial hemangiomas. Int J Ped Otolar 2007;71:1311-1315.
[13] M Waner, J Kastenbaum, K Scherer. Hemangiomas of the nose. Arch Facial Plast Surg.
2008;10(5):329-334.
[14] JG McCarthy, LJ Borud, JS Schreiber. Hemangiomas of the nasal tip. Plast Reconstr Surg
2002;109(1):31-40.
[15] SM Warren, MT Longaker, BM Zide. The subunit approach to nasal tip hemangiomas.
Plast Reconstr Surg 2002;109(1):25-30.
[16] S Cho, SY Lee, JH Choi, KJ Sung, KC Moon, JK Koh. Treatment of Cyrano angioma with
pulsed dye laser. Dermatol Surg 2001;27:670-72.
[17] MJ Denk, N Ajkay, X Yuan, RS Rosenblum, N Freda, WP Magee. Surgical treatment of
nasal hemangiomas. Ann Plast Surg 2002;48:489-495.
[18] L Burgos, JC L Gutierrez, AM Andres, JL Encinas, AL Luis, O Suarez, M Dias, Z Ros.
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[19] JC van der Meulen, PhM Gilbert, R. Roddi. Early excision of nasal hemangiomas: The L-
approach. Plast Reconstr Surg 1993;94(3):465-75.
[20] I Pitanguy, BHB Machado, HR Radwanski, NFG Amorim. Surgical treatment of
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[21] K Faguer, A Dompmartin, D Labbe, MT Barrellier, D Leroy, J Theron. Early surgical
treatment of Cyrano-nose hemangiomas with Rethi incision. B J Plast Surg. 2002;
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94 Rhinoplasty

[22] M Hochman, A Mascareno. Management of nasal hemangiomas. Arch. Facial Plast Surg
2005; 7:295-300.
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2009; 73: 1402-1406.
[24] IT Jackson, J Sosa. Excision of nasal tip hemangioma via open rhinoplasty - a skin
sparing technique. Eur J Plast Surg 1998;21:265-268.
[25] 25. B Eivazi, HJ Cremer, C Mangold, A Teymoortash, S Wiegand, JAWerner.
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[28] C. Leaute-Labreze, E. Dumas de la Roque, T. Hubiche, F. Boralevi. Propranolol for
severe hemangiomas of infancy, N. Engl. J. Med 2008; 358: 26492651.
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 Part 4

Nasal Tip Refinement in Rhinoplasty

 8

Rhinoplasty The Difficult Nasal Tip

Total Resection of the Alar Cartilages and
Temporal Fascia Technique
A 24 Year Experience
Salvador Rodrguez-Camps Devs
Division Chief of Aesthetic and Plastic Surgery,
University Hospital Casa de Salud, Valencia
Spain

1. Introduction
This technique begins with a secondary rhinoplasty case (operated 3 times previously) in
1987 with a highly unappealing nasal tip whose cartilages were completely broken. I had to
choose between eliminating the whole nasal dome and resetting it with a new cartilaginous
structure (taking cartilages from the ear), or removing all the cartilage remains and covering
with two-layered temporal fascia. I decided on the second option, and the result was highly
satisfactory (fig. 1). Why this unprecedented idea? It was an impulse. Because of my
reflexive character and perfectionism, it seemed contradictory and, yet, I sensed that this nasal
tip, so badly arranged and anti-aesthetic after 3 operations, would only withstand a fourth
operation which guaranteed certain success. So I thought that submitting the patient to a
reconstruction of the whole cartilaginous nasal tip structure was not the best solution.
Amputating and reconstructing seemed more complex and bloody than amputating and
covering with some soft tissue. I chose temporal fascia as it is soft and not very extensible,
and would provide the new tip more solidity. It came to my mind in a flash and I acted with
all the consequences to help my patient, Paquita. As I knew the patient, I did a follow-up
and, years later, the result remained stable. However, as all the plastic surgery treaties and
publications warn us about the importance of conserving an alar cartilage band of no less
than 3-5 mm on its caudal edge to avoid collapses, I thought that this process could wait
before being repeated. So gradually, I started performing more cases, and I saw that the
result was no chance happening. I extended the indications and ventured with particularly
difficult primary rhinoplasty cases involving extremely domed, flat and wide tips. The years
went by and I continued improving and perfecting this process, which went against what
was technically correct. I indicated it by taking great care and followed the results for as
long as possible. After finishing the operation, I checked that the result remained aesthetic
and that the nasal base was equilateral and stable; this was precisely one of the keys: a solid
tripod and an equilateral stable base. To achieve this effect, I introduced some technical
resources which helped me to convert a long-pointed or flattened nose into what ensured
98 Rhinoplasty

me good results: an equilateral base. Then I started work with alar wedges, vestibular
wedges, resecting or using a stitch in the centre of the crus medialis feet, partial reduction of
the soft triangles, Converse stitch, etc., to stabilise the tip. As the years passed, I continued
extending the indications and obtaining good results; but, beware; what I was doing was
still technically incorrect. So I decided to wait a little longer and acquire as much
experience as possible. I had to ensure that everything I was doing was not incorrect by
chance, and all I wanted was absolute security to be able to defend the technique when it
emerged with all the consequences. I began to attenuate some case or another during
rhinoplasty speeches without causing commotion in the forum. When I felt quite certain, I
presented the technique officially in a SECPRE (Spanish Society of Reconstructive, Aesthetic
and Plastic Surgery) Congress (Pamplona, Spain, 2006), then in Melbourne, Australia, in the
ISAPS Congress (International Society of Aesthetic Plastic Surgery, 2008), where it went
down well. Finally, I decided to publish it in Aesthetic Plastic Surgery (2009), in Ciruga
Plstica Iberolatinoamericana (2010) and in the Spanish Association of Aesthetic and Plastic
Surgery Journal (2010). I can state that acknowledgement has been excellent, particularly
thanks to the results achieved. Consequently, we should think the technique must be correct
if the results are good.

Fig. 1. (A, B, C, D, E, F, G and H)

This is my first case done in 1987.
Rhinoplasty The Difficult Nasal Tip
Total Resection of the Alar Cartilages and Temporal Fascia Technique A 24 Year Experience 99

Secondary rhinoplasty operated on 3 previous occasions. Details of completely destroyed,

contorted alar cartilages, with a pointed and unsightly tip. Treatment was Type I
resection-reconstruction: Total Resection of the Alar Cartilages, including domes and a
trunk of crus medialis. Patch and band of temporal fascia for covering. Result after 2
years.
Since Joseph masterly established the basic concepts of Modern Rhinoplasty in 1904, upon
which plastic surgeons still base ourselves today, research and contributions to this
fascinating surgical technique have been constant, and each and every millimetre of the
nasal pyramid has been studied and discussed from both the functional and aesthetic
viewpoints. And all this always with the same maxim: NO excessive resection, and even
less TOTAL resection, of alar cartilages given the risk of alar collapse. Nonetheless for
almost 25 years, we have studied, verified and finally demonstrated, with good results, that
,YES, alar cartilages can be removed totally after correct diagnosis and suitable indication.
A correct anatomical diagnosis of the tip and nasal base, and of the respiratory tract
(septum, nasal turbinates and valves), and adequate indication, are always suitable in a
nose whose tip is extremely difficult to put right with traditional techniques using
cartilage grafts.

Fig. 2. (A, B, C, D, E, F, G and H) Secondary rhinoplasty. Pinocchio nose. Inadequately

removed thick alar cartilages. Treatment was Type I resection-reconstruction.: Total
Resection of the Alar Cartilages, including domes and a trunk of crus medialis. Patch and
band of temporal fascia for covering. Killian septoplasty. Result after 1 year
100 Rhinoplasty

Fig. 3. (A, B, C, D, E, F, G, H, I, J, K, L, M, N, O and P) Secondary rhinoplasty. Details of

inadequately treated cartilages and the tip-columela-lip unit. Postoperative sequence: after 7
days (removing the splint and placing Steri-StripR protection); aspect after 15 days. Type III
resection-reconstruction: Total Resection of the Alar Cartilages, respecting domes. Patch of
Temporal Fascia
Rhinoplasty The Difficult Nasal Tip
Total Resection of the Alar Cartilages and Temporal Fascia Technique A 24 Year Experience 101

This paper attends to something new: a rhinoplasty technique based on the total resection of
alar cartilages, which are replaced with a temporal fascia covering to soften the nasal tip by
forming a single covering among the skin, the underlying fibroadipose tissue, the temporal
fascia itself and vestibular skin.
The indication for this new technique is secondary rhinoplasty cases, for extremely difficult
nasal tip cases with broken or badly arranged cartilages (fig. 2and fig. 3), for traumatic
rhinoplasty, and also for primary rhinoplasty situations in which the nasal tip is excessively
bulbous, disfigured, flat or wide (fig. 4; fig. 5; fig. 6, fig. 7 and fig. 8). Where a surgical tip
may appear after the oedema disappears, it is highly competitive with other techniques
based on complex cartilaginous structures with auricular grafts.

Fig. 4. (A, B, C, D, E, F, G and H) Primary rhinoplasty. Excessively bulbous and protuding

tip. Type II resection-reconstruction: Total Resection of the Alar Cartilages, including
domes. Patch and band of temporal fascia. Killian septoplasty. Result after 1 year
We have 24 years experience (1987 2011) and more than 550 successful operations with
fully satisfied patients.
The refinement and beauty of the nasal tip with a solid and equilateral base are the aim of
this technique, without historical prejudices and taboos; and we have achieved this
exactly.
102 Rhinoplasty

Fig. 5. (A, B, C, D, E, F, G and H) Primary rhinoplasty. The tip is not only protuding, but also
bulbous and fleshy. Type II resection-reconstruction: Total Resection of the Alar Cartilages,
including domes. Patch and band of temporal fascia. Result after 1 year

Fig. 6. (A, B, C, D, E, F, G and H) Primary rhinoplasty. Broad tip with a thick skin and a
retracted columela. Type V resection-reconstruction.: Total Resection of the Alar Cartilages,
respecting domes and suturing both crus medialis high. Temporal fascia patch, Intercrus-
medialis tutor and filled in nasal-labial angle. Result after 1 year
Rhinoplasty The Difficult Nasal Tip
Total Resection of the Alar Cartilages and Temporal Fascia Technique A 24 Year Experience 103

Fig. 7. (A, B, C, D, E, F, G and H) Primary rhinoplasty. Protruding and bulbous tip with very
thick skin. Type III resection-reconstruction: Total Resection of the Alar Cartilages,
respecting domes. There was no need for temporal fascia given the thickness of the skin. In
this particular case, we performed a blepharoplasty simultaneously. Result after 1 year

Fig. 8. (A, B, C, D, E, F and H) Primary rhinoplasty. Deviated nose with globulous nasal tip.
Type II resection-reconstruction: Total Resection of the Alar Cartilages, including domes.
Patch and band of temporal fascia. Killian septoplasty. Result after 1 year
104 Rhinoplasty

2. Material and methods

Rhinoplasty is decidedly a very difficult operation although, technically, it seems deceptively easy
(Jack Sheen).
I have operated more than 550 patients with this technique and have over 24 years
experience in it (19872011) with highly satisfactory results.
In secondary and traumatic Rhinoplasty suits this technique, always Rethis approach (Open
Rhinoplasty), which is especially designed for it. Yet we are increasingly employing it in
primary rhinoplasty when the solution for a cartilaginous dome proves difficult with other
techniques. We are fully accelerating in this last case and have introduced some variation, as
we will go on to explain. Mainly after cancer surgery on the nasal tip, we also have gained
experience in nasal reconstruction.
What do I mean when I speak of other nasal tip remodelling techniques? All those known
as conventional techniques based on repositioning alar cartilages with grafts removed
from ears. Then there are the extreme cases in which the creation of a genuine cartilage
scaffolding is easy to detect in many cases when the oedema has disappeared some
months later. It is true that these techniques always improve the appearance of the new
nasal tip, but it is not hard to detect the presence of peaks and edges corresponding to the
grafts taken mainly from the auricular concha. Although I am not in favour of
cartilaginous grafts in the nasal tip given the subsequent reabsorption, torsion,
asymmetry problems or noted through the skin, I admit I still use some of them to project
and define a nasal tip with the shield of Sheen or the champagne glass of Juri, but I no
longer use cartilaginous grafts to reconstruct the nasal dome and/or the nasal wings.
Other techniques have contributed to the success of the nasal tip treatment, to refine it.
Thus, Safian (1930) begins an interesting process which Goldman (1957) would
significantly improve, with his vertical dome division (VDD: anterior triangular shape
incision of both domes), and Simons and Adamson will popularize it definitively. Lipsett
(1959) will modify this technique with multiple parcial thickness incisions in the nasal
domes for bending the cartilages.

