Rhinoplasty and septoplasty: Closed and open
LUC CESTELEYN, N RAVINDRANATHAN and CORAZON COLLANTES-JOSE
PRINCIPLES AND JUSTIFICATION
Rhinoplasty is the most frequently requested aesthetic
procedure usually directed towards reduction, augmenta-
tion or subtle renement of the bony-cartilaginous skel-
eton. e skin so-tissue envelope (SSTE) redrapes to its
new foundation. Many components of the operation can
be variably aected by the healing process. e philosophy
is preservation, reconstruction and cartilaginous graing,
providing tip support (TS) and creating a strong, high pro-
le that provides and maintains the shape to the overly-
ing SSTE by opposing the distorting scar contracture, and
preserving or correcting the nasal airway.
THE BONY PYRAMID: UPPER THIRD
e nasal vault:
1. Paired nasal bones, thick at the frontal bone junction
2. Nasal processes of the maxilla overlap the upper lateral
cartilages (ULCs) (no downward rasping)
THE CARTILAGINOUS VAULT (NASAL
e quadrangular septal cartilage acts as a supporting
strut and contributes to the convex dorsum (nasal hump).
It extends anteriorly as the posterior septal angle (PSA)
from the anterior nasal spine (ANS) as a cantilever, to sup-
port the nasal tip at the anterior septal angle (ASA), and
posteriorly articulates with the vomer and perpendicular
plate of the ethmoid. Superiorly, it connects deep to the
nasal bones and the paired ULC to form the cartilaginous
vault. e septum's most caudal mobile aspect articu-
lates with the medial aspect of the lower lateral cartilages
(LLCs), supporting the tip, and facilitates LLC movements
Inferiorly, the ULC are folded back on themselves at the
plica nasi, where they articulate with the overlying supe-
rior border of the LLC, and their inferior borders makes
an angle of 10°–15° with the septum at the valve area.
e integrity of this angle is important for nasal airway
patency and may be disrupted by disarticulation of the
ULC from the nasal bone, rupture of the connection with
the LLC and disconnection with the SSTE (Figure 85.1
Principles and justication 877
e cartilaginous vault (nasal bridge): Middle third 877
e tip: Mobile and supple lower third 878
Preoperative evaluation 879
Nasal Tip Surgery 883
Septal shortening 883
Surgical techniques 886
How I do it: A modied open structure rhinoplasty technique 887
878 Rhinoplasty and septoplasty: Closed and open rhinoplastic techniques
THE TIP: MOBILE AND SUPPLE LOWER THIRD
e LLC is composed of a medial (MC3b) and a lateral
crus (LC3a) to form an arch with domes at the level of their
connection by an intermediate crus (ImC3c). e straight
and thin MC is connected by the interdomal ligament and
by the suspensory ligament to the ASA at the so medial
triangle of Converse. ey come together in the midline
to be part of the columella where they strongly articulate
with the septum by ligaments in the mobile membranous
septum. ey end posteriorly in the MC foot plates around
the ANS, and superiorly diverge (angle of divergence) as
ImC, also making an angle of rotation (infra-tip break) to
form the dome and then the quadrangular and convex LC.
At the dome and LC the lower border of the cartilage is
some distance from the nostril border; the space of super-
position of skin and vestibular skin is the so triangle of
Converse or facet, to be respected by the marginal incision
which follows the caudal LC margin. e LC extend down
to the pyriform orice and are connected with the ULC
by brous and musculoaponeurotic tissue or supercial
musculoaponeurotic system (SMAS). e weak triangle
of Webster is located between the ULC, the LLC and the
pyriform aperture (osteotomies can disrupt the triangle
and result in airway obstruction).
The support of the nasal tip
Support mechanisms are divided into major and minor
components (Figure 85.3). e nasal pyramid is a tripod
concept consisting of the LLC (Anderson). e LC repre-
sents the upper legs and the linked MC the lower leg of the
tripod. Tip-characteristics [tip projection (TP), tip rota-
tion (TR) and nasal length] may be adjusted by alteration
of the tripod limbs and the tip-supporting structures.
Figure 85.2 Surgical anatomy of the septum: (1) nasal
bone, (2) ULC, (3) quadrangular septal cartilage, (4) ASA, (5)
middle septal angle, (6) PSA-ANS, (7) maxillary crest, (8) per-
pendicular ethmoid plate.
Figure 85.1 Surgical anatomy of the nose. (a) Soft tissues.
(b) Osseocartilaginous structures and landmarks: (1) nasal
bone, (2) ULC, (3) LLC: 3a LC, 3b MC, 3c ImC, (4) nasion,
(5) rhinion, (6) ASA, (7) dome. (c) Alar cartilages and tip-structures.
