What It Is

Removal of a portion of the cephalic edge of the lateral crus of the lower lateral cartilage ( Fig. II.1 ). This may also be termed a horizontal excision of the lateral crus.

What It Does

Decreases nasal tip bulk to assist with tip narrowing and definition. This technique also creates a space into which the tip may rotate cephalically.

Tips

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  Over-resection of the lateral crus or dome condemns the tip to a host of bad outcomes such as warping, twisting, bossa formation, collapse, and alar retraction. The literature varies on the minimum width of intact lateral crus that should be left behind, but approximately 7 mm is a fair guideline. Enough support must be left to allow the crus to serve its supportive role. Care must be taken to preserve strength at the dome as well ( Fig. II.2 ).

  
  
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  Dissect the vestibular skin free after making the incision but before removing the cartilage to keep bleeding to a minimum and avoid entering the nasal cavity.

What It Is

Removal of a segment of the lateral crus lateral to the dome. The segment may be rectangular or triangular depending on the desired effect.

What It Does

Decreases bulbosity of the tip, and allows for rotation (upward) of the tip. If a medially based triangular excision is done, the tip can narrow slightly; conversely, if the excised triangles are based laterally, the tendency is for the tip to widen.

Tips

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  Free the underlying vestibular skin to allow the cartilages to move.

  
  
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  Make a single cut and allow the cartilages to overlap before excising a block of lateral crus ( Fig II.3 ). The effect of the excision can be gauged in this way, and over-excision avoided.

  
  
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  Reestablish the continuity of the crus with permanent or long-lasting absorbable sutures ( Fig. II.4 ).

  
  
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  Remember to tack the vestibular skin back to the crus to avoid malposition or scar tissue filling a dead space.

  
  
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  An alternative to excision of a portion of the lateral crus is the overlap (see Technique 27, below).

What It Is

Removal of a strip of cartilage at the junction of the caudal edge of the septum and repositioning of the septal base into the midline ( Fig. II.5 ).

What It Does

Allows an overly long or subluxed caudal septum to become free of the maxillary crest and nasal floor and relocated into the midline ( Fig. II.6 ). This technique is frequently used in combination with a Wright midline septal anchoring suture (see Technique 23, below).

Tips

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  Take only as much cartilage as is needed to allow the caudal portion of the septum to rest securely on the midline maxillary crest.

  
  
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  Take time to free the base of the septum from the closely adherent fibrous tissue that surrounds it before performing the excision. This will facilitate both judging the amount to remove and relocating the septum to the midline.

What It Is

Removal of dorsal cartilage, usually by shaving with a knife, and dorsal bone, usually by rasping or osteotomy ( Fig. II.7 ).

What It Does

Creates a more aesthetically ideal dorsal profile. It can also remove the attachment between the upper lateral cartilages and the dorsal septum, which facilitates and sometimes necessitates the placement of spreader grafts. Reduction of the bony dorsum can weaken the nasal bones in the midline, which is helpful in infracturing or outfracturing them after lateral osteotomies have been performed.

Tips

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  If spreader grafts have not been placed and the upper laterals no longer contact the dorsal septum as a result of reduction of the cartilaginous dorsum, take time to suture them to the septum to avoid nasal valve issues going forward.

  
  
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  Reduction of the cartilaginous dorsum first allows graduated, precise rasping of the bone to bring the profile into good alignment. It is more difficult to reduce the cartilaginous dorsum to match the re duction of the bony dorsum. In other words, do the cartilage first.

  
  
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  Recognize that septoplasty can lower the dorsum to some extent over time, so do not over-reduce the cartilage. Similarly, if a significant hump is to be removed, it is important to leave more than adequate dorsal cartilage as part of the L-shaped strut during septoplasty.

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  A dorsum that appears straight on profile will actually have a slightly convex bony and cartilaginous skeleton because the nasal skin varies in thickness. It is thicker at the nasion and supratip than at the rhinion ( Fig. II.8 ).

What It Is

Removal of a portion of an overly prominent anterior nasal spine. This is usually accomplished with a bone-biting rongeur ( Fig. II.9 ).