2.1 The resection

An equilateral and stable nasal base is our main objective. To fulfil this objective, we have
classified resections into 5 types (although, in very special cases, it is convenient to make
some little combinations between them).

2.1.1 Type I
Complete resection of alar cartilages, including domes and one trunk of the crus
medialis.
This is indicated for noses that are long-pointed, have a long columela, and for large and
elongated nostrils. Here we introduce some of our technical resources, such as alar wedges,
and resecting the crus medialis feet.

2.1.2 Type II
Complete resection of alar cartilages, including domes. This is indicated for noses with a
slightly elongated nasal base.
Rhinoplasty The Difficult Nasal Tip
Total Resection of the Alar Cartilages and Temporal Fascia Technique A 24 Year Experience 105

2.1.3 Type III

Total resection of alar cartilages, respecting domes. Applicable to noses whose nasal base is
very close to the objective (equilateral nasal base).

2.1.4 Type IV
Total resection of alar cartilages, respecting domes, and leaving two small alar wedges
whose latero-caudal length is no longer than 8 mm and is of an arrow-tip shape. Indicated
for cases where the nasal base is equilateral.

2.1.5 Type V
Total resection of alar cartilages, respecting domes and approaching the Crus Medialis feet,
and suturing domes as high as possible to accomplish projection. Then we remove
vestibular wedges, place a Converse stitch, smoothly reduce the soft triangles, release the
columela of the base and remove a trunk of the septum depressor muscle. Generally, it is
only here where we introduce a septum tutor intercrus to prolong and strengthen the
columela projecting the nasal tip. This is indicated for flat and negroid noses with a short
columela, separated nasal wings and broad nostrils.
Many times, it is not necessary to use the temporal fascia for covering the crus medialis,
because of the thickness of the skin (fig. 7).
(Fig. 9, fig. 10, fig. 11, fig. 12, fig. 13)

Fig. 9. (A, B and C) Cleft rhinoplasty. Very broad tip with cartilaginous hypertrophy. Type
III resection marking: Total Resection of the Alar Cartilages, respecting domes

2.2 The reconstruction

We place two stitches with 5-0 nylon, and conceal the knots, on top of the crus medialis to
keep them firmly together. If the approach is complete, sometimes it is not necessary. A
patch and/or a band of temporal fascia is placed covering the crus medialis.
106 Rhinoplasty

Fig. 10. (A, B, C, D and E) Different resection types

Fig. 11. (A and B) Details of Type II resection: Total Resection of the Alar Cartilages,
including domes. Patch and band of temporal fascia
Rhinoplasty The Difficult Nasal Tip
Total Resection of the Alar Cartilages and Temporal Fascia Technique A 24 Year Experience 107

Fig. 12. (A, B, C and D) Secondary rhinoplasty on an extremely broad tip and an inadequate
resection. Details of Type II resection and immediate result: Total Resection of the Alar
Cartilages, including domes. Patch and band of temporal fascia

Fig. 13. (A, B, C and D) Different resection types

2.3 The temporal fascia

In 1984, Dr. Guerrerosantos introduced this procedure to increase the dorsal unit of the nose
and to fill the naso-frontal angle. We use it for the tip to achieve a firm covering and a
beautiful, smooth protection in terms of both sight and touch by joining it as a single plane
to the fibroadipose covering to the skin (fig. 14).
We only exclude temporal fascia in those nasal tips with a thick skin, with abundant
sebaceous glands and a dense fibroadipose covering.
108 Rhinoplasty

To avoid a pointed nasal tip, conversely, its placing is essential in Caucasian women and
European north-eastern people with delicate and thin skin. There is no problem with a
shrink wrap effect, until nowadays. The technique works very similar in every ethnic
group, but we need to use the temporal fascia generally and, however, rarely in black or
Asian people because of the thickness of the skin. In every ethnic group we have had no
problem with retraction.

Fig. 14. (A, B, C and D) Details of temporal fascia arranged to be utilized for reconstruction
purposes. A fascia seal covering the ends of the crus medialis in a Type II reconstruction
The seal extension will also depend on the thickness of the wings skin. We place 1 or 2-
layered temporal fascia depending on requirements and the resection type, and we
sometimes include muscle fibres to provide bulk.
In this way, the anatomy of the new nasal tip and the wings will outwardly to inwardly
comprise the following single-body layers:
Superficial skin
Fibroadipose covering
External fibrous lamina
Temporal fascia
Internal fibrous lamina
Internal vestibular skin

2.4 The technical resources

According to the former shape of the nasal base, and to achieve an equilateral nasal base,
we use a serie of technical details that enable a firm, consistent base which resists alar
collapse during inspiration: reduction of soft triangles (to achieve nostrils with a longer
look), resecting a trunk of the septum depressor muscle (to help project the nasal tip and
avoid it from moving and lowering when talking and laughing), Converse stitch (to
narrow an excessively wide columelar base), releasing the columela (to project the tip,
block it and open the naso-labial angle), alar wedges (to bring wings closer together and
to reduce the nostrils size), resection or approach of the Crus Medialis Feet (to lower the
nasal tip or to project it), tutor intercrus (to strengthen the columela and to project the tip),
vestibular wedges (to narrow nostrils), septoplasty (Killian) and/or luxation or
cauterisation of the nasal turbinates (to ensure the respiratory tract function and to be
able to perform the technique without the possibility of collapse), and filling the naso-
Rhinoplasty The Difficult Nasal Tip
Total Resection of the Alar Cartilages and Temporal Fascia Technique A 24 Year Experience 109

labial angle with resected remains (fig. 15) (to obtain beauty between the lip and the nasal
base).

Fig. 15. Details of removed and sutured alar cartilages prepared to be introduced into the
naso-labial angle for the purpose of opening it
As regards the septum and nasal turbinates being responsible for a correct respiratory tract,
we have highlighted that many of the bulges in the cartilaginous dome of the tip are due to
natural compensation caused by a deviation of the septum and/or to a hypertrophy of the
turbinates. If we perform the total resection of alar cartilages technique with their domes
without having previously treated any pathology in the septum and turbinates, then we will
cause nasal respiratory insufficiency with spontaneous collapse and/or during inhalation.
If, on the other hand, the septum and turbinates are normal, we should not come across
complications of any kind of either a functional or an aesthetic type when undertaking a
total resection of the cartilaginous dome of the nasal tip.

2.5 The postoperative period

The postoperative period does not differ much with our technique from that of other
techniques (if anything, recuperation is shorter). However, we have to maintain the
vestibular cotton pads pushing the domes for 4-5 days (fig. 16). A plaster splint remains in
place for 7 days, and a double layer of Steri-StripR is used for 7 additional days.

Fig. 16. (A and B) Details of prepared cotton pads of sufficient length to be positioned to
push the vestibular skin from the dome and to ensure a compact union with the fascia and
tip skin
110 Rhinoplasty

3. Results
Judging from our patients degree of satisfaction, the results obtained since 1987 to date in
2011, range from very good to excellent. Other nasal tip reconstruction techniques
performed with complex cartilaginous structures did not provide us with the best results
because a surgical tip emerged when the oedema disappeared, with traces of barely
admissible tips and edges.
We reconstruct the nasal tip using the cartilages we have available, and if they do not serve
this purpose, we resect them directly. We very rarely resort to cartilaginous grafts since we
adopted our technique. Personally, I reached the conclusion some time ago of NOT using
cartilaginous grafts in the nasal tip, provided this is feasible, for ultimate problems of
displacement, reabsorption, distortion and an unappealing presentation in terms of sight
and touch.
Despite what I have stated herein, I wish to express my maximum respect and admiration to
all the Rhinoplasty Masters from whom I have learnt.
We have had no problems with the ever-feared alar collapse, which is most certainly due to
other factors such as an excessive resection of the triangular cartilages, a vestibular valve
lesion without correcting a significant deviation of the septum during surgery, or
hypertrophic turbinates which could contribute to or even cause nasal respiratory failure
with a uni or a bilateral collapse. Regarding complications, there is nothing particular to
highlight in either aesthetic or functional terms.

4. Discussion
I realised that this technique was controversial, from the beginning, and that our
Rhinoplasty Masters did no advice an excessive resection of alar cartilages, but preferred to
maintain a cartilage band of a width of no less than 3-5 mm in the latero-caudal sense to
avoid alar collapse. However, by following the steps of our technique and by maintaining its
main objective (an equilateral, solid nasal base with a firm, yet soft nasal tip in terms of sight
and touch, with no cartilaginous remains in view) I have verified and demonstrated that this
may be avoided.
Nonetheless, all this involves experience in rhinoplasty and a totally accurate technique. It
proves a most useful technique, but to be used only in extremely difficult nasal tip cases.

5. Conclusion
My new technique has posed no problems when well indicated, diagnosed and performed,
and has matured sufficiently over time in casuistry.
Finally, the nasal tip becomes as firm and consistent, or more, than prior to surgery. Its five
anatomical layers retract in a uniform fashion without distortions. To the touch, it is solid
yet smooth and, aesthetically, it offers a beautiful result. Only a biopsy would enable us to
verify the state of the stratification, but it is complicated proposing this to a patient who is
satisfied with his or her nose, and we are all aware of the possible negative consequences of
extracting a cylinder of tissue with the more than likely alteration to the vectorial system
and to shape. It would be rather like requesting a structural sampling in a cathedral vault
to learn the characteristics or state of its materials. Thus, our colleagues should trust in the
technique thanks to its results.
Rhinoplasty The Difficult Nasal Tip
Total Resection of the Alar Cartilages and Temporal Fascia Technique A 24 Year Experience 111

The most difficult plastic surgery operation is undoubtedly rhinoplasty and, within it, nasal
tip cases are extremely difficult. Nonetheless, the operation is the most appealing and
fascinating of our speciality, but great care must be taken while performing it.
I literally cite: The author must be congratulated for his work, and be honoured and highly
commended for the results obtained. This study is unique and it offers excellent results Indeed,
these results will convince many of us in practicing these aggressive resections
The complete and permanent removal of what Mother Nature has designed requires the broadest
experience, competence and an aesthetic feel by a Master Craftsman in a procedure that permits a
minor error, or absolutely none. I therefore completely agree with the author that this procedure
cannot be generally applied to all nasal tip operations, and that it is not suitable for enthusiastic
beginners in surgery who lack both experience and aesthetic criteria It is likely that the author
has found temporal fascia an ideal substitute after totally resecting alar cartilages. (Dr. Neeta Patel,
in her commentary on this technique in the Aesthetic Plastic Surgery Journal. January 2009).
Furthermore: Dr. Rodrguez-Camps contribution makes this nasal tip technique most interesting
for difficult cases
We are well aware that the nasal tip is one of the most difficult parts of Rhinoplasty, and that all of
us have the technique that provides the best results available; but we also know that some rhinoplasty
cases are very difficult to solve. Dr. Rodrguez-Camps technique of totally removing alar cartilages
and then introducing temporal fascia is novel and interesting Needless to say, the results
obtained by Dr. Rodrguez-Camps are excellent and we are enthusiastic about using this nasal
aesthetic technique (Dr. Guerrerosantos in his commentary on the technique in Ciruga
Plstica Iberolatinoamericana. Jan.-Feb.-March 2010).
We conclude that when it seemed that everything had been described, and that the results
depended only on our hands, something new and fresh appears: The Total Resection of the
Alar Cartilages and Temporal Fascia Technique.