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87785Rhinoplasty and septoplasty: Closed and open rhinoplastic techniquesLUC CESTELEYN, N RAVINDRANATHAN and CORAZON COLLANTES-JOSEPRINCIPLES AND JUSTIFICATIONRhinoplasty is the most frequently requested aesthetic procedure usually directed towards reduction, augmenta-tion or subtle renement of the bony-cartilaginous skel-eton. e skin so-tissue envelope (SSTE) redrapes to its new foundation. Many components of the operation can be variably aected by the healing process. e philosophy is preservation, reconstruction and cartilaginous graing, providing tip support (TS) and creating a strong, high pro-le that provides and maintains the shape to the overly-ing SSTE by opposing the distorting scar contracture, and preserving or correcting the nasal airway.PRE-OPERATIVESurgical anatomyTHE BONY PYRAMID: UPPER THIRDe nasal vault: 1. Paired nasal bones, thick at the frontal bone junction (no osteotomies) 2. Nasal processes of the maxilla overlap the upper lateral cartilages (ULCs) (no downward rasping)THE CARTILAGINOUS VAULT (NASAL BRIDGE): MIDDLETHIRDe quadrangular septal cartilage acts as a supporting strut and contributes to the convex dorsum (nasal hump). It extends anteriorly as the posterior septal angle (PSA) from the anterior nasal spine (ANS) as a cantilever, to sup-port the nasal tip at the anterior septal angle (ASA), and posteriorly articulates with the vomer and perpendicular plate of the ethmoid. Superiorly, it connects deep to the nasal bones and the paired ULC to form the cartilaginous vault. e septum's most caudal mobile aspect articu-lates with the medial aspect of the lower lateral cartilages (LLCs), supporting the tip, and facilitates LLC movements during respiration.Inferiorly, the ULC are folded back on themselves at the plica nasi, where they articulate with the overlying supe-rior border of the LLC, and their inferior borders makes an angle of 10°–15° with the septum at the valve area. e integrity of this angle is important for nasal airway patency and may be disrupted by disarticulation of the ULC from the nasal bone, rupture of the connection with the LLC and disconnection with the SSTE (Figure 85.1 and 85.2).CONTENTSPrinciples and justication 877Pre-operative 877e cartilaginous vault (nasal bridge): Middle third 877e tip: Mobile and supple lower third 878Examination 879Preoperative evaluation 879Operation 880Nasal Tip Surgery 883Septal shortening 883Surgical techniques 886How I do it: A modied open structure rhinoplasty technique 887 878 Rhinoplasty and septoplasty: Closed and open rhinoplastic techniquesTHE TIP: MOBILE AND SUPPLE LOWER THIRDe LLC is composed of a medial (MC3b) and a lateral crus (LC3a) to form an arch with domes at the level of their connection by an intermediate crus (ImC3c). e straight and thin MC is connected by the interdomal ligament and by the suspensory ligament to the ASA at the so medial triangle of Converse. ey come together in the midline to be part of the columella where they strongly articulate with the septum by ligaments in the mobile membranous septum. ey end posteriorly in the MC foot plates around the ANS, and superiorly diverge (angle of divergence) as ImC, also making an angle of rotation (infra-tip break) to form the dome and then the quadrangular and convex LC. At the dome and LC the lower border of the cartilage is some distance from the nostril border; the space of super-position of skin and vestibular skin is the so triangle of Converse or facet, to be respected by the marginal incision which follows the caudal LC margin. e LC extend down to the pyriform orice and are connected with the ULC by brous and musculoaponeurotic tissue or supercial musculoaponeurotic system (SMAS). e weak triangle of Webster is located between the ULC, the LLC and the pyriform aperture (osteotomies can disrupt the triangle and result in airway obstruction).The support of the nasal tipSupport mechanisms are divided into major and minor components (Figure 85.3). e nasal pyramid is a tripod concept consisting of the LLC (Anderson). e LC repre-sents the upper legs and the linked MC the lower leg of the tripod. Tip-characteristics [tip projection (TP), tip rota-tion (TR) and nasal length] may be adjusted by alteration of the tripod limbs and the tip-supporting structures.123345678Figure 85.2 Surgical anatomy of the septum: (1) nasal bone, (2) ULC, (3) quadrangular septal cartilage, (4) ASA, (5) middle septal angle, (6) PSA-ANS, (7) maxillary crest, (8) per-pendicular ethmoid plate.SupratipareaTipColumellaLobuleDorsumAlar grooveExt. narisNasolabialfoldNasolabialangleRoot ofnose(a)14523a3b673c(b)Lateral crusLateral crusDome(lateral genu)Medial genuMiddle crusMiddle crusMedial crusMedial crusAngle ofrotationAngle ofdivergence(c)Figure 85.1 Surgical anatomy of the nose. (a) Soft tissues. (b) Osseocartilaginous structures and landmarks: (1) nasal bone, (2) ULC, (3) LLC: 3a LC, 3b MC, 3c ImC, (4) nasion, (5) rhinion, (6) ASA, (7) dome. (c) Alar cartilages and tip-structures. Preoperative evaluation 879The supercial muscoloaponeurotic system and the skin-soft tissue envelopee supercial muscoloaponeurotic system (SMAS) covers the nasal pyramid in a continuous sheet of mimetic muscles interconnected by a tendon-like aponeurosis. e SSTE is elevated in the plane just deep to the SMAS, above the perichondrium and beneath the nasal bone periosteum to which it is adherent. e SSTE overlying the nose varies in thickness, mobility and pliability; thickest