CME - Logga in – Lipus kursverktyg · 2020-01-20 · CME Rhinoplasty Rod J. Rohrich, M.D. Jamil Ahmad, M.D. Dallas, Texas; and Mississauga, Ontario, Canada Learning Objectives:

CME

RhinoplastyRod J. Rohrich, M.D.

Jamil Ahmad, M.D.

Dallas, Texas; and Mississauga,Ontario, Canada

Learning Objectives: After reading this article, the participant should be ableto: 1. Discuss desired preoperative aesthetic and functional assessment of thepostsurgical nose with rhinoplasty patients. 2. Identify factors that have thepotential to affect procedural outcomes. 3. Develop an operative plan to addressaesthetic goals while preserving/improving nasal airway function. 4. Recognizeand manage complications following rhinoplasty.Summary: Rhinoplasty is one of the most commonly performed aesthetic sur-gical procedures in plastic surgery. Over the past 20 years, the trend has shiftedaway from ablative techniques involving reduction or division of the osseocar-tilaginous framework to conserving native anatomy with cartilage-sparing suturetechniques and augmentation of deficient areas to correct contour deformitiesand restore structural support. Accurate preoperative systematic nasal analysisand evaluation of the nasal airway, along with identification of both the patient’sexpectations and the surgeon’s goals, form the foundation for success. Intra-operatively, adequate anatomical exposure of the nasal deformity; preservationand restoration of the normal anatomy; correction of the deformity usingincremental control, maintenance, and restoration of the nasal airway; andrecognition of the dynamic interplays among the composite of maneuvers arerequired. During postoperative recovery, care and reassurance combined withan ability to recognize and manage complications lead to successful outcomesfollowing rhinoplasty. (Plast. Reconstr. Surg. 128: 49e, 2011.)

Rhinoplasty remains one of the most com-monly performed aesthetic surgical proce-dures in plastic surgery, with over 255,000

performed in 2009.1 Over the past 20 years, thetrend has shifted away from ablative techniquesinvolving reduction or division of the osseocarti-laginous framework to conserving native anatomywith cartilage-sparing suture techniques and aug-mentation of deficient areas to correct contourdeformities and restore structural support.2,3

The foundation for a successful experience forboth patient and surgeon involves accurate pre-operative analysis and clinical diagnosis, identifi-cation of both the patient’s expectations and thesurgeon’s goals, and a thorough review of the planof care and expected postoperative recovery. In-traoperatively, adequate anatomical exposure ofthe nasal deformity; preservation and restorationof the normal anatomy; correction of the defor-mity using incremental control, maintenance, andrestoration of the nasal airway; and recognition of

the dynamic interplays among the composite ofmaneuvers are required.2,4 During postoperativerecovery, care and reassurance combined with anability to recognize and manage complicationslead to successful outcomes.2

ESSENTIALS OF PREOPERATIVEASSESSMENT AND MANAGEMENTThe preoperative consultation for rhinoplasty

serves as an opportunity to obtain the patient’snasal history, examine the nasal airway, and per-form nasofacial analysis. In addition, the surgeon

From the Department of Plastic Surgery, University of TexasSouthwestern Medical Center, and The Plastic Surgery Clinic.Received for publication November 16, 2010; accepted De-cember 9, 2010.Copyright ©2011 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e31821e7191

Disclosure: Dr. Rohrich receives royalties fromQuality Medical Publishing, Inc., and Micrins,Inc. Dr. Ahmad has no financial interests related tothe content of this article.

Related Video content is available for this ar-ticle. The videos can be found under the “Re-lated Videos” section of the full-text article, or,for Ovid users, using the URL citationsprinted in the article.

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should solicit the expectations of the patient andevaluate his or her suitability for rhinoplasty.

Nasal HistoryIn addition to reviewing the patient’s medical

history, the patient should be asked about a historyof allergic disorders such as hay fever, asthma, andother problems including vasomotor rhinitis andsinusitis.5 These conditions should be well con-trolled before rhinoplasty. Nasal obstruction sec-ondary to inferior turbinate hypertrophy is usuallyfound in patients with a long history of allergicrhinitis.6,7 Prior nasal trauma and operations in-cluding rhinoplasty, septal reconstruction/septo-plasty, and sinus surgery should be noted. Smok-ing, alcohol consumption, and use of illicit drugs,in particular cocaine,8 can compromise outcomes.A review of current medications may reveal thosethat can cause increased risk of bleeding9 andpostoperative ecchymosis, including acetylsalicylicacid, nonsteroidal antiinflammatory drugs, fishoil, and certain herbal supplements.10