6. References
Burget G, M.D. & Menick F, M.D.: Aesthetic Reconstruction of the Nose. First Edition.
Mosby. 1994.
Converse J, M.D.: Reconstructive Plastic Surgery. Second Edition. W. B. Saunders Company.
Philadelphia, London, Toronto. Vol. 2 Chapter 29, 1040-1281. 1977.
Ezquerra Carrera F., Sainz-Arregui J. & Berrazueta Fernndez M. J.: La Rinoplastia No
Basica Primaria. Cir. Plast. Iberlatinamer. Vol. 27 N0. 1. January-February-March
2001. Pages 45-54.
Goldman IB.: Eye Ear Nose Throat Mon, 1957 Dec; 36 (12):742-3.
Guerrerosantos, J.: Temporoparietal Free Fascia Grafts in Rhinoplasty. Plastic and
Reconstructive Surgery. Vol. 74. Issue 4. pag. 465-474. October 1984.
Jack P. Gunter, M.D., Rod J. Rohrich, M.D. & William P. Adams, Jr. M.D.: Dallas
Rhinoplasty. Nasal Surgery by the Masters. Second Edition. Quality Medical
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Juri J, M.D., Juri C, M.D., Grilli D, M.D., Zeaiter MC, M.D. & Belmont J, M.D.: Correction of
the Secondary Nasal Tip. Annals of Plastic Surgery. Vol. 16. N0. 4. 322-332. April
1986.
Lipsett EM.: A new approach surgery of the lower cartilaginous vault. AMA Arch
Otolaryngol, 1959 Jul; 70(1): 42-7.
112 Rhinoplasty

Meyer R.: Secondary and Functional Rhinoplasty. The Difficult Nose. First Edition. Grune &
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Peck G, M.D. Techniques in Aesthetic Rhinoplasty. First Edition. Gower Medical Publishing
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Rodriguez-Camps S: Secondary Rhinoplasty in Cleft Nose. Rethi Technique. XX Spanish
National Plastic, Reconstructive and Aesthetic Surgery Society (SECPRE) Meeting.
Video Presentation. Len, Spain. October, 1989.
Rodriguez-Camps S: Nasal Reconstruction after Mohs Micrographic Surgery. Poster.
Spanish National Reconstructive, Aesthetic and Plastic Surgery Society (SECPRE)
Congress. Valladolid, Spain. June, 1994.
Rodriguez-Camps S: Reconstruccin Nasal tras Ciruga Microgrfica de Mohs. Cir Plast
Iberolatinoamer. Vol. XXI, no.3, 215-223, 1995.
Rodriguez-Camps S: Total Reconstructive Rhinoplasty with the medial forehead flap. VIII
Spanish National Reconstructive, Aesthetic and Plastic Surgery Society (SECPRE)
Congress. Video Presentation. Santiago de Compostela, Spain. June, 1995.
Rodriguez-Camps S: Nose Reconstruction with medial forehead flap after Mohs Surgery.
International Video-Journal of Plastic and Aesthetic Surgery. Vol. 2, n 3, December
1995.
Rodriguez-Camps S: Aesthetic Rhinoplasty under local anaesthesia without sedation. XXXI
Spanish National Reconstructive, Aesthetic and Plastic Surgery Society (SECPRE)
Congress. Video Presentation. Madrid, Spain. September, 1996.
Rodriguez-Camps S: Augmentative Rhinoplasty with auricular cartilage. Spanish National
Reconstructive, Aesthetic and Plastic Surgery Society (SECPRE) Congress.
Barcelona, Spain. April, 1997.
Rodriguez-Camps S: Relapsing Basal Cell Ephithelioma of the nasal tip. Resection. Two-
stage reconstruction with a frontal flap. Nasal Plastic surgery Symposium,
tribute to Dr. Vilar-Sancho. The Ramn y Cajal Hospital, Madrid, Spain.
February, 1998.
Rodriguez-Camps S: Augmentative Rhinoplasty with an Auricular Gibbus. Aesth Plast
Surg. Vol.22. n. 3.196-205, 1998.
Rodriguez-Camps S: Miscellaneous Rhinoplasty: Primary and Secondary. XXXIV Spanish
National Reconstructive, Aesthetic and Plastic Surgery Society (SECPRE) Congress.
Marbella, Spain. April, 1999.
Rodriguez-Camps S: Rhinoplasty: Primary, Secondary and Reconstructive. II Plastic,
Reconstructive and Aesthetic Surgery Society Meeting of the Valencian Community
(SCPRECV). Alicante, Spain. February, 2000.
Rodriguez-Camps S: Nasal Reconstruction After Epithelioma. Aesth Plastic Surg. Vol. 25.
No. 4:273-277. July-August 2001.
Rodriguez-Camps S: Aesthetic Nasal Reconstruction from the Oficial Book of the XXXVII
Spanish National Reconstructive, Aesthetic and Plastic Surgery Society (SECPRE)
Congress. Rhinoplasty, Chapter 11. Oviedo, Spain. June, 2002.
Rodriguez-Camps S: Rhinoplasty. The Aesthetic Tip-Columela-Lip Unit. XV Latin American
Federation of Plastic Surgery Congress (FILACP) and XXXIX Spanish National
Reconstructive, Aesthetic and Plastic Surgery Society (SECPRE) Congress. Seville,
Spain. May, 2004.
Rhinoplasty The Difficult Nasal Tip
Total Resection of the Alar Cartilages and Temporal Fascia Technique A 24 Year Experience 113

Rodriguez-Camps S: Rhinoplasty: Nasal Base. V Plastic, Reconstructive and Aesthetic

Surgery Society Meeting of the Valencian Community (SCPRECV). General
University Hospital, Alicante, Spain. November, 2004.
Rodriguez-Camps S: Nasal Reconstruction. VI National Reconstructive, Aesthetic and
Plastic Surgery Society Meeting of the Valencian Community (SCPRECV). Valencia,
Spain. October, 2005.
Rodriguez-Camps S: Closed Rhinoplasty. Teaching Course on National Reconstructive,
Aesthetic and Plastic Surgery. School of Medicine. University of Barcelona, Spain.
November, 2005.
Rodriguez-Camps S: Secondary Rhinoplasty: Our procedure. Total Resection of the Alar
Cartilages and Domes with a Temporal Fascia Stamp on the Tip. XLI Spanish
National Reconstructive, Aesthetic and Plastic Surgery Society (SECPRE) Congress.
Paper. Pamplona, Spain. May, 2006.
Rodriguez-Camps S: Nasal Reconstruction. VII Reconstructive, Aesthetic and Plastic Society
Meeting of the Valencian Community (SCPRECV) Meeting. Alzira, Valencia, Spain.
October, 2006.
Rodriguez-Camps S: Reconstructive Rhinoplasty. Teaching Course on Reconstructive,
Aesthetic and Plastic Surgery. School of Medicine. University of Barcelona, Spain.
November, 2006.
Rodriguez-Camps S: Rhinoplasty. The Difficult Nasal Tip: Total Resection of the Alar
Cartilages. XIX Congress of the International Society of Aesthetic Plastic Surgery,
(ISAPS). Panelist. Melbourne, Australia. February, 2008.
Rodriguez-Camps S: Rhinoplasty. The Difficult Nasal Tip: Total Resection of the Alar
Cartilages. Aesth. Plast. Surg. Vol. 33. No. 1. 72-83. January 2009.
Rodriguez-Camps S: Una nueva tcnica para el tratamiento de la punta nasal difcil.
Experiencia personal de 22 aos (1987-2009). Ciruga Plstica Ibero-latinoamericana
Journal. Cir. Plast. Iberolatinoam. Vol. 36. No. 1. Pages 3-12. January-February-
March 2010.
Rodriguez-Camps S: New technique to treat a very difficult nasal tip. Total resection of the
Alar Cartliages and Temporal Fascia Covering XLV Spanish National
Reconstructive, Aesthetic and Plastic Surgery Society (SECPRE) Congress. Gerona,
Spain. May, 2010.
Rodriguez-Camps S: Demostrating the Total Resection of the Alar Cartilages and Temporal
Fascia Technique on a corpse as part of the VI Theoretical-Practical Course on
Anatomical Disection organized by the Spanish Association of Aesthetic Plastic
Surgery (AECEP). I Course on Rhinoplasty and Facial Implants. Department of
Human Anatomy and Embryology II, School of Medicine at the Complutense
University of Madrid. Madrid, Spain. July 2010.
Rodriguez-Camps S: Un paso adelante en Rinoplastia: Tcnica de Reseccin Total de los
Cartlagos Alares y Fascia Temporal. Spanish Association of Aesthetic Plastic
Surgery Journal (AECEP). N. 12. Pages 13-24. July-December 2010.
Sheen J.: Aesthetic Rhinoplasty. Second Edition. The C.V. Mosby Company. Saint Louis
1978.
Soria, J.H., Pintos, J.C., Conde, C.G. & Losardo, R.J.: Sobrepunta Nasal como Expresin de
una Comunicacin Septal. Cir.Plast. Iberolatinoam. Vol.35 n. 4. October
114 Rhinoplasty

NovemberDecember 2009. Pages 243-248. Commentary on the work: Dr.

Rodrguez-Camps, S.
Tardy M. E. Jr., M.D.: Surgical Anatomy of the Nose. First Edition. Raven Press, Ltd. New
York, USA. 1990.
Wolfgang Gubisch, M.D.: Overresection of the Lower Lateral Cartilages: A Common
Conceptual Mistake with Functional and Aesthetic Consequences. Aesth. Plast.
Surg. 33:6-13 (2009).
 Part 5

Minimally Invasive Techniques

 9

Minimally Invasive Approach for Rhinoplasty

S. Cohen
Plastic and Aesthetic Surgery, Private Clinic, Ramat Gan
Israel

1. Introduction
The nose, the most prominent aesthetic feature in the facial profile, is a three-dimensional,
intricate trapezoid solid, encompassing the external bony and cartilaginous vault with an
overlying skin cover and internal cavities. Through their intricate structural
interdependency, these topographic features contribute both to form and function. Given its
central location in the midface, the nose interrelates with the adjacent structures through
juxtaposition, ultimately giving rise to the overall size, shape, and aesthetics of the nose.
Ideal facial and nasal forms have been depicted from ancient Egyptian hieroglyphics to the
Renaissance era. These cannons dictated what is most desirable and possibly achievable.
Correction of aesthetic nasal deformities date back to India in 600 BC by Sushruta Samhita.
Since then, there has been a long evolution of techniques. Different surgical approaches have
been advocated, each with its inherent advantages and liabilities. Optimal rhinosculpturing
outcomes are not achieved merely as a consequence of the access route but rather rely on a
precise execution of a technique that addresses the deformity.
Science and art are inseparable in rhinoplasty. Gratifying results performed by surgical
intervention or minimally invasive procedures require systematic analysis of the anatomic
variables, adherence to structured strategy, artistic perception, and precise manipulation. It
is a well known tenet to all surgical endeavors that a sound knowledge of anatomy is
requisite and the reader is advised to refer to a comprehensive review of Surgical anatomy of
the nose, by O'Neal, et al. 1996 (1).