at the nasion, the supratip and at the naso labial angle (NLA), thinnest at the rhinion and the domes (Figure 85.1b). e mimic muscles of nasal animation can inuence long-term heal-ing with regards to the position of the tip, the upper lip or NLA and can be individually and synergistic overactive. A ‘plunging tip’ deformity can be due to overactivity of levator labii alaeque nasi (LLAN) and depressor septi nasi (DSN) muscles.EXAMINATIONFacial analysis for the rhinoplasty patientBesides the classical divisions in thirds and hs, exami-nation should include: the curved unbroken aesthetic line from the eyebrow or supraciliary ridge over the nasal root to the lateral wall of the dorsum till the tip-dening (highlight) point, the width of the dorsum, the base of the bony pyramid, the ULC and the alar base (no larger than the intercanthal distance), nasofrontal angle (NFA) and so-tissue nasion or sellion (deepest portion of NFA): normally positioned horizontally 12 mm anterior to the corneal plate and vertically between upper eyelash and supratarsalfold.Nasal analysisMORPHOLOGY (DEFINITION) OF THE TIPDouble break (lateral view, Figure 85.4): supra tip break (STB) and columellar-lobular angle (CLA) or infra tip break dening transition from mesial to intermediate crus. e tip position is determined by TP and TR. TP = CB (Figure 85.4), overprojection if CB >60% of AB. TR is reected in the nasio-labial angle (90°–120°).ALAR COLUMELLAR RELATIONSHIPe columella should be visible and project 2–3 mm below the alar rim, as ‘columellar show’. Overprojection of the columella and retracted alar rim exposes the columella and membranous septum in a ‘true and pseudo hanging colu-mella’. A hypertrophic ala is a hanging ala. Retraction of the septum in drooping tips with acute NLA diminishes the columellar show in a ‘retracted’ columella (Figure85.5).PREOPERATIVE EVALUATIONPre-operative photographs in a frontal, lateral, oblique and base view and smiling to check the synergic muscle activity for plunging tip and gum smile, are essential. Dierences in anatomical shape of the LLC, thickness, strength and recoil or ‘spring’ of the ASA and the LLC are assessed by palpation as well as skin thickness and quality. Oily thick skin limits post rhinoplasty tip denition because of lack of contractility even aer defatting. in skin shows all post-operative irregularities and may necessitate interpo-sitioning of temporoparietal fascia.Evaluation of the airway is critical (see Chapter 87).17238945Figure 85.3 Tripod concept and elements of structural tip support (TS): (1) major, (2) and (3) minor; (1) size, shape and strength of LLC (major TS), (2) medial crural-septal ligament, (3) intercartilaginous ligament, (4) SSA and cartilaginous dor-sum, (5) interdomal – suspensory ligament to ASA, (–) attach-ment LLC and ULC to SMAS, (7) ANS and membranous septum, (–) thickness skin and SMAS, (9) alar sidewalls.(a) (b)Figure 85.4 Nasal analysis: (a) morphology; (b) projection (AB: nasal length, CB: tip-base distance). 880 Rhinoplasty and septoplasty: Closed and open rhinoplastic techniquesOPERATIONApproach to the nasal skeleton: Closed endomucosal versus open extramucosale choice is based on the anatomical deformity and the training and experience of the surgeon. e closed or endonasal access combines an interseptocolumellar (transxion) incision with lateral intra- or intercartilagi-nous incisions.In the transcartilaginous approach (cartilage splitting technique), the amount of cephalic resection of the LLC is determinated pre-operatively, before the through nasal skin and cartilage incision. e transxion incision (TI) (Figure85.6c) is initiated over the SSA, continues between cartilaginous and membranous septum and extends vari-ably from SSA to the anterior nasal septum (ANS). e complete TI divides the septo-crural ligaments with poten-tial loss of TP. e cephalic strip of cartilage is removed. e incision does not interrupt the plica nasi. A low incision, 3–6 mm from the lower border of the LC, with resection of one piece of LLC that can be reinserted if required (Millard and Peck) gives, even in thick skin noses with narrow nos-trils, good access for scalpel dissection on the dorsum.Non-delivery techniques are conservative with stable healing and minimal tip numbness only indicated for minimal tip renements (minimal volume reduction), little TR, in thin skin noses with symmetric strong LLC needing maximal cartilage preservation.In the intercartilaginous approach (delivery tech-nique) (Figure 85.7), bilateral intercartilaginous incisions are combined with marginal incisions follow-ing the lower border of the alar cartilages, respecting the so triangle of Converse. e LLC is delivered as chondrocutaneous bipedicled aps, allowing for direct inspection and appropriate tip modications, dome sutures and asymmetry correction. e intercartilag-enous incision can disturb the valve and interruption of the interdomal ligament can lead to decreased nasal TS and TP loss.e open approach or external rhinoplasty technique (Figure 85.8) combines marginal incisions, 1 mm behind the columellar border, with a mid-transcolumellar con-nection. e SSTE is then dissected o the nasal skeleton under direct vision. 1. Advantages: Perfect visualization of the cartilages, better diagnosis, an intact valve, easier and precise graing. 2. Indications: Severe post-traumatic deformities, second-ary rhinoplasties, dicult and cle noses, simultane-ously maxillary orthognathic surgery to reconstruct TS and a strong prole. 