Nasal AirwayEvaluation of the nasal airway should be per-

formed in all patients presenting for rhinoplasty.The key structures that affect nasal airflow (Fig. 1)include the external and internal nasal valves (Fig. 2),the inferior turbinates, and the nasal septum.5 Thepatient should be examined for collapse of theexternal nasal valves on deep inspiration, and aCottle test should be performed to evaluate pa-

tency of the internal nasal valves. Internal nasalexamination is aided with the use of a nasal spec-ulum. Oxymetazoline nasal spray facilitates mu-cosal constriction if mucosal edema is present.Narrowing or collapse of the internal valves withinspiration should be noted,11–15 along with infe-rior turbinate hypertrophy, which typically occurson the side opposite septal deviation.5–7 Septaldeformities16–19 including deviation, tilt, spurs,and perforations are identified. The availability ofseptal cartilage is assessed, as this is the primarysource of autogenous graft material. The presenceof nasal polyps or tumors may require furtherinvestigation and treatment.

Nasofacial AnalysisNasofacial analysis plays a key role in achieving

facial harmony after rhinoplasty.2,20,21 Systematic na-sal analysis is important to identify deformities, eval-uate anatomical relationships, and establish goals forsurgery (Table 1) (see Video 1, which demonstratessystematic nasal analysis in primary open rhino-plasty, available in the “Related Videos” section ofthe full-text article on PRSJournal.com or, for Ovidusers, at http://links.lww.com/PRS/A358).2 Aestheticideals and proportions that help to guide inpreoperative analysis and planning have beendescribed in detail,20 –33 including gender-spe-cific characteristics34 –38 and considerations inadolescents39–41 and the aging population.42–46 Inaddition, there is increasing awareness of the im-

Fig. 1. The inspiratory current is normally described as a para-bolic curve through the nasal vault. Air enters at the level of thenares and gently arcs superiorly above the head of the inferiorturbinate. The main flow of air is through the middle meatus. Asmall amount courses through the inferior meatus and an evensmaller amount courses up toward the cribriform plates. (FromHoward BK, Rohrich RJ. Understanding the nasal airway: Princi-ples and practice. Plast Reconstr Surg. 2002;109:1128 –1146.)

Fig. 2. The external nasal valve exists at the level of the innernostril. It is formed by the caudal edge of the lateral crus of thelower lateral cartilage, the soft-tissue alae, the membranous sep-tum, and the sill of the nostril. The internal nasal valve accounts forapproximately half of the total airway resistance and is borderedmedially by the septum, inferiorly by the nasal floor, laterally bythe inferior turbinate, and superiorly by the caudal border of theupper lateral cartilage. The junction between the septum andupper lateral cartilage is normally 10 to 15 degrees. (From How-ard BK, Rohrich RJ. Understanding the nasal airway: Principlesand practice. Plast Reconstr Surg. 2002;109:1128 –1146.)

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http://links.lww.com/PRS/A358

portance of ethnic congruence47–66 in aestheticsurgery, and this should be taken into consider-ation when planning rhinoplasty for these patients.External nasal examination provides informationabout the underlying osseocartilaginous framework.Examination during smiling may reveal descent ofthe nasal tip, shortening of the upper lip, or a trans-verse crease in the midphiltral area that may benefitfrom depressor septi muscle transposition (seeVideo 2, which demonstrates depressor septi muscletranslocation in primary open rhinoplasty, avail-able in the “Related Videos” section of the full-textarticle on PRSJournal.com or, for Ovid users, athttp://links.lww.com/PRS/A359).67

Nasal skin is typically thinner and more mobilesuperiorly and thicker around the nasal tip.68–70

Skin is thinnest over the osseocartilaginous junc-tion and thickest over the nasion and supratiparea. More dramatic intraoperative manipulationof the osseocartilaginous framework is required inpatients with thick nasal skin, whereas subtlechanges will be visible in patients with thin skin.2,21

Nasal skin characteristics such as thick sebaceousor thin skin will influence the outcome and re-

Table 1. Systematic Nasal Analysis

View Characteristics

FrontalFacial proportionsSkin type/quality Fitzpatrick type, thin or thick,

sebaceousSymmetry and nasal

deviationMidline, C-, reverse C-, S- or

S-shaped deviationBony vault Narrow or wide,

asymmetrical, short or longnasal bones

Midvault Narrow or wide, collapse,inverted-V deformity

Dorsal aesthetic lines Straight, symmetrical orasymmetrical, well- or ill-defined, narrow or wide