2. Nasal aesthetics
Balance, harmony and symmetry are essential elements of beauty; thus, a thorough nasal
and facial analysis in frontal, lateral, and basal views is of paramount importance in
achieving state-of-the-art results in rhinoplasty.
Although a complete description of nasal analysis is beyond the scope of this article, certain
fundamental considerations merit discussion.
In the frontal view, assessment of balance is achieved by dividing the face into horizontal
thirds (trichion to glabella, glabella to subnasale, and subnasale to menton), and vertical
fifths. The nose should represent one-third of the length of the face and one-fifth, the width
(Figure 1). The ideal shape of the nose is outlined by two slightly curved divergent lines
extending from the medial brows to the tip-defining points. The width of the alar base is
equal to the intercanthal distance (Figure 1). The width of the nasal base comprises
approximately 70% to 80% of the alar base.
118 Rhinoplasty

Fig. 1. The face is divided into thirds by horizontal lines drawn from the hair line, glabella,
subnasale and menton. The nose should represent one-third of the length of the face and
one-fifth of its width. Alar base is equal to the intercanthal distance
In the lateral view, important parameters include nasal length, tip rotation, tip projection
and dorsal contour. Nasal length (or dorsal length) is determined by the vertical distance
from the nasion (root of the nose overlying the nasofrontal suture) to the tip-defining point.
Tip rotation is equivalent to the nasolabial angle, which measures the rotation of the nasal
base from the upper lip. In women, it is 950 to 1050. In men, it is 900 to 950 (Figure 2). Nasal
tip projection is commonly assessed by Goode's method (2). Goode defines ideal nasal
projection (measured from the alar crease to the tip-defining point) as 0.55 to 0.60 in relation
to the dorsal length. Assessment of the dorsal contour should identify any concavity,
convexity or irregularity. In women, the aesthetic nasal dorsum lies approximately 2 mm
behind and parallel to a line from the nasofrontal angle to the tip, with a slight supratip
break offsetting the nasal tip from the dorsum. In men, the dorsum should be slightly higher
and a subtle convexity is typical.
The relationship of the ala and columella is likewise assessed on profile. Acceptable
columellar show is between 2 mm to 4 mm.
On profile view, one should be acquainted with the Powell and Humphreys aesthetic
angles applied in facial analysis (2). Of these, nasofrontal and nasofacial angles should be
carefully assessed. As an angle interrelates two juxtaposed lines, changing the inclination of
one line will consequently alter the perceived overall proportions, and in particular, the
apparent nasal length.
Minimally Invasive Approach for Rhinoplasty 119

The nasofrontal angle (the angle formed between the forehead inclination and the nasal
dorsum) is 1307 degrees in men and 1347 degrees in women (Figure 3). A deep
nasofrontal angle contributes to the illusion of a short nose (and apparent overprojection),
and a shallow nasofrontal angle adds apparent length to the nose. The nasofacial angle
refers to the inclination between the nasal dorsum and the frontal plane (defined as a line
from the nasion to the pogonion, the most prominent anterior projection of the chin). It is 360
in men and 340 in women.

Fig. 2. Tip rotation is determined by the nasolabial angle. In women, it is 95-1050; in men, it
is 90-950

Fig. 3. Nasofrontal angle in women is 13470; in men, it is 13070

120 Rhinoplasty

On base view, attention should be paid to symmetry, triangularity, columella-to-labial ratio,

and width of the alar base. The nasal base should appear as an isosceles triangle with the
upper third representing the tip lobule and the lower two-thirds corresponding to the
columella.
As facial structures interrelate through juxtaposition, ultimately altered proportions of one
part affect the perceived aesthetic appearance of adjacent parts. Nasal aesthetic appearance
is likewise influenced by interrelated structures of the chin, forehead and premaxilla, and
these should be individually analyzed.
Chin projection is assessed by a perpendicular line drawn between the Frankfurt horizontal
line (FHL, a line connecting the superior aspect of the tragus to the infraorbital rim) and
nasion. This perpendicular line should intersect the pogonion at 02 mm. Alternatively, a
perpendicular line from FHL through subnasale should intersect the pogonion 33 mm
posterior to the line. An underprojected chin may lead to the perception of an overprojected
nose and vice versa. A flat forehead gives the illusion of increased nose length (3).
As the premaxilla and the pyriform aperture serve as scaffolding for the nasal pyramid,
anterior or posterior displacement of these anatomic landmarks may give the illusion of
overprojection or retruded nasal profile, respectively. Deficiency of the premaxilla may
present as a congenital deformity. Maxilla alveolar hypoplasia along with midfacial
retrusion may be congenital or arise as part of the normal aging process (4). Loss of the
underlying nasal support imparts an impression of a relative lengthening and retrusion to
the aging nose (4)
Different aesthetic facial proportions exist among different faces and ethnicities.
Nevertheless, similar concepts of beauty exist among people of various cultural
backgrounds in cross-cultural studies (5). Accepted cultural standards and essential
elements of beauty are the ultimate goals regardless of the patients ethnic descent or race.

3. Minimally invasive techniques in rhinoplasty

During the last two decades, minimally invasive facial aesthetic procedures have gained
widespread popularity. According to the American Society for Aesthetic Plastic Surgery
(ASAPS), the annual number of nonsurgical cosmetic procedures increased by 228% from
1997 to 2010, and in 2010, nonsurgical procedures accounted for 83% of the aesthetic
procedures performed overall (6).
While botulinum toxin injection tops the ASAPSs annual list as the most commonly
performed cosmetic procedure since 2000, soft tissue augmentation procedures accounted
for more than 15% of the procedures performed in 2010. Breakdown by filler type of soft
tissue augmentation procedures reported by the ASAPS in 2010 indicated that calcium
hydroxylapatite (CaHA) is the second most frequently used filler following hyaluronic acid
(HA) filler derivatives.
Purported advantages over traditional surgeries include lack of scars, minimal down-time, less
pain, and lower cost. The nose is amenable to a variety of minimally invasive techniques.

3.1 Indications
Minimally invasive nonsurgical techniques in rhinoplasty allow for gratifying results in a
variety of indications, including augmentation type primary rhinoplasty(rhinosculpturing),
correction of post-rhinoplasty contour defects, treating the aging nose, dealing with the
ethnic nose and ameliorating/ reversing selected functional nasal impairments.
Minimally Invasive Approach for Rhinoplasty 121

4. Augmentation type rhinosculpture

Augmentation type, minimally invasive techniques might be utilized to correct both
aesthetic and functional nasal deformities (i.e., internal valve collapse). Architectural
deficiencies or imperfections necessitating augmentation type procedures can be
systematically categorized by dividing the nose and nasal skeleton into thirds:
1. Upper-third low radix (root of the nose), widened bony pyramid, bony contour
irregularities.
2. Middle-third low dorsum, dorsal contour irregularities, saddle nose deformity.
3. Lower-third inadequate tip projection, underrotated tip, retracted columella.
1. Upper-third
Low radix. The radix corresponds to the nasofrontal groove at a level approximately between
the supratarsal fold and the upper lash margin on straight gaze, and approximately 9-14 mm
anterior to the corneal projection. When the radix begins lower than the upper lash margin,
nasal length is shorter and the nasal base size appears to be larger. By augmenting a low
radix, the nasofrontal angle is displaced cephalically, increasing the distance from nasion to
the tip-defining point. This creates the perception of a larger appearing nose, improves the
apparent overprojected tip, and gives rise to a more balanced and proportional aesthetic
appearance.
Widened bony pyramid. The width of the bony vault should be analyzed both at the bony
base and at the dorsal ridge. Ideal width varies from individual to individual and is
influenced by the overall facial width, nasal length and projection, and by skin thickness.
Apparent widening of the bony pyramid might be secondary to loss of height and light
reflex from the nasal dorsum. In the case of a widened bony pyramid, augmentation of the
central bony pyramid may effectively narrow the perceived width.
Bony contour irregularities. These irregularities can be de-emphasized and unsightly
depressions can be eliminated or reduced.
2. Middle-third
Low dorsum. Dorsal height is assessed on profile view. Low dorsum refers to a dorsum
that lies more than 2 mm behind and parallel to a line from the nasofrontal angle to the tip-
defining point, and presents primarily as a congenital deformity, a consequence of previous
trauma or as a common characteristic of the ethnic nose, such as the platyrrhine and the
African American nose. Augmentation of a low dorsum is performed by using a dorsal graft
or via a minimally invasive technique.
Saddle nose deformity. This deformity refers to an abnormally concave nasal dorsum in
profile. Predisposing factors include previous trauma, rhinoplastic surgery (overresection of
the septum, excessive dorsal hump resection), infectious disease (i.e., syphilis, leprosy),
inflammatory disease (i.e., Wegener granulomatosis), neoplastic causes and platyrrhine
nasal structure. Associated nasal defects commonly seen include cephalic tip rotation,
middle vault collapse, and loss of tip support. In appropriately selected cases, correction for
saddle deformity can be achieved by nasal dorsum augmentation alone, whereas more
severe deformities mandate structural realignment with conventional approaches.
3. Lower-third
Inadequate tip projection. Tip projection is conventionally assessed by measuring the
distance of the tip-defining point from a facial parameter (i.e., nasion, alar crease) (7,8).
122 Rhinoplasty

However, in some cases, the nasal bases are large, yet the tip cartilages have poor projection.
An alternative functional definition is proposed by Constantian (9). A tip with inadequate
projection is defined as any tip that does not project to the level of the septal angle
(identified in the supratip as the edge of the dorsal septal angle). An underprojected tip
generates the illusion of a dorsal pseudo-hump in the supratip region, secondary to lack of
support and discontinuity in the supratip-lobule region. Augmentation of the nasal tip and
supratip lobule region can affectively support and project the tip and disguise discontinuity
in the caudal dorsum.
Underrotated tip. As alluded to previously, the perceived degree of tip rotation is defined
by the nasolabial angle. Desired tip rotation is influenced by gender and by the patients
height (inversely proportional). In women, it is 95 to 105 degrees, whereas a more acute
angle of approximately 90 degrees is considered aesthetic in men. Cephalic or caudal
positioning of the tip leads to corresponding change in the nasal length, tip rotation and
columellar inclination. An overly obtuse nasolabial angle makes the nose appear short,
whereas the converse adds apparent length. By augmenting a ptotic tip, the tip-defining
point is displaced cephalically so the distance between nasion to the tip-defining point is
reduced, thus making the nose appear shorter and aesthetically projected. Augmentation of
the anterior nasal spine of the maxillary bone located at the central part of the nasal base
opens the nasolabial angle and rotates the tip cephalically.

5. Post-rhinoplasty deformities
Postoperative rhinoplasty complications range from 8% to 15% (10) and result primarily
from failure to maintain adequate cartilaginous and bony structural support. Aesthetic
deformities often have functional implications and reflect the interdependency of form and
function.
Detailed systematic analysis of each of the structural and functional anatomic variables is of
utmost importance to determine the correct diagnosis and to properly select a treatment
plan. Postoperative complications that result from overresection/overcorrection following
overzealous surgery are often amenable to augmentation techniques and will be presented
in accordance to the nasal thirds:
1. Upper-third (nasion to rhinion) - low radix, low dorsum, dorsal irregularities, skeletal
deformities.
2. Middle-third inverted V deformity, supratip deformity, saddle nose deformity.
3. Lower-third external valve incompetence, loss of tip support.
1. Upper-third
Dorsal irregularities result from unsmoothed residual bony or cartilaginous (mid-dorsal
notch) fragments following hump removal. Poorly performed osteotomies result in
palpable skeletal deformities. These include "open roof" deformity, "step off deformities
and Rocker deformity. Rocker deformity occurs when medial osteotomy is taken too high
into the thick frontal bone. Consequently, the superior aspect of the osteotomized nasal bone
projects or "rocks" laterally. By augmentation of these untoward postrhinoplasty sequelae,
these deformities are de-emphasized or even eliminated. Likewise, an overresected dorsum
or low radix, otherwise necessitating dorsal or radix grafts, can be successfully augmented
using minimally invasive procedures.
Minimally Invasive Approach for Rhinoplasty 123

2. Middle-third
Inverted V deformity refers to inferomedial collapse of the upper lateral cartilage (ULC)
consequent to inadequate support of the ULC following overresection of the cartilaginous
roof during hump removal. At its caudal end, the ULC ideally forms an angle of 10 to 15
degrees with the septum near the anterior-septal angle. This region is defined as the
internal nasal valve and requires patency for normal airway.
When the middle vault collapses towards the anterior septal edge, internal nasal valve
collapse ensues, resulting in nasal airway obstruction and inverted V deformity.
Alignment of the internal valve area can improve the nasal airway and disguise the
accompanying aesthetic deformity, thus targeting both form and function. Traditionally,
correction of internal valve incompetence is accomplished by placing spreader grafts, either
unilaterally or bilaterally, that serve as spacer grafts between the dorsal septum and upper
lateral cartilage during rhinoplasty.
Supratip deformity (Polly beak) refers to postoperative fullness of the supratip and a blunt tip
lobular poorly differentiated from the dorsum. Inadequate tip support and over-resection of
the bony hump or cartilage [e.g., dorsal septum, dome or lower lateral cartilage (LLC)] are
etiologies that are amenable to augmentation by minimally invasive techniques, with injection
to appropriate areas simulating the effect of a columellar strut and dorsal grafts.
3. Lower-third
External valve incompetence. The external nasal valve refers to the area delineated by the
cutaneous and skeletal support of the mobile alar wall. Overresection of the lateral crus can
lead to collapse of the external valve with negative pressure of respiration, and consequent
nasal airway obstruction. Alar retraction, pinching, bossae and tip asymmetry are
accompanying changes. Augmentations of the inadequate skeletal support can stabilize the
external valve and ameliorate nasal obstruction. Traditionally, it is accomplished by alar
batten grafts. The size and precise placement of this augmentation are dependent upon the
corrections needed to be performed.
Loss of tip support. One of the most common iatrogenic complications of rhinoplasty is loss
of tip support secondary to interrupted major or minor tip support mechanisms. Major
support mechanisms include the interlocking attachment of ULC and LLC, LLC size, shape
and length, and the medial crural foot plate attachments to caudal septum. Minor support
mechanisms are the cartilaginous and membranous septum, the interdomal ligament
(fibrous connective tissue attachment between the medial and middle crura) and LLC
attachment to the skin.
Recognition of the effects of incisions and resections during rhinoplasty that violate these
support mechanisms should be thoroughly appreciated. The exact causes of loss of support
should be identified and countered. Commonly, cartilage grafts are used for augmentation
to establish acceptable contours: alar batten grafts are used to support the alar rims, strut
grafts stabilize the medial crura, and tip grafts support and contour the tip. Once identified,
loss of tip support can be overcome via invasive or minimally invasive augmentation type
techniques.