3. Disadvantages: Increased scarring by dissection of the skin from the cartilages, potential trauma to the tip and dorsal skin by manipulation and retraction.Surgery of the dorsumExposure of the osseocartilaginous vault requires sharp dissection as close as possible to the cartilages and ABNormalNormal alar rim, AB=1–2 mmNormal columella, BC=1–2 mmTrue hanging columellaNormal alar rim, AB=1–2 mmProminent columella, >2 mmPseudo hanging columellaRetracted alar rim, >2 mmNormal columella, 1–2 mmCombinationRetracted alar rim, >2 mmProminent columella, >2 mmHanging alarHanging alar rim, <1 mmNormal columella, 1–2 mmRetracted columellaNormal alar rim, 1–2 mmRetracted columella, <1 mmCFigure 85.5 Alar–columellar relationship. Operation 881subperiosteally at the nasal bones keeping the SMAS intact; in thick skin noses defatting or resection of the SMAS is possible (Figure 85.9). For hump resection, an extramucosal dissection is utilized elevating the mucosa of the ULC and the nasal bones periosteum starting from the submucoperichondrial layer of the septum to prevent mucosal tearing during hump reduction and endonasal mucosal retraction. Cartilage graing has less risk of infection, elimination or rejection in a closed compartment (Figure85.9b). Hump resection is performed with a scalpel for the cartilage as a single unit (ULC and septum) and with a Rubin guided osteo-tome, introduced in the ‘sh mouth’ created, for the bony hump. Bony irregularities are corrected with bone scissors or upwards rasping. An ‘open roof deformity’ results aer hump resection.Overresection of the bony hump and underresection of the cartilaginous hump causes a ‘pollybeak or surgi-cal look’. A slight residual convexity should be preserved at the rhinion aer hump resection as straight line removal of the skeletal hump can result in a concave, over-reduced bridge. is can be corrected by cartilage onlay graing or reintroduction of a reduced resected hump (Skoog).(a)(b)(c)Figure 85.6 Transcartilaginous approach: (a) the cartilage splitting incision through the vestibular skin; (b) and through the LC; (c) transxion incision (TI): the partial TI stops short of the ANS. The complete TI divides the septo-crural ligaments with potential loss of TP.(a)(b)Figure 85.7 Intercartilaginous access or delivery tech-nique: (a) intercartilaginous and (b) marginal incisions. 882 Rhinoplasty and septoplasty: Closed and open rhinoplastic techniquesNarrowing the nose: Osteotomy techniquese primary indication for narrowing the nose by lateral osteotomies is to close the open roof deformity following hump resection (Figure 85.10).e standard approach is intranasal aer stab inci-sion and tunnelling, or directly through the mucosa, at the pyriform rim just superior to the inferior turbinate, respecting the valve area at Webster's triangle. e lateral osteotomy runs low in the nasofacial groove to below the medial canthus, where it is angled towards the midline. In primary rhinoplasties, the lateral osteotomy alone is suf-cient, because, by twisting the osteotome and nger pres-sure, a back fracture creates superior and medial fractures. (a)(b)(c)(d)Figure 85.9 Dorsal hump surgery: (a) dissection below the SMAS and exactly on the perichondrium and ideally below the periosteum at the bridge leaving the lateral side of the nasal bones attached to the SSTE; (b) separation of the nasal mucosa away from the ULC and septum; (c) hump resection initiated with scalpel on cartilaginous portions of hump (Peck); (d) hump resection completed with rounded edges osteotome (Rubin) on the bony portions of hump.21(a)(b)Figure 85.8 The open/external approach: (a) (1) transcolu-mellar, (2) bilateral vertical columellar and marginal incision; (b) elevation of the SSTE oering a direct view on the tip and middle vault. Septal shortening 883If not, transnasal medial osteotomies with an osteotome placed laterally along the septum and driven upwards till the sound change indicates thick bone, and transcutane-ous superior osteotomies are performed.For more predictable and precise osteotomies, a trans-cutaneous approach, lateral to the nasofacial groove, with a 2-mm osteotome, leaving no visible scar, is preferred. e superior transverse osteotomy, as well as an osteotomy of a deviated bony septum, can be carried out through the glabellar skin.Common problems: ‘rocker’ formation (osteotomy too high), lateral depression (too low), stair step deformity (too medial) and recoil of bony ap or drop into the nasal fossa (too wide undermining or too thin maxilla).NASAL TIP SURGERYGeneralities and tip dynamicsTIP PROJECTION AND TIP ROTATIONAs described earlier, the nasal tip can be likened to a tripod (Figure 85.3) with the LC representing two legs and the conjoined MC a third. Selective increase or decrease in the length of the tripod legs can be used to attain the desired TP and/or TR, for example, by shortening the two superior legs of the tripod, one can increase TR and decrease TP, or by shortening the conjoined MC, one decreases TP and TR. It is nearly impossible to alter TP without changing TR (Anderson and Webster).Cephalic volume reduction: Complete and interrupted strip, rim strip and lateral crural ap proceduresIn tip renement, the complete strip (Figure 85.11), leav-ing behind a 6-mm caudal LC for alar support, is a basic and conservative technique, for mild increase in tip de-nition with slight decrease in TP and increase in TR. e complete strip will resist upwards rotation and