Nasal tip Ideal/bulbous/boxy/pinched,supratip, tip-definingpoints, infratip lobule

Alar rims Gull-shaped, facets, notching,retraction

Alar base WidthUpper lip Long or short, dynamic

depressor septi muscles,upper lip crease

LateralNasofrontal angle Acute or obtuse, high or low

radixNasal length Long or shortDorsum Smooth, hump, scooped outSupratip Break, fullness, pollybeakTip projection Overprojected or

underprojectedTip rotation Overrotated or underrotatedAlar-columellar

relationshipHanging or retracted alae,

hanging or retractedcolumella

Periapical hypoplasia Maxillary or soft-tissuedeficiency

Lip-chin relationship Normal, deficientBasal

Nasal projection Overprojected orunderprojected, columellar-to-lobular ratio

Nostril Symmetrical or asymmetrical,long or short

Columella Septal tilt, flaring of medialcrura

Alar base WidthAlar flaring

Video 1. Video 1, which demonstrates systematic nasal analysisin primary open rhinoplasty, is available in the “Related Videos”section of the full-text article on PRSJournal.com or, for Ovid us-ers, at http://links.lww.com/PRS/A358. Used with permissionfrom the University of Texas Southwestern.

Video 2. Video 2, which demonstrates depressor septi muscletranslocation in primary open rhinoplasty, is available in the “Re-lated Videos” section of the full-text article on PRSJournal.com or,for Ovid users, at http://links.lww.com/PRS/A359. Used withpermission from the University of Texas Southwestern.

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covery following rhinoplasty; patients with thicknasal skin are prone to prolonged postoperativeedema and scar formation, requiring a longerrecovery.2,21

Standardized Photography and Digital ImagingStandardized photography including frontal,

lateral, oblique, and basal views should be ob-tained for every patient.2,71,72 These are a criticalcomponent of the medical record for preopera-tive planning and evaluation of postoperativeresults.2,71–79 Digital imaging is commonly appliedand can aid in communication and setting patientexpectations. Although some authors report pos-itive correlation between the preoperative digitalimaging and postoperative results,79 it should bemade clear to patients that the images do notguarantee a result.2,71,72

Patient Expectations and Suitabilityfor Rhinoplasty

Evaluation of patient expectations is a keycomponent of the preoperative consultation. Thepatient should list specific concerns about his orher nasal appearance and/or function and shouldattempt to rank these in order of importance.2,71

Most patients have realistic expectations for sur-gery and can understand the limitations of rhino-plasty with adequate discussion. Reviewing photo-

graphs with the patient allows the patient toappreciate different views of his or her face andnose that can help identify specific areas of con-cern. A patient that focuses on minor or uncor-rectable problems or has unrealistic expectationsdespite extensive discussion will likely be disap-pointed following surgery regardless of the aes-thetic improvement; it is better to avoid operatingon these patients.2,71

Assessment of the emotional stability of thepatient is critical when evaluating the patient seek-ing rhinoplasty.2,71,80–88 Motivating factors shouldbe identified and the surgeon must differentiatebetween healthy and unhealthy reasons for seek-ing rhinoplasty. Feelings of inadequacy, immatu-rity, family conflicts, divorce, and other major lifechanges may be unhealthy motivating factors be-hind the patient seeking aesthetic surgery. Poorpostoperative patient satisfaction is often based onemotional dissatisfaction as opposed to technicalfailure, and this can be avoided by preoperativeidentification of these unhealthy motivating fac-tors (Fig. 3).2,9,71

GOALS OF TREATMENTThe aesthetic goals following rhinoplasty are

largely dependent on the patient’s concerns andexpectations. In attempting to satisfy the patient,it is still important to restore nasofacial balanceand harmony, and to preserve gender-specific

Fig. 3. “Danger signs” that may indicate the patient has underlying psychological issues.(From Rohrich RJ, Janis JE, Kenkel JM. Male rhinoplasty. Plast Reconstr Surg. 2003;112:1071–1085.)


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characteristics and ethnic congruence. In patientswith nasal airway obstruction, it is important torestore the nasal airway. For patients who presentwithout nasal airway problems, respecting and pre-serving the key structures is requisite.