6. The aging nose

Aging is associated with changes in nasal aesthetics. These include downward rotation of
the tip lobule, creating an acute columellar lobule angle, maxillary alveolar hypoplasia with
124 Rhinoplasty

resultant divergence of the medial crural feet and columellar shortening. The aesthetic result
is a relatively longer nasal length, a droopy tip appearance and an apparently prominent
dorsal hump (4).

7. Material and methods

7.1 Pretreatment considerations
Achieving satisfactory aesthetic outcomes relies on realistic expectations of properly
selected patients in conjunction with precise execution of a selected technique that
optimally addresses the deformity. During the initial interview, the patients desires and
goals should be carefully assessed in terms of realistic expectations of what can be
accomplished. Medical history should be reviewed with focus on use of medication or
supplements that might increase bleeding (e.g., nonsteroidal anti-inflammatory drugs,
salicylate drugs, vitamin E, Omega-3, Ginseng, Ginko Biloba), allergies, history of cold
sores, previous nasal operations or dermal filler treatments, and whether the patient is
pregnant or lactating.
Before injection, the patient is counseled about the potential benefits against the inherent
limitations of minimally invasive rhinosculpturing. Treatment course, possible adverse
events, and the anticipated durability of treatment are reviewed. Following a full disclosure,
informed consent is obtained and pretreatment photographs are taken in frontal, oblique,
lateral and basal views.

7.2 Radiesse the preferred injectable filler

Radiesse (Bioform Medical Inc, San Mateo, California) is an injectable filler material
composed of synthetic CaHA microspheres (30%), suspended in an aqueous carrier gel
(70%). CaHA is the primary constituent of bone and teeth and has been in use for more than
20 years in medicine (11,12).
Injectable CaHA is FDA approved for correction of moderate to severe facial wrinkles and
folds and for restoration/correction of lipoatrophy in patients with HIV (13).
Following injection, the carrier gel is gradually absorbed and CaHA particles remain. Local
histolocytic and fibroblastic response at the injection site result in neocollagenesis around
the microspheres (14), thus contributing to the prolonged effects. Results achieved following
injection remain almost unchanged until 12 months. After 12-18 months, the achieved
volumes begin to diminish, though some results can be noted 24 months post-injection. The
average longevity therefore could be considered to be 12-18 months (15-19). Longer duration
of effect, up to 24 months, can be seen in some patients with a touch-up at one year of half
the amount injected the first time (20).
CaHA was reported to generate longer lasting results and higher levels of patient
satisfaction in 2 head to head studies with widely used HA fillers (21,22). Due to its
composition and inherent biocompatibility, Radiesse is particularly suitable injectable
material for augmentation of bony and cartilaginous contour deformities in the nasal area.

7.3 Pre-injection procedure

Before treatment, injection sites should be carefully marked by a washable marker with the
patient in an upright position, and prepared with suitable antiseptic. Topical anesthesia
using EMLA (lidocaine 2.5% and prilocane 2.5%) is applied for at least 15-20 minutes before
Minimally Invasive Approach for Rhinoplasty 125

injection. As regional infiltrative anesthesia frequently distorts surface landmarks, my

personal preference is to premix 1cc of Radiesse with 0.3% lidocaine, a ratio equivalent to
the widely used FDA-approved HA fillers. Radiesse is supplied in 1.5cc or 0.8 cc disposable
syringes with Leur-lock fittings and should be injected with a 27-gauge 0.25 inch (6 mm)
long needle.

7.4 Injection techniques

Radiesse should ordinarily be injected into the subdermal supraperiosteal plane in a
retrograde fashion using a linear threading, fanning or cross-hatching technique,
depending on the area being treated. The needle is placed at an angle of 30-45 degrees to
the skin, and a subcutaneous space or track is created. Needle location is assessed with the
index finger of the non-dominant hand to avoid visible nodules that might be created by
superficial injection. Slow, continuous, even pressure applied to the syringe plunger
whilst withdrawing the needle assures adequate control and helps to avoid product
palpability. Frequent reassessment throughout the procedure is recommended when the
patient is in the upright position, as the product is deposited incrementally.
Overcorrection is to be avoided. As a practical rule, it is advisable to gradually achieve the
final result over 2-3 sessions.
Systematic approach in rhinosculpturing is recommended starting with the nasal root and
dorsum and proceeding to the supratip area, tip lobule and finally, the nasal base. Each
injected area should address a specific deformity or aesthetic imperfection outlined
during nasal examination and nasal aesthetic analysis. Important technical considerations
and treatment goals will be discussed in relation to the above-mentioned anatomical
regions:
Nasal root
Radiesse is injected into the supraperiosteal plane in the intended area using linear
threading technique, starting in the midline. The index and thumb of the nondominant hand
should be placed on either side of the nasal bones to prevent product migration. By doing
so, the nasofrontal angle is increased (displaced cephalically), thus improving radix location
in cases of low radix and the apparent short nose.
Nasal dorsum
Careful inspection of the light reflex from an upright standing position can reveal any
irregularities in dorsal contour. Proper material deposition addresses dorsal contour
irregularities, low radix, inverted V deformity, and improves the dorsal concavity of saddle
nose deformity.
Nasal tip
The tip of the nose area is sensitive, so the injection point should be properly planned. It
is recommended to start in the midline, slightly caudal to and between the tip-defining
points, so a larger surface area can be approached using a single needle puncture.
Injection depth is in the subcutaneous plane above the LLC. The index and thumb of
the nondominant hand pinch the membranous caudal septum in order to alleviate pain
and to stabilize the injected area. Next, the needle is advanced up to the supratip break
point. (This point defines the cephalic limit of the nasal tip and is created by the
126 Rhinoplasty

difference between the projection of the tip-defining point and the height of the nasal
dorsum.)
Injection while the needle is withdrawn can effectively correct a bifid tip and enhance tip
projection. When continuing injection using the fanning technique, simulating an isosceles
triangle, whose shanks point toward the medial portion of the lateral crura, pinched tip is
improved and tip support is stabilized. This is especially the case when loss of tip support is
due to excessive excision of the medial half of the lateral crus. By augmenting the
inadequate skeletal support of the external valve, external valve incompetence can be
improved.
Nasal base
Tip rotation, projection and support can be modified by augmentation. Injection of Radiesse
into the central nasal base above the anterior nasal spine of the maxillary bone advances the
premaxilla and opens the nasolabial angle, thus rotating the tip cephalically and improving
a droopy tip. The needle is inserted at 450 to the upper lip toward the nasal spine and
Radiesse is deposited 1 mm supraperiosteally while the index finger and thumb of the
nondominant hand grasp the membranous septum cephalically. If further enhancement of
tip support, projection and rotation is desired, augmentation material is placed between the
medial crura toward the tip lobule, simulating columellar strut. By doing so, columellar
show improves.
Functional nasal problems
Common causes of airway obstructions are internal and external valvular incompetence and
inadvertent loss of tip support. Airway obstruction and loss of skeletal support require
augmentation type procedures.
Spreader graft injection
With the aid of a head light, a double-hook or a nasal speculum is placed onto the nostrils.
The alar rims are averted with the nondominant hand, thus exposing the internal nasal
valve. Radiesse is injected into the submucoperichondrial and submucosal planes at the
interface between the upper lateral cartilages and the dorsal cartilaginous septum using a
25-gauge 1.25 inch needle, in a retrograde linear threading technique. The injection serves
as a spacer and opens the anterior septal angle, thereby increasing the cross-sectional area
of the internal valve. This maneuver significantly increases the airflow into the nasal
passages.
Alar batten graft injection
External valve incompetence requires structural support provided traditionally by
placement of alar batten grafts. Once the site of collapse is identified during inspiration, the
area is marked. The needle is threaded through the vestibule toward the supra-alar crease at
the junction of the ULC and LLC, and injection is performed in a fanning technique.
Alternatively, needle puncture is performed percutaneously toward the premarked area.
Depth of injection reaches the subdermal and supra-perichondrial plane. Injection of alar
batten reinforces the ala and nasal sidewall that had been prone to collapse with respiration.
It should be noted that alar batten injection is difficult technically due to the tight skin
envelope. Small doses, deposited over 2-3 sessions in an incremental fashion is
recommended.
Minimally Invasive Approach for Rhinoplasty 127

7.5 Post-injection consideration

Following injection, immediate molding and massage is advisable to smooth the surface and
avoid irregularities. Injection site reactions such as redness and swelling are frequent and
resolve spontaneously. Application of ice on to the injected areas helps to reduce tissue
edema and ecchymosis. Patients are instructed to avoid the sun, tanning lights, sauna and
intense facial treatment for at least 24 hours. Patient follow-up visits are typically scheduled
2 weeks post-injection. Micropore-like tapes are applied to the injected areas to diminish
swelling. Refinement treatments are provided as needed.

8. Case presentations
8.1 Case presentation 1
Figure 4a. A 40-year-old female presented with inadequate tip projection and superior tip
rotation (porcine deformity) following rhinoplasty. A step-off deformity in the right nasal
sidewall is presented secondary to overresection of the bony and cartilaginous roof. The
lateral crus is deficient as well. The remaining cartilaginous rim appears knuckled owing to
contractural healing forces acting on weakened cartilages (bossae) in a patient with thin
skin. Physical examination revealed incompetence of the internal and external valves.

Fig. 4a. Preinjection lateral view demonstrating an inadequate tip projection, superior tip
rotation, and step-off deformity in the right nasal side wall and bossae following prior
rhinoplasty
Figure 4b. Post-injection photograph following spreader graft injection, and alar batten graft
injection to support the internal and external valves, respectively. Radiesse was also
injected to the nasal sidewall to smooth the step-off deformity and to the caudal dorsum at
the supratip region to de-emphasize the overrotated tip (nasolabial angle was 1040 before
treatment and 920 following injection). Support of the skeletal deficient areas improved both
form and function. The end result is an aesthetically pleasing nasal profile and well
supported and projected tip.
128 Rhinoplasty

Fig. 4b. Postinjection lateral view showing improved nasal profile and well supported and
projected tip

8.2 Case presentation 2

Figure 5a. Frontal view of a 47-year-old man with a history of 2 previous rhinoplastic
surgeries and cartilage grafts (septal, conchal) placement during his revision rhinoplasty 5
years prior to presentation. Nasal examination revealed a deviated nasal bony base to right
upper third, irregular nasal dorsum with slight saddle nose deformity, collapse of the left
middle vault, collapse of both alar wings (left side greater than the right side), inadequate
tip projection, asymmetric tip with deviation to the right, right side alar retraction and
slightly retracted columella.

Fig. 5a. Preinjection frontal view demonstrating a deviated nasal bony base to the right,
irregular nasal dorsum with slight saddle nose deformity, collapse of the left middle vault
and alar wings and an asymmetric, inadequately projecting tip
Minimally Invasive Approach for Rhinoplasty 129

Figure 5b. Frontal view following minimally invasive rhinosculpturing. Nasal sidewalls
and dorsal augmentations were performed along with spreader grafts and alar batten graft
injections. The unsightly right side bony irregularity was eliminated, the saddle deformity
was corrected and dorsal contour was improved. Tip support was stabilized and symmetry
was improved. Alar collapse was eliminated on the right side and improved on the left side
(left alar collapse was eliminated in a subsequent session.) Spreader graft and alar batten
graft injections enabled improved airflow due to the corresponding increase in the internal
nasal valve angle and external valve area, respectively.