renement, unless additional manoeuvres as incomplete incisions, cross-hatching or morselization are added. Sectioning the lateral parts of the LC will also increase TR. e amount of upwards rotation and decrease in TP is more important with more developed ULC.In more aberrant anatomy, interrupted strip procedures with vertical lateral excisions are indicated; they require suture reconstruction and need supportive struts or con-touring gras to stabilize and prevent loss of projection, alar collapse, notching, pinching and asymmetry. erim strip (Figure 85.12) and lateral crural ap (Webster) (Figure85.12) are useful in thick skin noses, strong enough to support the alae and prevent them from collapsing, needing tip repositioning: increased TR and decreased TP.Dome suture techniquesComplementing complete strip techniques, interdomal sutures and transdomal horizontal mattress sutures are indicated for greater tip-narrowing in broad-boxy or bid tips with excess divergence of intermediate crura. Aer removing the so tissue occupying the interdomal space, a more triangular lobule and improved support are obtained. If obliteration of the external so triangle occurs due to medialization of the LC, the cartilage has to be trimmed (Figure 85.13).SEPTAL SHORTENINGEssential in correction of a long nose, performed through a (high) TI or directly in the open technique. e shorten-ing encroaches on the ANS and can be modied as illus-trated in Figure 85.14.Adjunctive proceduresSEPTOPLASTY, SEPTAL GRAFT HARVESTINGSeptal surgery is performed to correct septal deviations with airway obstruction or aesthetic problems due to anterior deections, and to harvest (osseo) cartilaginous gras. All displaced structures should be exposed with Osteocartilaginous apSeptumSubperiosteal tunnelat osteotomy siteNasal boneOsteotomy siteFigure 85.10 Nasal osteotomies. The ‘open roof’ is cor-rected by lateral osteotomies to mobilize the pedicled osteo-cartilaginous ﬂap.Cartilageexcised15-17mm5-7mmFigure 85.11 Complete strip technique. 884 Rhinoplasty and septoplasty: Closed and open rhinoplastic techniqueslimited mucoperichondrial detachment and maintain-ing 1 cm of dorsal and caudal structure to prevent dorsal saddling, tip drooping, columellar retraction and septal accidity.Septocolumellar (hemi) TIrough a hemi-TI down to the spine to the cartilage, a submucoperichondrial dissection is performed with a Cottle's elevator. If fracture adhesions, cartilage overlaps, or severe scarring interfere, the area is inltrated with local anaesthesia to facilitate further elevation.Anterior septal correctionsAnterior cartilaginous thickenings can be thinned by shaving, concave cartilaginous deviations are corrected by resection of excess inferior cartilaginous combined with full thickness incisions on the concave side of the contra-lateral pedicled cartilage to break the spring (memory) (Figure 85.15). e swinging-door technique is used to reposition a displaced caudal septum. Aer unilateral elevation of the mucoperichondrial ap, the septal carti-lage is excised along the oor of the nose and repositioned on the premaxillary crest, and xated on the contralateral mucoperichondrium by a bur hole in the ANS. Bony spurs and angulated deformities (see Chapter 87) need resection or osteotomy.Posterior septal corrections and for graft harvestingCartilage incision 1 cm posterior to the border of the cau-dal septum. Elevation of the untouched mucoperichon-drium on the contralateral side where needed, mostly at the junction of the cartilage–maxillary crest.Septal modications, aer positioning of a long small speculum, by: 1. Resection/osteotomies: most common method for sep-tal correction and gra harvesting. Deviations limited to the posterior septum are treated by endonasal sub-mucous resection aer bilateral mucoperichondrial ap elevation. A 1-cm caudal and dorsal L-shaped strut is le attached to the perpendicular ethmoidal plate and maxillary crest–ANS area to maintain support. Cartilage and bone for graing can be harvested. 2. Segmental scoring/weakening.Figure 85.14 Septal shortening (Aiach).(a)(b)Figure 85.13 Interdomal sutures technique.(a)(b)Figure 85.12 Cephalic volume reduction: (a) rim strip technique; (b) lateral crural ap (Webster) technique. Septal shortening 885 3. Swinging-door aps, indicated in angular deviations of the dorsal strut, which are incised at the angle to 2 mm of the dorsal border. Repositioning in the midline and splinting for stabilization before multiple cartilage inci-sions interrupt a twisting dorsal strut, as well as stabili-zation of the caudal septum on the ANS. 4. Morselization, only possible aer bilateral ap eleva-tion, is sparingly used, as results are unpredictable.Tardy's modied incision after KillianIn Tardy's modied method (Figure 85.16), a vertical sinu-ous incision sited just cephalically to the caudal end of the septum and proximal to the mucocutaneous junction, avoiding scar formation or retraction in the cutaneous portion of the caudal septum allows full septal exposure through retrograde dissection to and around the caudal septum while maintaining the vital medial crural foot-plate attachment to the septum.Aer unilateral ap elevation, and if osseocartilaginous gras are not needed, disarticulation with slight pressure with the elevator at the chondro-osseous junction or in previous fracture lines, exposing the contralateral peri-chondrium permitting contralateral submucoperiosteal dissection. is oen allows the deviated cartilage to return to the midline as a ‘swinging door’, sometimes aer resection (a)(b)Figure 85.15 Anterior septal corrections through a hemi-transxion incision and unilateral ap elevation: (a) incision on the concave side and partial resection; (b) repositioning of cau-dal deections with displacement from bony groove, resec-tion of cartilaginous spur, osteotomy of palatal/vomeral crest oending medial reposition of caudal septum.