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Evaluation and Correction of the Crooked Nose

General Considerations The crooked nose is neither a single entity nor a specific description. Crooked noses represent a spectrum of nasal deformities, most commonly of traumatic origin, that are associated with a deviated or irregular appearance to the nose. For the casual onlooker, the crooked nose may be unsettling because of its disharmony with the rest of the face, much like a picture frame that sits…

The Management of Alar–Columellar Disproportion

Often unappreciated in rhinoplasty is the alar–columellar complex. Patients may present with a preexisting hanging or retracted columella or abnormal alar rim or columellar shape and configuration. In the patient with a preoperative normal relationship, certain surgical maneuvers, made to affect other desired changes elsewhere in the nose, may leave the patient with an unattractive alar–columellar complex after surgery. Alterations that are made to the lower…

Postrhinoplasty Nasal Lobule Deformities: Open Approach

Older reduction tip rhinoplasty techniques are effective in altering tip contour and definition, yet they depend on aggressive cartilage resection, morselization, and sacrifice of tip supports to achieve these goals. Weakening of the crura in this manner, when subjected to long-term forces of contracture, may lead to tip distortion and commonly seen postrhinoplasty deformities. Beginning in the 1980s, advancements in understanding of nasal tip anatomy and…

Correction of the Pinched Nasal Tip Deformity

The “pinched nasal tip” is a deformity caused primarily by collapse of the lateral crura of the lower lateral cartilages. Such collapse may be congenital due to inherent hypoplasia, weakening, or malposition of the cartilaginous support but is often secondary to acquired, commonly iatrogenic, causes. The resultant pinching effect gives an unaesthetic appearance characterized by an alar groove, which extends to the alar rim, causing shadowing…

Alloplasts in Nasal Surgery

Few concepts in rhinoplasty engender as much discussion and conflict as the use of alloplasts in the nose. Clear divisions within the specialty have developed, with some surgeons using alloplastic implants liberally while others staunchly maintaining that alloplasts should never be used in rhinoplasty. Central to this dichotomy is the risk versus benefit analysis and the thresholds one sets as acceptable. Should an alloplast ever be…

Mandibular Implants

Over the past two decades, great improvements have been made in the design of facial implants. Facial implants are able to enhance facial contour and provide permanent volumetric replacement. Facial implants can be used in many anatomic regions of the face, including the cheek, midface, nose, and mandible. Here we discuss the application of implants for the correction of profile imbalance as well as the rejuvenation…

Calvarial Bone Grafting in Rhinoplasty

Calvarial bone grafting is an established method of craniofacial reconstruction in facial plastic surgery. Konig and Muller were the first to describe autogenous calvarial bone grafting in 1890, advocating a combined osteocutaneous flap. Smith, Abramson, and Tessier popularized the technique for modern craniofacial reconstruction. More recently, split calvarial bone grafts have been shown to be safe and effective grafts for nasal reconstruction and a viable alternative…

Rib Grafting Simplified

The use of rib grafting in rhinoplasty has revolutionized the ability to treat complex nasal deformities. Its can be helpful for both primary nasal deformities (including posttraumatic, cocaine induced, and others), as well as secondary nasal deformities (including postoperative saddle deformities and otherwise graft-depleted patients). Situations in which patients have had their septal cartilage or the majority of their conchal cartilage harvested during previous interventions leave…

Suturing Techniques to Refine the Nasal Tip

Controlling the shape of the nasal tip can be one of the most challenging problems rhinoplasty surgeons face in practice. Prior to the advent of suture techniques, the cartilages of the nose were largely controlled, by excision, crushing, and scoring. At the time, these methods were thought to be the easiest method to create a new nasal shape. Unfortunately, they all potentially damaged the cartilage and…

The Mobile Tripod Technique: A Universal Approach to Nasal Tip Modification

One of the most important and difficult aspects of rhinoplasty surgery is creating a nicely shaped, natural-appearing nasal tip. This generally involves altering nasal tip definition, width, projection, and/or rotation. Nasal tip appearance is primarily determined by the shape and strength of the lower lateral cartilages (LLCs). In addition, the tip shape and position are affected by the relationship of the LLCs with adjacent support structures…