Fig. 5b. Frontal view following minimally invasive rhinosculpturing. Note the improved
dorsal contour, enhanced nasal symmetry and smoothened skeletal irregularities

9. Discussion
During the last decade, minimally invasive rejuvenation procedures have gained
widespread popularity and have become an indispensible component of todays modern
cosmetic procedures. The diversity/blossoming of todays product options, recent
innovations in injectable filler technology, and availability of fillers with documented safety
profile, acceptable longevity, biocompatibility and low adverse problems pave the path to
this paradigm shift. Moreover, minimally invasive facial procedures offer minimal
downtime, less pain, no scars and a lower cost alternative compared to invasive
procedures.
Rhinosculpturing using minimally invasive technique provides an attractive alternative to
conventional rhinoplasty in selected cases. These include virgin noses necessitating
augmentation type procedure for aesthetic refinement, correction of post-rhinoplasty
contour defects, treating the aging and ethnic nose, and ameliorating/reversing selected
functional nasal impairments. Nevertheless, conventional rhinoplasty remains a pre-
130 Rhinoplasty

eminent treatment in cases necessitating reduction type interventions, septal deformities,

and nasal deformities otherwise not amenable to minimally invasive techniques.
As with any aesthetic procedure, the aesthetic outcome is the ultimate measure of proper
selection and execution of a technique that is optimally tailored to the deformity
addressed.
Inadequate nasal skeletal structure and support mandates the need for implant materials to
improve both form and function. Augmentation materials can be broadly categorized as
autografts, homografts, and alloplasts. An ideal augmentation material should approximate
closely the shape, consistency and strength of the deficient nasal framework. It should be
easily obtainable, capable of being shaped, biocompatible, resistant to extrusion or
resorption by the body, and cost-effective. Myriad materials have been used over the years,
each with its inherent advantages and liabilities (23).
Autologous cartilage grafts have become widely used as an effective autogenous
supportive tissue. Sources include septal conchal and costal cartilage. If available, septal
cartilage remains the cartilage of choice because of its rigidity, proximity, and straight
contour. Septal grafts are commonly used as dorsal/radix grafts, spreader grafts, tip
grafts, columellar struts and lateral crural and alar batten grafts. Despite their
unsurpassed biocompatibility, disadvantages of cartilage grafts include limited supply,
potential donor site morbidity, poorly predictable resorption rates and potential
palpability, visibility or warping.
Injectable materials allow for non-invasive nasal augmentation and sculpture. Ideally, they
should be non-toxic, non-allergic, biocompatible, easy to use, long lasting (yet,
nonpermanent), inexpensive and reversible. They should demonstrate a high safety profile
and produce a predictable result with minimal downtime.
Radiesse is a semi-solid, cohesive, completely biodegradable, deep subdermal implant. Its
principle component is synthetic CaHA, the primary mineral constituent of bone and teeth.
Results from in vivo and in vitro safety studies demonstrate that injectable CaHA is
biocompatible, non-toxic, non-irritating and non-antigenic (24). Clinical, histologic and
electron microscopic findings after in vivo injection have demonstrated dermal matrix
integration in biopsy samples harvested from human volunteers (12). This CaHA injection
provides scaffolding for collagen growth, thereby prolonging the duration of the effect.
These histologic findings were accompanied by evidence of maintained clinical
improvement (12). Biocompatibility studies on CaHA implants have all been characterized
by minimal, if any, inflammatory response with no foreign body reaction or evidence of
local systemic toxicity (11,12). Furthermore, there was neither ossification nor migration
from the injection sites (20).
Two multicenter randomized trials comparing CaHA injections with the widely used HA
fillers demonstrate that CaHA injections generate longer lasting results and higher levels of
patient satisfaction (21,22). This might be explained by Radiesses unique composition and
by the higher elasticity and viscosity of Radiesse compared to the leading HA based dermal
fillers (25).
Radiesses chemical composition, physical properties and documented high safety profile
render it valuable as the preferred injectable filler for augmentation type rhinosculpturing.
Minimally invasive rhinosculpturing using Radiesse offers an attractive alternative to
conventional rhinoplasty for patients who are actively hoping to avoid invasive surgery,
and for those who are not candidates for surgery because of serious comorbidities. Patients
Minimally Invasive Approach for Rhinoplasty 131

wishing to appreciate the benefits of rhinosculpturing before a subsequent surgery and

those who refuse revision surgery are likewise candidates for minimally invasive approach
to rhinoplasty.
Selected functional nasal impairment can be ameliorated or even reversed via minimally
invasive approach using Radiesse. Nyte (26) reported a spreader graft injection with
Radiesse for a non-surgical solution in internal valve collapse in 23 patients. Alar batten
graft injection with Radiesse can be used as a minimally invasive approach for external
valve collapse. Radiesse might well serve as a viable alternative for other cartilage grafts
such as dorsal cartilage graft, radix graft, tip grafts and columellar strut to contour structural
nasal deficiencies. Cartilage graft injection using Radiesse spares donor sites, has minimal
downtime, relatively longer term longevity, and is efficacious and cost-effective. Cartilage
graft injection has low risk of extrusion, palpability or visibility.
Rhinosculpturing via minimally invasive approach should be considered as an alternative in
cases mandating revision rhinoplasty where surgical expertise is of utmost importance. In
those cases minimally invasive rhinosculpturing might spare the inevitable inherent
difficulties posed on rhinoplasty in a previously operated nose.
In conclusion, Radiesse rhinosculpturing adds to the armamentarium of the rhinoplasty
surgeon. It is an easy to perform procedure that might spare an operation and provides high
patient satisfaction. Although much can be achieved by minimally invasive approach to
rhinosculpturing, one must be cognizant of the fact that when selecting alternatives to
address specific deformities, proper patient selection, detailed systematic analysis of the
anatomical variables, artistic perception and precise execution are of paramount
importance.

10. References
[1] Oneal RM, Beil RJ Jr, Schlensinger J. Surgical anatomy of the nose. Clin Plast Surg
1996;23(2):195-222.
[2] Powell N, Humphrey B. Proportions of the aesthetic face. New York: Thieme-Stratton;
1984.
[3] Tardy ME, Becker DG, Weingerg MS. Illusion in rhinoplasty. Facial Plast Surg
1995;11:117-138.
[4] Rohrich RJ, Hollier JR LH, Janis JE, Kim J. Rhinoplasty with advancing age. Plast
Reconstr Surg 2003;114(7):1936-1944.
[5] Larrabee WFJr. Facial beauty. myth or reality. Arch Otolaryngol Head Neck Surg
1997;123:571-2
[6] American Society for Aesthetic Plastic Surgery. 1997-2010 Cosmetic Surgery National
Data Bank Statistics. http://www.surgery.org. Accessed October,10 2010.
[7] Petroff MA, McCollough EG, Hom D, Anderson JR. Nasal tip projection: quantitative
changes following rhinoplasty. Arch Otolaryngol Head Neck Surg 1991;117:783-8.
[8] Ricketts RM. Divine proportion in facial esthetics. Clin Plast Surg 1982:9:401-22.
[9] Constantian MB. Practical nasal aesthetics. In: Habal M, ed. Advances in Plastic and
Reconstructive Surgery. St Louis, Mosby-Year Book, 1991:85-107.
[10] Becker DG, Becker SS. Reducing complications in rhinoplasty. Otolaryngol Clin North
Am 2006;39:475-92.
132 Rhinoplasty

[11] Havlik RJ; PSEF DATA Committee. Hydroxylapatite. Plast Reconstr Surg 2002;15:1176-
9.
[12] Hobar PC, Pantaloni M, Byrd MS. Porous hydroxyapatite granules for alloplastic
enhancement of the facial region. Clin Plast Surg 2000;27:557-69.
[13] Radiesse [package insert], San Mateo, CA: Bioform Medical Inc., 2009.
[14] Marmur ES, Phelps R, Goldberg D, Marmur et al. (2004) Clinical, histologic and
electron microscopic findings after injection of a calcium hydroxylapatite filler. J
Cosmet Laser Ther. 2004 Dec;6(4):223-6.
[15] Tzikas TL. Evaluation of Radiesse FN: A new soft tissue filler. Dermatol Surg
2004;30:764-8.
[16] Kanchwala SL, Holloway L, Bucky LP. Reliable soft tissue augmentation: a clinical
comparison of injectable soft-tissue fillers for facial-volume augmentation. Ann
Plast Surg 2005;55:30-5.
[17] Jacovella PF. Calcium hydroxylapatite facial filler (Radiesse): indications, technique,
and results. Clin Plast Surg 2006;33:511-23.
[18] Jansen DA, Graivier MH. Evaluation of calcium hydroxylapatite-based implant
(Radiesse) for facial soft tissue augmentation. Plast Reconstr Surg 2006 Sep;118(3
Suppl):22S-30S, discussion 31S-33S.
[19] Silvers SL, Eviatar JA, Echavez MI, Pappas AL. Prospective, open-label, 18-month trial
of calcium hydroxylapatite (Radiesse) for facial soft-tissue augmentation in patients
with human immunodeficiency virus-associated lipoatrophy: one-year durability.
Plast Reconstr Surg 2006 Sep;118(3 Suppl):34S-45S.
[20] Feldmerman LI. Radiesse for facial rejuvenation. Cosmet Dermatol 2005;18:823-6.
[21] Moers Carpi MM, Tufet JO. Calcium hydroxylapatite versus nonanimal stabilized
hyaluronic acid for the correction of nasolabial folds: a 12-month, multicenter,
prospective, randomized, controlled, split-face trial. Dermatol Surg 2008
Feb;34(2):210-5.
[22] Moers-Carpi M, Vogt S, Santos BM, Planas J, Vallve SR, Howell DJ. A multicenter,
randomized trial comparing calcium hydroxylapatite to two hyaluronic acids for
treatment of nasolabial folds. Dermatol Surg. 2007;33 Suppl 2:S144-51.
[23] Lovice DB, Mingrone MD, Toriumi DH. Grafts and implants in rhinoplasty and nasal
reconstruction. Otolaryngol Clin North Am 1999;32(1):113-41.
[24] Hubbard WH. Bioform implants. Biocompatibility. Franksville, Wis: Bioform, Inc., 2003.
[25] BioForm Medical Inc., 2009, data on file.
[26] Nyte CP. Spreader graft injection with calcium hydroxylapatite: a nonsurgical
technique for internal valve collapse. Laryngoscope 2006:116:1291-2
 Part 6

Complications
 10

Mucous Cysts as a Complication of Rhinoplasty

Aris Ntomouchtsis, Nikos Kechagias, Persefoni Xirou,
Georgios Christos Balis, Katerina Xinou and Konstantinos Vahtsevanos
Department of Oral and Maxillofacial Surgery, Theagenion Cancer Hospital, Thessaloniki
Department of Histopathology, Theagenion Cancer Hospital, Thessaloniki
Department of Radiology, Theagenion Cancer Hospital, Thessaloniki
Greece

1. Introduction
Aesthetic and reconstructive surgery of the nose remains the most challenging and difficult
of all head and neck plastic surgical operations. (Tardy, 1995) Rhinoplasty is considered as a
highly demanding procedure. The nose is the most prominent part of the face and
derogations may be less appropriate than deviations.
Complications can refer either to the skeletal framework or to the soft-tissue regions and
they can be divided into functional and aesthetical. According to the time of presentation
they can be intraoperative or postoperative early or late complications.
Implantation cysts and deforming masses are infrequent and very rare, but avoidable
complications of rhinoplasty. Displacement of fragments of epithelium may result in
subcutaneous graft entrapment and subsequent encystation. Epidermoid cysts or mucous
cysts may be developed, depending on the type of epithelium trapped. They must be
addressed with a thorough evaluation of the extent of the lesion to choose the most
appropriate procedure for removal. Knowledge of the various capabilities and presentations
of postrhinoplasty cysts, will better equip surgeons for a successful outcome. Although a
mucous cyst is a benign lesion, it is considered to be a serious complication of rhinoplasty.
Mucous cysts are presented in many locations and ages, with a wide range of concurrent
symptoms. Most of them are appeared several months or years after rhinoplasty.
Complete resection of the mucous cyst is the gold standard of treatment. Identification of
involved structures will ensure appropriate procedure selection. Almost all the cases
reported in the literature have been described as solitary lesions which were successfully
eradicated following a single surgical procedure.
There was only one paper reported a case of a patient who had presented two mucous
cysts,the first one two months postoperatively and the second one five months after surgical
extirpation (Mouly, 1970), and only two authors reported recurrence after surgical
intervention. (Zijlker and Vuyk, 1993; Ntomouchtsis et.al. 2010) Regarding the high number
of rhinoplasty procedures performed worldwide every year, the number of the 30 published
cases is on the contrary very low. These observations make it possible that specific local
conditions must exist before a mucous cyst may be expected to develop and one important
factor is likely to be the size of the displaced epithelial fragment. There is also exists the
possibility that all occurred complications have not been presented yet.
136 Rhinoplasty

It is interesting that there have been two reports of respiratory implantation cysts of the
mandible following combined rhinoplasty and genioplasty, where the chin augmentation is
achieved using osteocartilagenous grafts harvested from the nasal dorsum. (Anastassov and
Lee, 1999; Imholte and Schwartz, 2001)
thorough evaluation of the extent of the lesion is the best way for the surgeon to choose
the most appropriate procedure for removal.