(a)(b)(c)Figure 85.16 Tardy's septoplasty technique: (a) serpentine mucoperichondrial incision 2–3 mm above caudal septum bor-der; (b) unilateral mucoperichondrial ap, disarticulation of the cartilaginous septum and contralateral subperiosteal dissec-tion; (c) resection of subluxated cartilage (and bone) along the oor of the nose and replacement of the anteriorly pedicled septum as a ‘swinging door’ to the midline. 886 Rhinoplasty and septoplasty: Closed and open rhinoplastic techniquesof brous tissue bands, subluxated cartilage or bone along the nasal oor. Correction of bony obstructions is per-formed with a biting forceps. Cartilaginous obstructions are corrected by incisions in dierent directions through the cartilage but not into the opposite mucoperichondrium, to create multiple cartilage islands, supported and nour-ished by the opposite intact mucoperichondrialap.Transoral sublabial approachUse• Children with caudal subluxation. An intact caudal sep-tum is important for the development of the columel-lar–labial complex.• In secondary septoplasties and post-traumatic rhi-noplasties for anterior bony crest (re)sections or gra oers the possibility of separate elevation of the aps to reduce the chances of perforation.Open or external approache open rhinoplasty technique oers a remarkable expo-sure for anterior and infero-anterior septal corrections, secondary septoplasties and gra harvesting from the ASA and caudal septal border to correct caudal deviations.Separation of the domes and the MC to the ANS, with submucoperichondrial dissection cranially to the ethmoid. Caudally, separate elevation of the periosteum by tunnelling from the ANS on the oor of the nose. By semicircular sweep-ing motions both tunnels are connected over the chondro- osseous junction area to prevent lacerations. Bilateral dissection is possible but in angulated deformities, a unilateral attachment is preferred for stabilization. e medial crural support is re-established by suturing the MC together post-septoplasty.From the anterior septal border to correct anterior devi-ations in secondary septoplasties, where the dissection from the caudal border is impossible due to scar forma-tion, and has to be dissected from anteriorly at the middle third aer section of the ULC at their septal junction; modication and gra harvesting can then be carried out behind the area of adherences.At the end of the procedure redundant bony-cartilagi-nous fragments can be repositioned as free gras between the septal aps, to prevent a accid septum (oating during inspiration and expiration). rough-and-through mat-tress resorbable sutures reapproximate the septal aps and stabilize the repositioned fragments. Inadvertent perfora-tions of the mucoperichondrium are meticulously closed if they are opposing each other. Incisions are closed and disrupted supporting ligaments: interdomal and medial crural–septal attachments are restored. Bilateral so silas-tic stenting is placed for 5–7 days (Figure 85.17).Nasal graftingGraing provides shape and denition, establishes solid TS, opposes scar contracture and distortion of the SSTE and functionally graing is used to improve and maintain an open nasal airway.Septal cartilage is the preferred source of graing mate-rial. Other excellent sources include remnants of the resected osseocartilaginous dorsal hump and the cartilage obtained from the cephalic trim of strong LLCs. Conchal ear cartilage can also be used. in bony plates from the perpendicular ethmoid and vomerine septum may be used where a more rigid gra is needed. Description of all graing techniques is beyond the scope of this section, they include columellar struts, tip onlays, infratip lobular gras etc. In addition to these tip gras, contouring gras are frequently required.Alar base surgeryAesthetic narrowing of the nasal skeleton and tip must bebalanced by concomitant reduction of the alar base. Alar surgery is one of the nal steps in aesthetic rhi-noplasty in a conservative and symmetric manner (Figure85.18).SURGICAL TECHNIQUES• Internal nostril oor reduction preserving the nostril sill provides subtle improvement in repositioned nasal tips without visible scar.• Alar lobule excision at the nostril oor and sill results in reduction of are as well as in slight reduction of the alar bulk, and provides medial alar repositioning.• In reduction of overprojecting tips, alar wedge excisions reduce the overall length of the alar sidewalls.