What It Does

Removes bulk from the proximal columella and nasolabial angle. This technique is most commonly used when the midline nasal structures, the nasal bones, bony septum, cartilaginous septum, and anterior nasal spine are especially prominent, as in the “tension nose.”1 An off-center nasal spine can also contribute to deviation and obstruction at the nasal base ( Fig. II.10 ).

Tips

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  Be meticulous in cauterizing the soft tissue around the spine and caudal septal base prior to removing the spine. The tissue here is tenacious and well provided with blood vessels.

  
  
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  Leave adequate spine to support the projection of the nasolabial angle as well as the base of the caudal septum should it extend to the spine.

  
  
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  Palpate the spine after removal to ensure that it is smooth. If a sharp spicule of bone remains, which is often the case, it may be directly rasped to a smoother shape.

What It Is

Excision of the caudal edge of the medial crura ( Fig. II.11 ).

What It Does

Decreases the anteroposterior dimension of the medial crus, which results in reduced projection of the infratip lobule.

Tips

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  This is a powerful technique that can easily be accomplished through an open or closed approach ( Fig. II.12 ).

  
  
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  This technique weakens the supportive function of the medial crus, so concurrent placement of a columellar strut is almost always a good idea.

  
  
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  This technique flattens the nasal base, which provides an ideal platform for attachment of a tip graft or proximal columellar augmentation graft.

  
  
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  Removal of a portion of the medial crus results in an excess of vestibular skin, which may need to be trimmed prior to closure of the open rhinoplasty flap or closed incision.

What It Is

Removal of a portion of the ala, which may be restricted to the external nasal skin or include vestibular skin as well.

What It Does

Decreases flaring of the ala and width of the nasal base. It also may change the shape of the nostrils.

Tips

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  There are many variations on these incisions that the rhinoplasty surgeon should study and select from based on the desired effect.2

  
  
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  The proximal incision is usually placed 1 mm lateral to the junction of the ala and the face rather than directly in it to preserve the natural contour of where the two structures meet ( Fig. II.13 ).

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  Defer alar base excision until the end of the case, especially if tip projection is being altered.

  
  
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  Increasing tip projection decreases the amount of alar flare and accordingly the amount of ala that requires resection. Conversely, tip deprojection increases flare and the need for removal of alar tissue.

What It Is

Placement of a straight piece of cartilage into a pocket created between the medial crura ( Fig. II.14A ). The graft is normally secured in place with absorbable mattress sutures.

What It Does

First and foremost a strut increases nasal tip support. It may also be used, along with the sutures that secure it, to project the tip, to narrow the tip by decreasing the angle of divergence between the intermediate crura, and to straighten the medial and intermediate crura if they are buckled or weak ( Figs. II.14B–E and II.15 ).

Tips

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  The pocket created between the medial crura should not extend to the maxillary crest or anterior nasal spine. If it does, the strut might settle to one side or the other of the crest/spine, which would lead to tip asymmetry.

  
  
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  Although most easily placed via an open approach, a columellar strut can be placed during a closed rhinoplasty as well ( Fig. II.14F,G ).

  
  
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  Multiple pieces of cartilage can be sutured together for increased length or strength of the strut depending on what you need and what you have to work with.

What It Is

A shield-shaped piece of cartilage is sutured to the columellar cartilage and domes with multiple small permanent or slow-absorbing sutures ( Fig. II.16 ). It generally projects above the level of the domes.

What It Does

Increases tip projection and gives shape and definition to an amorphous tip

Tips

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  Bevel the edges of the tip graft carefully, so that sharp edges do not show through the skin when edema resolves and the skin “shrink-wraps” the graft ( Fig. II.17A,B ).

  
  
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  If the graft projects too high over the domes, an obvious “tombstone” deformity may be result.

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  A double tip graft may be fashioned by sewing two pieces of cartilage together. In addition to providing increased strength, it is also an effective way of increasing nasal length by filling in a deficient infratip lobule ( Fig. II.17C,D ).

  
  
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  A cap graft (see Technique 17, below) placed behind the leading edge of the tip graft can lend it strength.

  
  
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  When suturing the graft in place, it can be helpful to tie the first suture loosely to permit some movement of the graft relative to the medial crura and domes. Once the subsequent sutures have fixed the graft in an optimal position, the original “holding” suture can be removed.