2. Clinical signs and differential diagnosis

Patients normally complain about a gradually swelling mass in the operation field or in its
proximity. They may also feel continuous pressure over the lesion. Cysts may be featured as
circular, mobile and non tender mass when they are palpated. Otherwise it can be an
immobile, painless, soft smooth subcutaneous mass fixed to the skin and to the deep planes.
The overlying skin tends to be more vascular than the closest region.
Functional and aesthetic problems could be caused by the lesion, such as remarkable
asymmetry of the tip and the nostrils, persistent nasal obstruction and increased snoring,
impaired nasal breathing and swelling, deviation of the septum and saddle nose deformity.
Symptoms and signs of inflammation, like infection and abscess formation, can accompany
the mass. (Zijlker and Vuyk, 1993; Flaherty et al., 1996; Kotzur and Gubisch, 1997; Bracaglia
et al.,2005; Tastan et al.,2010 It has been reported that antibiotics have managed to halt the
enlargement but can not always achieve resolution of the cysts. (Shulman and Westreich,
1983; Dini, 2001)
The main differential diagnosis of mucous cyst must also includes other entities beyond
infections, such as lipogranulomas/ paraffinomas, which are thought to represent foreign
body reactions to displaced lipid ointment from nasal packings through intranasal incisions.
(Gryskiewicz, 2001) Other various benign tumor-like nasal lesions must be taken under
consideration, such as epidermoid inclusion cysts, tumefective cartilage proliferation,
osteomas, lipomas, pleomorphic salivary adenomas, granulomatous diseases. Congenital
midline nasal masses including, gliomas, encephaloceles, and nasal dermoid sinus cysts are
reported to occur. Lesions such as inverting papillomas, juvenile nasopharyngeal
angiofibroma, ethesioneuroblastoma and even frontal sinus mucoceles must be excluded.
(Baarsma , 1980; Hacker and Freeman , 1994; Romo T 3rd et al. 1999) It could be harmful to
misdiagnose malignant neoplastic lesions that can involve the nasal region such as
squamous cell carcinoma, malignant melanoma, adenocarcinoma, sarcoma, and lymphoma.
Clinical examination, nasal endoscopy, imaging studies and finally cytology or/and
histological analysis after biopsy will define the possible diagnosis.
The sites of mucous cyst occurrence can vary. The majority of these these cysts occur over
the nasal bone along the line of nasal osteotomy, with the nasal dorsum being the most
affected site. Table 1. In few cases, rare locations have been described, including paranasally
along the maxillary osteotomy, (Karapantzos et.al., 1999; Raine et.al., 2003), the lateral wall,
the tip of the nose, the alar, the inner canthus, the radix nasi, and even the glabellar region.
(Mouly, 1970; Rettinger and Zenkel, 1997; Bracaglia et al. 2005; Riedel et.al. 2007; Pausch et
al. 2010; Ntomouchtsis et al. 2010; Dionyssopoulos et al. 2010)

3. Radiologic findings
The list of differential diagnoses ranges from postoperative nasal lesions, various other
benign, congenital, infectious or neoplastic processes unrelated to surgery.
Mucous Cysts as a Complication of Rhinoplasty 137

A/A Author Year Sex/Age Location Duration Rhinoplasty

1 McGregor 1958 N.A. Dorsum 5 days Direct open
Canthus inner
2 Mouly 1970 F/N.A. 2m & 5m Direct open
bilateral
3 Senechal 1981 M/31 Radix 10y Direct open
4 F/44 Paranasal 8y Direct open
5 Shulman 1983 F/32 Dorsum/Tip 2m closed
6 Lawson 1983 M/28 Dorsum Several m Direct open
7 Harley 1990 F/27 Dorsum 6y closed
8 M/22 Dorsum 10m closed
9 Toriumi 1990 N.A N.A N.A N.A
10 Zijlker 1993 F/31 Dorsum 1y open
11 Flaherty 1996 F/24 Dorsum 5y closed
12 Kotzur 1997 M/45 Dorsum 6y Direct open
13 M/23 Dorsum 4y closed
14 M/24 Dorsum 2y closed
15 Rettinger 1997 M/N.A Alar lateral 1y Direct open
16 Karapantzos 1999 /25 Paranasal 3m Direct open
17 Romo 1999 M/33 Dorsum 2y Direct open
18 Tan Ergin 2000 M/47 Dorsum 6m Direct open
19 Dini 2001 M/29 Dorsum 3m Direct open
20 Raine 2003 F/58 Paranasal 20y close
21 Liu 2003 M/33 Dorsum 7y Direct open
22 Bracaglia 2005 F/30 Lateral Wall 2m Endoscopic
23 F/38 Radix 1y Endoscopic
24 Riedel 2007 F/34 Lateral Wall 6m close
25 Pausch 2010 F/17 Dorsum 14m open
26 F/19 Alar lateral 1y open
27 Struijs 2010 M/64 Dorsum 40y open
28 Tastan 2010 F/25 Tip 1y open
29 Dionyssopoulos 2010 F/26 Glabella 22m Direct open
30 F/20 Canthus inner 6m open
31 Ntomouchtsis 2010 F/29 Glabella 15m Direct open
Table 1. Table of all published cases in the English literature
Preoperative assessment with computed tomography and/or magnetic resonance imaging
can help narrow the differential diagnosis by evaluating the nature of contents within the
138 Rhinoplasty

mass and the possibility of bony or intracranial involvement. (Leong and Sharp, 2009) CT
assesses for any bony involvement, while MRI gives better definition of soft tissues and is
likely the best method for detecting intracranial masses. (Barkovich et al., 1991)
A CT scan or magnetic resonance imaging is needed to determine the extent of the lesion
and thus the best surgical approach. Magnetic resonance imaging gives a more detailed
image and has fewer false-negatives and fewer false-positives than CT. (Zerris et al., 2002)
Only 3 of the 31 reported cases have described the radiological (CT or MR) features of
postrhinoplasty mucous cysts. (Raine et al., 2003; Leong and Sharp, 2009; Ntomouchtsis et
al., 2010)

Fig. 1. ad Brain MRI showing an oval-shaped subcutaneous cystic lesion in the midline, in
front of the frontal sinuses. The lesion shows homogeneously high signal intensity in axial
T2 (a) and STIR images (b), low signal intensity in sagittal T1-weighted image (c), and
peripheral enhancement in sagittal T1-weighted image after gadolinium injection (d)
A CT scan or magnetic resonance imaging is needed to determine the extent of the lesion
and thus the best surgical approach. Magnetic resonance imaging gives a more detailed
image and has less false-negatives and less false-positives than CT. (Zerris et al., 2002) CT
assess for any intracranial connection. MRI which gives better definition of soft tissues is
likely the best method for detecting intracranial masses. (Barkovich et al., 1991)
Mucous Cysts as a Complication of Rhinoplasty 139

Mucous cysts usually appear as well-defined, homogenous, non-enhancing or peripherally

enhancing lesions with no bony destruction and without any intracranial communication.
The content of these cysts is mostly hypointense in CT, and shows low to intermediate
signal in T1-weighted and high signal in T2-weighted images in MR. (Koeller et al., 1999;
Leong and Sharp, 2009; Ntomouchtsis et al., 2010) Unfortunately, these findings are not
specific because they can be encountered also in foreign body inclusion cysts (Pausch et al.,
2010), epidermoid cysts and sebaceous cysts. Raine et al described a case of a mucous cyst,
which appeared as a well-defined hypointense soft tissue mass in CT with no bony elements,
findings more consistent with a fibrous or granulomatous lesion. (Raine et al., 2003)
The differential diagnosis of mucous cysts from paraffinomas, dermoid cysts and lipomas is
easier, because the latter are fat-containing hypointense lesions in CT, usually showing high
signal in T1- and T2-weighted images in MR. (Koeller et al., 1999; Liu et al., 2003)
Therefore, CT and MR imaging is helpful in the preoperative evaluation of a post-
rhinoplasty lesion, because it can demonstrate the benign nature and the cystic content of
the mass, excluding other benign non-enhancing lesions (granuloma, sebaceous cyst,
dermoid cyst, lipoma), solid enhancing lesions (traumatic aneurysm, hemangioma,
neurofibroma, lymphoma, basal cell carcinoma, metastasis) or lesions that cover underlying
calvarial masses (eosinophilic granuloma, meningioma, metastasis). Color Doppler
ultrasonography can also be used in differential diagnostic problems of cystic lesions as an
alternative of MRI. (Riedel et al., 2007) If any concern exists as to the possible diagnosis, a
preoperative biopsy should be considered.

4. Surgery
Surgical eradication remains the appropriate treatment for mucous cysts of the nose.
Complete resection avoiding rupture is curative. The surgical procedure is dependent on the
location and extent of the lesion and on patient age. The reconstruction of the
intraoperatively resulting defect is a challenging problem, which has to be solved, mainly
from a aesthetic point of view.
Many surgical approaches have been described and successfully attempted as presented in
the literature. Endonasal intercartilagineous and intracartilagineous incisions, although they
offer limited exposure, they have been used successfully for mucous cysts involving the tip
and supratip regions. (Flaherty et al., 1996; Kotzur and Gubisch, 1997; Shulman and
Westreich, 1983; ; Dionyssopoulos et al. 2010) Extracolumellar incision is used for an open
rhinoplasty technique. It gives excellent exposure for complete extirpation of the lesion and
reconstruction of the defect and leaves inconspicuous scars in the long run. Incision through
the overlying skin of the lesion permits direct and excellent exposure but must be
considered as a third option due to visible scars are leaved.
The direct percutaneous approach, even when a geometrically broken line incision is used,
may result in a visible scar. There has even been an endoscopic approach proposed.
(Bracaglia et al., 2005)
The open approach through the existing scars should be preferred for revision of
rhinoplasty in cleft lip patients. (Pausch et al., 2010)
Dorsal nasal cysts formation is prevented by extremely meticulous removement of all debris
from the operative site by suction and submucosal separation of the upper lateral cartilages.
There are two ways of dealing with the upper lateral cartilages where they are attached to
the septum. The mucosa can either be detached and left intact or released by a transmucosal
140 Rhinoplasty

incision by using junction tunnels, which preserve the mucosa. The mucoperichondrium
and mucoperiosteum are elevated bilaterally at the junction of the septum with the nasal
wall. The upper lateral cartilage is released by preserving the mucosal integrity through
submucosal dissection. Entrapment of mucosa and formation of nasal cysts should be
prevented by maintaining intact the mucosal integrity under osteotomy or cartilage incision
sites. (Johnson and Anderson, 1977; Ress, 1980) Creation of dead space is declined by trying
to avoid undermining osteotomy sites.
Irrigation at the end of the procedure can provide additional clearing of remnants from the
surgical field. Careful removal of all mucosal fragments from the osteotomy sites at the time
of primary surgery is mandatory and can by preventative.
Complete surgical extirpation of cysts may lead to disfigurement of the nasal framework.
Direct reconstruction of the defect sets the goal of surgical treatment of this rare condition.
Cartilaginous grafts (e.g., rib or concha grafts) are recommended for reconstruction of the
nasal frame in such cases.