• Maximal alar reduction with medial repositioning will be eected from the alar sliding ap technique, with a generous incision in the alar–facial junction. Reduction of the volume, curve and are will result, the extent of each dependent on the angulation of the excision. Skin repair is accomplished with intradermal absorbable suture. Skin sutures are placed 1 mm above the alar–facial groove to avoid sebaceous glands located in the junction. e repair can be further supported and enhanced with the use of an alar cinch suture of 3/0PDS.Figure 85.17 Reapproximating the mucoperichondrial septal aps and stabilizing the septal remnants. How I do it: A modied open structure rhinoplasty technique 887HOW I DO IT: A MODIFIED OPEN STRUCTURE RHINOPLASTY TECHNIQUEGeneral anaesthesia with orotracheal intubation is pre-ferred. e nose is packed with neurosurgical cottonoids in a cocaine–epinephrine (adrenaline) solution for vaso-constriction and shrinkage of the mucosae; local anaesthe-sia (0.5% xylocaine – 1:100,000 epinephrine) is inltrated between the skin and the skeleton and submucosally.e mid-columellar incision (inverted V) to the level of the medial crura at a site just anterior to and above the are of the medial footplates is made with a No. 15 blade. e transcolumellar incision is connected to bilateral columel-lar marginal incisions running 1 mm behind and parallel to the rim of the columella. e lateral part of the marginal incision is placed along the caudal margin of the lateral crura. e back of the scalpel is used to palpatetheedge of the cartilage to identify the correct position for the lateral incision. A double skin hook retracts the alar margin while simultaneously applying nger pressure over the LLC to evert the caudal margin. en the hook is placed between the lateral portion of the marginal incision and the columel-lar portion, with simultaneous traction on the nasal skin with a single hook to make the connecting incision, respect-ing the facet or so triangle of Converse, which should be preserved; incisions too close to the nostril rim can result in alar notching or distortion of the facet.Using small pointed serrated scissors or a scalpel, the SSTE overlying the medial crura is dissected without injuring the underlying cartilage. By using three-point counter-traction, sharp dissection along the medial crura and LLC is performed in the avascular immediate supra-perichondrial plane, preserving the subdermal plexus and avoiding ap breakdown. Flap elevation is carried laterally to the point of attachment of the lateral crura with so tis-sue. e interdomal ligament is not disturbed.e loose connective tissue (Pitanguy's ligament) over-lying the ASA at the so supratip triangle is resected and an avascular supraperichondrial plane is identied over the lower dorsum. At the rhinion, the remainder of the dissection of the nasal bones is performed subperiosteally, using sharp dissection. An Aufricht retractor is placed and lateral bands between the SSTE and the osseocartilagi-nous structure are divided bluntly, until the entire nasal skeleton can be clearly observed.For septoplasty and cartilage harvesting for later gra-ing a hemi-TI is used. In dicult septoplasties or in asym-metric tips, the interdomal ligament is cut and the medial crura separated. Using a speculum the caudal edge of the septal cartilage is visualized. e subperichondrial plane is established using the tips of pointed scissors or Cottle's elevator and the mucoperichondrium is elevated using sweeping motions. Incisions are made in the cartilaginous septum at 1 cm parallel to the caudal septum and dorsum, leaving in an inverted L-shape support, allowing the max-imal amount of cartilage to be harvested. Deviated carti-laginous fragments are disarticulated and removed.Turbinate surgery further corrects airway obstruction.Routinely, the author prefers to address the osseocarti-laginous vault before the tip and lower third with alar base correction as the last step.Under direct visualization, reduction of the cartilaginous dorsum is performed with a No. 15 blade, the cartilage is maintained in continuity with the nasal bone. Sharpened Rubin osteotomes are used to resect the bony hump to nasion in continuity with the cartilaginous resection. Initially, a 16-mm osteotome is placed in the ‘sh mouth’ created by the cartilage resection, then a 14-mm Rubin as the line of resec-tion approaches the narrower naso-frontal angle. In the gla-bellar area, the hump is sharply separated from the attaching so tissues, before being removed and preserved together with the harvested cartilage in a physiologic solution. Irregularities are removed with sharp resection to avoid disruption of the osseous-cartilaginous junction.e dorsum appears to be broadened and the ‘open roof’ aspect shows through the overlying skin.Closure of the open roof deformity is through the use of osteotomies, under direct vision using a 3-mm micro-osteotome, creating a laterally fading line for controlled back-fracture created by the lateral osteotomies. Only in broad strong noses are medial osteotomies utilized. If these are especially thick then triangular wedges are removed along the medial osteotomy.e lines of the lateral osteotomies are low to the face, respecting Webster's triangle and directed towards the highest thin part of the nasal bones. No inltration, stab incision or periosteal raising is carried out to prepare the lateral osteotomies. e same 3-mm osteotome is Figure 85.18 Alar base surgery: Alar resection in com-bined vertical and horizontal part. 888 Rhinoplasty and septoplasty: Closed and open rhinoplastic techniquesimmediately engaged on the pyriform aperture just supe-rior to the inferior turbinate's origin. e osteotome is initially engaged in a plane perpendicular to the pyriform aperture. Once a triangle of bone is preserved at Webster's area, the osteotome is directed up the lateral bony wall under nger control. Just below the level of the medial can-thus, the cut is directed more anteriorly to meet the medial osteotomy when required. e back fracture is completed with rotation of the osteotome and nger pressure. e