The Middle Vault: Upper Lateral Cartilage Modifications

The importance of the middle third of the nose has been increasingly recognized in recent years. Reductive rhinoplasty techniques performed without regard for the structural integrity of this region can cause structural and functional compromise. In this chapter, the anatomy, physiology, and pathologies in this important region will be described, followed by a discussion of the various techniques that are used to address the middle third,…

Cartilage Grafting in Rhinoplasty and Nasal Reconstruction

General Principles Maintaining or achieving structural integrity of the nasal form is a formidable task in rhinoplasty and nasal reconstruction. Maintaining the form and function of the nose is an equally important objective as creating a pleasing aesthetic contour. In this regard, numerous autograft, allograft, and synthetic materials have been proposed as the ideal replacement or augmentation matrix in nasal surgery. Despite trials of use of…

Nasal Osteotomies

In 1898, Jacques Joseph was one of the first surgeons to promote the concept of the nasal osteotomy as a way to reshape and reposition the bony vault. The primary indications for osteotomies are to straighten a deviated nasal dorsum, narrow the nasal side walls, and close an open nasal vault. While the objectives remain clear, osteotomies continue to be a source of trepidation for rhinoplasty…

Reducing Complications in Rhinoplasty

The nationally reported revision rate for primary rhinoplasty ranges from 8% to 15%. Unfortunately, there will likely never be a shortage of patients requiring revision rhinoplasty. Experienced surgeons consistently achieve a high level of satisfaction among their patients. Still, complications can occur despite technically well-performed surgery. All surgeons have complications. Success in rhinoplasty is based on well-developed judgment, wisdom, and accumulated knowledge and experience. Similar to…

Endonasal Rhinoplasty: Transcartilaginous Approach

Rhinoplasty is one of the most challenging operations in plastic surgery. The three-dimensional nature of the nose, conformed by skin and soft tissue envelope (S-STE), and the shape and orientation of the nasal cartilages and bones are variables that, when grouped together, confer a nearly limitless number of different configurations seen in nasal appearance. Additionally, each of the constituent parts of the nose are intricately related…

Secondary Rhinoplasty via the External Approach

The incidence of postoperative nasal deformities requiring secondary rhinoplasty varies from 5% to 12%. The etiologies of postoperative nasal deformities ( Table 7-1 ) are usually related to one or any combination of the following three problems: (1) displacement or distortion of anatomic structures, (2) underresection due to incomplete surgery, and (3) overresection due to overzealous surgery. Diagnosing these deformities and reconstructing the nasal osseocartilagenous framework form the foundation…

Primary Endonasal Rhinoplasty: Double-Dome Technique via Intercartilaginous Dome-Delivery

Surgical refinement of the nasal tip is considered by many to be one of the most challenging components of rhinoplasty. At the heart of the challenge is the need to not only adequately access and visualize but also control the complex three-dimensional architecture of the alar cartilages while being cognizant of tip support mechanisms and postoperative contracture. Although numerous approaches have been described throughout the literature,…

Primary Open Structure Rhinoplasty

Primum non nocere The first goal during rhinoplasty, as with all other aspects of medicine and surgery, is to do no harm, and it pertains to both nasal function and aesthetics. Moreover, every rhinoplasty patient will present with a set of positive nasal functional or aesthetic features that need be preserved. Capitalizing on years of training and cumulative experience while paying close attention to the patient's…

The Psychology of Rhinoplasty: Lessons Learned from Fellowship

Starting a practice in cosmetic facial surgery is daunting. Every new facial plastic surgeon is eager to make his or her mark and to put into practice his or her numerous years of training, although, in truth, the real education is only just beginning. The true value in having completed a fellowship is in acquiring a lifetime of lessons in what really matters to a cosmetic…

Nasal Analysis

Introduction Nasal analysis in the setting of the preoperative consultation is undoubtedly one of the most critical elements of the rhinoplasty process. This is the time in which the patient and surgeon communicate expectations, build rapport, and mutually decide whether to proceed with surgery. In addition, it provides an opportunity for the surgeon to analyze the patient's anatomy and personal aesthetics, thereby developing a surgical plan…