5. Intraoperative findings
On exploration the cystic mass could appear as a distinct capsule with no direct connection
between it and the nasal mucosa, as it has been reported in the majority of the published
cases. (Harley and Erdman, 1990; Romo T 3rd et al., 1999) On the other hand the cyst could
be found either tightly attached to the surrounding tissues, or adherent to the overlying
skin, or in connection with the underlying cartilaginous and bony nasal structures, or even
attached to previously used autogenous grafts. (Kotzur and Gubisch, 1997; Tan Ergin and
Akkuzu , 2000; Pausch et al., 2010)
The underlying nasal bone or cartilage in the area of the lesion can be depressed with an
impression deformity, or eroded or even resorbed. [21,30,31] (Harley and Erdman, 1990; Tan
Ergin and Akkuzu , 2000; Pausch et al., 2010)
During the operation the lesion can be removed removed either intact or perforated.If the
latter happens, clear fluid or partly fatty fluid or mucous fluid or even thick white-yellowish
liquid usually is yielded from the cystic wall. (Flaherty et al., 1996; Kotzur and Gubisch,
1997; Romo T 3rd et al., 1999)
Dead space or deformity of bone or cartilage could be created,in the operation field, after
complete cyst removal. which has to be managed through careful suturing in layers and to
be repaired, usually by using autogenous graft.

6. Histopathology
Macroscopically a mucous cyst appears as an oval shaped,soft smooth walled cyst, located
subcutaneously, easily separated from its surrounding structures and filled with mucinous
material. Microscopically the cyst wall is lined by ciliated columnar respiratory type
epithelium with dispersed goblet cells. (Ntomouchtsis et al., 2010)
Due to the fact that diagnosis is based primarily on microscopic findings, particularly the
lining of the cysts, similar cutaneous cystic formations can enter in the differential diagnosis.
Cutaneous ciliated cysts show numerous papillary projections lined by a simple cuboidal or
columnar ciliated epithelium, while mucin-secreting cells are absent. These cysts can be
found on the lower extremities (females) or on the back (males) and measure several
centimeters in diameter. (Elder et al., 2010)
Mucous Cysts as a Complication of Rhinoplasty 141

Fig. 2. Cyst filled with mucinous material (H-E 20)

Fig. 3. The cyst wall is lined by ciliated columnar respiratory type epithelium with dispersed
goblet cells (H-E 200)
142 Rhinoplasty

Bronchogenic cysts are lined by a mucosa consisting of ciliated pseudostratified columnar

epithelium, while goblet cells may be interspersed. The wall frequently contains smooth
muscle and mucous glands. Thyroglossal duct cysts differ from bronchogenic cysts in that
they do not contain smooth muscle and they frequently contain thyroid follicles.
Bronchogenic cysts are most commonly seen on the suprasternal notch and rarely on the
anterior aspect of the neck or on the chin. Thyroglossal duct cysts are clinically
indistinguishable from bronchogenic cysts, except that they are usually located on the
anterior aspect of the neck. (Elder et al., 2010)
Apocrine hidrocystoma is a multi-loculated cystic lesion with occasional papillary
projections. The inner surface of the cyst and the papillary projections are lined by a row of
columnar secretory cells of variable height showing decapitation secretion indicative of
apocrine secretion. Peripheral to the layer of secretory cells are elongated myoepithelial
cells, their long axes running parallel to the cyst wall. Apocrine hidrocystoma occurs usually
as a solitary, translucent cystic nodule on the face and occasionally on the ears, scalp, chest,
shoulders, or vulva. Multiple apocrine hidrocystomas are rarely encountered. Frequently,
the lesion has a blue hue, while the diameter ranges from 1 to 20 mm. (Elder et al., 2010)
Eccrine hidrocystoma shows a single cystic cavity, while the cyst wall usually shows two
layers of small, cuboidal epithelial cells. In some areas, only a single layer of flattened
epithelial cells can be seen, their flattened nuclei extending parallel to the cyst wall. Small
papillary projections extending into the cavity of the cyst are observed rarely. Eccrine
secretory tubules and ducts are often located below the cyst and in close approximation to it,
and, on serial sections, one may find an eccrine duct leading into the cyst from below.
However, no connection can be found between the cyst and the epidermis. In this condition,
usually one lesion -- but occasionally several, and rarely numerous lesions -- are present on
the face. As in apocrine hidrocystoma, the lesion consists of a small, translucent, cystic
nodule 1 to 3 mm in diameter that often has a bluish hue. (Elder et al., 2010)
Cutaneous metaplastic synovial cysts show villous-like projections and a lining that
resembles hyperplastic synovium (not epithelium). This type of cysts is rare and presents
months or years after a surgery as solitary tender subcutaneous nodule. The cause of
formation of cutaneous metaplastic synovial cysts remains unclear, but previous trauma
usually precedes their onset. Taking in consideration this entity is significant, since a recent
publication reports a case of cutaneous metaplastic synovial cyst on a patients face after
receiving hyaluronic acid filler injections. (Inchingolo et al., 2010)
Foreign body inclusion cysts, even though called cysts inappropriately, microscopically
they represent granulomatous reaction to bone or cartilage fragments following rhinoplasty.
[34] (Chang and Jin, 2008)
Follicular cysts (epidermal, trichilemmal, dermoid, etc) can be often found on the face,
regardless of any previous intervention, but can easily be excluded from the diagnosis since
they are lined by stratified squamous epithelium resembling epidermis and filled with
keratinous material. Even though we should be aware of this type of cysts since there have
been reports of post rhinoplasty epidermal cysts. (Grocutt and Fatah, 1989; Tastan et al., 2010)
All of the aforementioned cysts show similar clinical or pathological findings with the
cutaneous mucous cysts, but a careful histological examination can spot the differences and
exclude them from the diagnosis.
In conclusion, histological examination of all cysts that present on the face after an
intervention is of paramount importance, not only to exclude malignancy, but also to
narrow down the list of differential diagnoses.
Mucous Cysts as a Complication of Rhinoplasty 143

7. Theories of creation
The aetiology of this lesion remains unknown and controversial. Different theories of
creation exist. The first hypothesis assumes the herniation of nasal mucosa in the direct
postoperative period, for example after a patient blew his or her nose. (McGregor et al.,
1958) The herniation or subsequent growth of nasal mucosa can take place through the
infracture sites or incisions, although no reported cases mentioned any connection of a cyst
to the normal mucous layer of the nose. (Mouly, 1970; Harley and Erdman, 1990)
The most reasonable explanation is the proliferation of ectopic or displaced mucous
membranes, followed by improper clearing of mucous epithelial remnants and bony or
cartilage parts. This seeding of mucous tissue and remnants attached to bone or cartilage
either in situ or as a part of an autogenous graft seems to be the main reason for which the
mucous grafts grow and proliferate in their ectopic position (Shulman and Westreich, 1983;
Harley and Erdman, 1990; Kotzur and Gubisch, 1997; Dini et al., 2001)
Another aspect that has to be emphasized is that in some of the described cases in the
literature, the location of appearance does not coincide with the osteotomy lines or even
with the intervention field of a rhinoplasty. This could be explained by poor surgical
technique during a close rhinoplasty, which can lead to extreme surgical trauma, violation
of the intranasal mucosal lining and subsequent encystation of nasal mucosal epithelium,
displaced at the time of surgery. (Zijlker and Vuyk, 1993; Dini et al., 2001; Ntomouchtsis et
al., 2010) This explains the different locations described in the literature, and the absence of
connections with the internal nasal lining that is observed and described during surgical
eradication.
On the other hand, the reappearance of a cyst can also be attributed to a faulty surgical
technique. (Ntomouchtsis et al., 2010) It is also hypothesized that cysts may develop by
occlusion of sebaceous glands because of scar tissue formation. (Rettinger and Zenkel, 1997)
In cleft lip nose rhinoplasty, however, cystic masses of the nose might have other origins, so
congenital malformations or remnants of the nasolacrimal duct have also been described.
Mucous cysts of the nose are not specific complications of cleft nose surgery, although they
have been observed in this specific patients group. (Aikawa et al., 2008; Pausch et al., 2010)

8. Prevention
In order to prevent iatrogenic cyst formation it is important to use an appropriate surgical
technique. The manoeuvres must be executed carefully with respect to the soft and hard
tissues of the operation field. The need for atraumatic and careful tissue dissection has been
emphasized by virtually all authors who have described postrhinoplasty mucous cysts.
By preserving the mucosal integrity and using sharp instruments one can hope to avoid the
involuntary dispersion of tissues into other layers while dissecting. The mucosal lining must
be kept intact during the rhinoplasty, or in any case of disruption a meticulously restoration
is mandatory. Mucosal lining can be preserved when subperichondrial and subperiostal
tunnels are being established over the septum and under the nasal dorsum before any
surgical alterations will be made to the structures. (Zijlker and Vuyk, 1993) Completing of
all osteotomies is also important for maintaining mucosal integrity during intranasal
osteotomy and to decrease the chance of cyst formation. The osteotomy sites must be placed
properly, and performed with adequate water injection and hydrodissection. The mucosa
around the lateral osteotomy site should be elevated, to prevent entrapment. For security
144 Rhinoplasty

the osteotomy sites should be thoroughly inspected at the completion of the procedure. (Liu
and Kridel, 2003).
On the other hand many surgeons prefer not to elevate tunnels, as this additional stripping
and dissection of periosteum decreases the structural support of the nasal framework after
osteotomies are complete. They report better stability and more predictable outcomes with
external perforated osteotomy, by using a small osteotome (2-4 mm) that simultaneously
minimize disruption of periosteal surfaces, stabilize medial movement, reduce lateral wall
collapse and decreases dead space. (Goldfarb et al., 1993; Rohrich et al., 2001; Rohrich et al.,
2003) It as experimentally been shown that this technique decreases soft-tissue disruption or
displacement compared to continuous osteotomies. (Byrne et al., 2003) It must also be
emphasized that none of the reported postrhinoplasty cysts are connected to this surgical
technique.
Meticulous removal of all bony, cartilaginous and mucous remnants is essential. It is
essential that if osteocartilagenous grafts are used harvested from the nasal frame they must
be prepared by removing the respiratory epithelium prior to implantation. (Raine et al.,
2003) Irrigation at the end of the procedure can be an additional measure to clear the
surgical field of remnants. (Gryskiewicz, 2001) The created dead space must be closed in
layers. Intranasal incisions should be closed properly. Rhinoplasty is a very demanding
procedure. In complicated cases, especially in revision surgery, the risk of complications is
higher when performed by inexperienced surgeons. The best prevention of mucous cysts
occurring after rhinoplasty is not only meticulous elimination of all bony, cartilage, and
epithelial tissues and mucous parts, but also, and even more important, emphasis on a most
atraumatic and careful operation. (Kotzur and Gubisch, 1997) The key to a good outcome is
localizing the lesion and selecting the most appropriate procedure.

9. Conclusion
Relative to the high number of rhinoplasty procedures performed each year worldwide, the
number of the 31 presented published cases is on the contrary very low. (Senechal et al.,
1981; Lawsonet al., 1983; Toriumi and Johnson, 1990; Struijs and Bauwens, 2010 ) The only
data reported regarding the frequency of postrhinoplasty mucous cysts are from two case
reports, where there are count 1/6000 and 3/5000, a percentage of 0.02 and 0.06
respectively. (Kotzur and Gubisch, 1997; Dini et al., 2001) Otherwise there is a large number
of unreported cases or the postrhinoplasty cyst is a really rare condition. (Karapantzos et
al., 1999)
It is possible that intraoperative tissue dispersion would occur in large number of cases, but
does not lead automatically to the development of cysts. Although the physiopathology is
uncertain, it seems that entrapped fragments of epithelial tissue are proliferated, if specific
local conditions are created. It remains unclear what factors influence the final formation in
these rare cases.

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