inward fractures can be performed with greater accuracy and precision transcutaneously at the lateral mid portion of the osteotomy and through the glabella if necessary with a 2-mm micro-osteotome and without stab incision.e mobility of the nasal bones can be palpated through the skin and controlled under direct vision. e dorsum is palpated and visually checked to make sure that no irreg-ularities or projections of bone or cartilage exist. Small bony fragments can be resected with bone scissors and cartilaginous protrusions can be trimmed by blade.e concept of the open-structure rhinoplasty supports reconstitution of disrupted support mechanisms by sutur-ing and graing which will resist the eects of scarring and contracture of the so-tissue envelope. e elevation of the SSTE during rhinoplasty violates a minor support mechanism. erefore, the medial crura are generally strengthened with a septal cartilage gra or the resected osseocartilaginous hump, sandwiched between them as a supporting strut. A pocket to receive the gra is dissected between the medial crura towards, but not to, the nasal spine. e strut not extending above the ASA is xated with through and through Vicryl™ 4.0 from the level of the medial footplates. Care is taken not to distort or rotate the nasal tip area by malpositioned sutures. e strut increases support and stability and maintains symmetry of the nasal tip. It can also serve as a foundation for a tip gra.e medial crural/columellar strut complex is sutured to the caudal septum. is will eectively reconstruct the medial crural–septal ligaments sectioned when a TI isused.If tip narrowing and upwards TR is desired, cephalic trim of the LLC is performed. Care is taken not to weaken the lateral crura, by leaving a symmetrical strip of carti-lage at least 6 mm in width. Over-resection can weaken the lateral legs of the nasal tripod, resulting in external valve collapse on inspiration and retraction of the nostril rim from scar contracture on the LLCs. is is remedied dur-ing surgery with alar batten gras.e recurvature of the ULC contributing to intercrural width is resected together with the cephalic edge of the LLC. e cartilage is removed while leaving the nasal skin intact at all times.Aesthetic adjustments to the position of rhinion to cre-ate a more natural dorsum are oen accomplished using Skoog's technique of replacing the resected dorsal hump aer sculpting to the desired shape and size, into the dor-sal pocket thereby avoiding irregular edges, asymmetry and the ‘open roof deformity’.Modication of the caudal aspect of the medial crura can be carried out for such abnormalities as a hanging columella deformity.Opening up an obtuse NFA or widening the root of the nose can be done by cartilaginous gras.Debulking of the undersurface of thick sebaceous tis-sue of the nasal tip is accomplished under direct visualiza-tion. Care is taken not to injure the dermis. e eects of debulking the tip skin can be seen in the redraping of the SSTE providing superior tip denition.A widely arched dome may be narrowed and lowered by excising triangles of LLC cartilage, leaving the skin intact. e free ends of the lateral crura are reconstructed into a con-tinuous strip by suturing the ends with 5/0 resorbable sutures to maintain the strength of the tip tripod. Irregularities can be trimmed. e interdomal ligament is restored by an inter-domal mucosal apposition mattress suture, lying just below the domes, acting to restore reattachments between the LLC and the ASA, thus contributing to TS.A septal cartilage gra sculpted into a three- dimensional shield-like tip lobular gra with bevelled contours is placed over the Stable nasal tip structure. is establishes the desired projection, angle of the infratip region, a double break and the bidomal shape. is gra is usually thick-est at its dorsal aspect and gradually tapers to the ventral. Resorbable 5/0 sutures can secure the gra to the under-lying septal crural foundation. An elongated tip gra extending along the greater part of the columella is used to provide greater stability for increased projection. In gen-eral, this gra is not xated so, aer initial wound closure, it can be displaced to the desired position, creating a more pleasing tip denition.Aer careful inspection of the reconstructed skeleton, the skin incisions are meticulously closed with 6/0 nylon sutures. With Rees and Skoog we believe that no amount of post-operative splinting, clamping or other forms of pushing and pulling, nor healing, will provide a better outcome.e SSTE is taped to the nasal skeleton, especially in the supratip region, thus eliminating dead space. An additional adhesive strip is placed along the nasal tip for support.A plaster of Paris with forehead extension, avoiding any movement, is used (Tessier). A generous amount of antibi-otic ointment is placed in both nares.A reinforced Silastic™ sheet is used as a septal splint at the right side where functional surgery has been per-formed. Although through-and-through sutures readapt the mucoperichondrial aps, nasal packing is frequently used. Unless contraindicated, intraoperative steroids and antibiotics are given routinely. A gauze is taped over the nostrils to function as a drip pad.e patient receives facial ice packing and a position of at least 45° is advised for up to 24 hours. Antibiotics are given for 3–4 days till the packing is removed. Upon follow-up in 7 days, the splint and the Silastic sheet (s) is removed, as well as the sutures.