ADVANTAGES AND DISADVANTAGES OFTREATMENT OPTIONS

Both the open approach and the endonasal(closed) approach are commonly used. The openapproach continues to gain in popularity for bothprimary and revision rhinoplasty (see Video 3,which demonstrates the open approach in primaryrhinoplasty, available in the “Related Videos” sectionof the full-text article on PRSJournal.com or, forOvid users, at http://links.lww.com/PRS/A360).89

There are advantages and disadvantages to bothapproaches,71,90–102 with the correct approach deter-mined by the patient’s anatomical deformity and thesurgeon’s experience (Tables 2 and 3).71,102

Some of the significant advantages of the openapproach include full visualization of the nasalframework to more accurately diagnose the causeof the nasal airway obstruction or the aestheticdeformity. Manipulation of the various structures,from the dorsum to the septum to the tip, can beperformed with precision and can yield reproduc-ible results. The open approach is particularly use-ful when addressing a posttraumatic deformity orin revision rhinoplasty.2,71,90 Patient dissatisfactionrelated to the transcolumellar scar does not ap-pear to be substantiated, in particular when an in-

verted-V or stairstep incision is used.103–105 In addi-tion, the safety of the transcolumellar incision hasbeen validated, provided that the lateral nasal arter-ies are preserved.106–108 The main source of patientdissatisfaction following the open approach tends toarise from prolonged nasal tip edema, and thisshould be discussed preoperatively.2,71 The endona-sal approach is advantageous in patients with anisolated dorsal hump deformity or where there isminimal modification of the tip required.2,71

KEY ELEMENTS OF SURGERYThe composite maneuvers required for suc-

cessful rhinoplasty and their sequence arelargely dependent on the patient’s concerns andexpectations, preoperative nasofacial analysis,

Video 3. Video 3, which demonstrates the open approach in pri-mary rhinoplasty, is available in the “Related Videos” section ofthe full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A360. Used with permission from the Uni-versity of Texas Southwestern.

Table 2. Advantages and Disadvantages of OpenRhinoplasty*

AdvantagesBinocular visualizationEvaluation of complete deformity without distortionPrecise diagnosis and correction of deformitiesAllows use of both handsMore options with original tissues and cartilage graftsDirect control of bleeding with electrocautery

DisadvantagesExternal nasal incision (transcolumellar scar)Prolonged operative timeProtracted nasal tip edemaColumellar incision separation and delayed wound healingSuture stabilization of grafts often required

*Adapted from Gunter JP, Rohrich RJ. External approach for sec-ondary rhinoplasty. Plast Reconstr Surg. 1987;80:161–174.

Table 3. Advantages and Disadvantages ofEndonasal Rhinoplasty*

AdvantagesLeaves no external scarLimits dissection to areas needing modificationPermits creation of precise pocket so graft material fits

exactly without need for fixationAllows percutaneous fixation when large pockets are

madePromotes healing by maintaining vascular bridgeEncourages accurate preoperative diagnosis and

planningProduces minimal postsurgical edemaReduces operating timeResults in fast patient recoveryCreates intact tip graft pocket

DisadvantagesRequires experience and great reliance on accurate

preoperative diagnosisProhibits simultaneous visualization of the surgical field

by a teaching surgeon and studentsDoes not allow direct visualization of nasal anatomyMakes dissection of alar cartilages difficult, particularly

in cases of malposition*Adapted from Janis JE, Ahmad J, Rohrich, RJ. Primary rhinoplasty.In: Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques. 2nded. St. Louis: Quality Medical Publishing, Inc. (in press).


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and intraoperative diagnosis (Table 4).2,71,109 –111

Several details are key to achieving the best re-sults following rhinoplasty.

Modifying the Nasal DorsumA prominent dorsal hump is a frequent com-

plaint of the patient seeking rhinoplasty. The na-sal dorsum is initially modified before addressingthe nasal tip, which establishes the balance be-tween the dorsum and tip that is essential toachieving the optimal aesthetic result.112,113 Thenasal dorsum can be reduced as a composite, orcomponent dorsal hump reduction can be per-formed. Component dorsal hump reduction hasthe advantage of incremental control and greaterprecision (Fig. 4) (see Video 4, which demonstratescomponent dorsal hump reduction in primary openrhinoplasty, available in the “Related Videos” sectionof the full-text article on PRSJournal.com or, for

Ovid users, at http://links.lww.com/PRS/A361). 112,113

It is performed using five essential steps:

1. Separation of the upper lateral cartilagefrom the septum.

2. Incremental reduction of the septumproper.

3. Incremental dorsal bony reduction.4. Verification by palpation.5. Final modifications, if indicated (spreader grafts,

suturing techniques, osteotomies).112,113

Managing the Nasal AirwayManaging the nasal airway involves preserving

or restoring the key structures that affect nasal

Table 4. Approach to Open Rhinoplasty

AnesthesiaIncisions (transcolumellar and infracartilaginous)Skin elevation/dissection of lower lateral cartilage/upper

lateral cartilageIntraoperative diagnosisAssessment of tip projectionComponent dorsal hump reduction/dorsal augmentationSeptal reconstruction/inferior turbinoplasty (if indicated)Cephalic trim of lower lateral cartilage (if indicated)Establishment of final tip projection (columellar strut graft

and suture technique)Final inspection/irrigationOsteotomiesWound closureDepressor septi muscle translocation (if indicated)Alar base surgery (if indicated)Splints and dressings

Video 4. Video 4, which demonstrates component dorsal humpreduction in primary open rhinoplasty, is available in the “RelatedVideos” section of the full-text article on PRSJournal.com or, forOvid users, at http://links.lww.com/PRS/A361. Used with per-mission from the University of Texas Southwestern.

Fig. 4. Component dorsal hump reduction. (Left) Creation of submucoperichondrial tunnels and separation of the upperlateral cartilages from the septum. (Center and right) Incremental reduction of the septum proper with preservation of theupper lateral cartilages, which results in a rounding of the dorsum. (From Rohrich RJ, Muzaffar AR, Janis JE. Componentdorsal hump reduction: The importance of maintaining dorsal aesthetic lines in rhinoplasty. Plast Reconstr Surg. 2004;114:1298 –1308.)


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airflow, including the nasal septum, the inferiorturbinates, and the internal and external nasalvalves (Fig. 5).2,5,6,11–16,71,114–118

Septal ReconstructionSeptal deviation can involve deviation of the

septal cartilage, perpendicular plate of the eth-moid bone, or vomer away from the midline andcan cause obstruction of one or both of the nasalairways, along with external deviation of thenose.2,5,16 –19,71,119 –124 Nasal deviations can be clas-sified into three basic types: caudal septal devi-ations, concave dorsal deformities, and con-cave/convex dorsal deformities (Table 5).2,71,119

Correction of septal deviation is key to imp-roving nasal airflow and correcting the devi-ated nose and is executed using the followingprinciples:

1. Exposure of all deviated structures throughthe open approach.

2. Release of all mucoperichondrial attach-ments to the septum, especially the deviatedpart.

3. Straightening of the septum and, if neces-sary, performing septal reconstruction whilemaintaining an 8- to 10-mm caudal and dor-sal L-strut.

4. Restoration of long-term support with but-tressing caudal septal batten or dorsal nasalspreader grafts.

5. If necessary, submucous resection of hyper-trophied inferior turbinates.

6. Precisely planned and executed externalpercutaneous osteotomies (Fig. 6).119

As opposed to septoplasty, where the septalcartilage is scored in an attempt to straighten it,or submucosal resection, where the entire sep-

Fig. 5. Causes of nasal airway obstruction. *Requires further evaluation and work-up. (FromRohrich RJ, Krueger JK, Adams WP Jr, Marple BF. Rationale for submucous resection of hypertro-phied inferior turbinates in rhinoplasty: An evolution. Plast Reconstr Surg. 2001;108:536 –544.)

Table 5. Classification of the Deviated Nose*

Type Description

I Caudal septal deviationa. Straight septal tiltb. Concave

deformity(C-shaped)

c. S-shapeddeformity

II Concave dorsal deformitya. C-shaped dorsal

deformityb. Reverse C-shaped

dorsal deformityIII Concave/convex dorsal

deformity (S-shaped)*Adapted from Rohrich RJ, Gunter JP, Deuber MA, Adams WP Jr. Thedeviated nose: Optimizing results using a simplified classification andalgorithmic approach. Plast Reconstr Surg. 2002;110:1509–1523.


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tum is removed other than the L-strut, septalreconstruction differs in that only the portion ofthe septum causing airway obstruction is re-moved, with the idea that native cartilage ispreserved.2,16,71 It is of critical importance to pre-serve an 8- to 10-mm L-strut of septal cartilage forstructural integrity.

Inferior Turbinoplasty/Outfracture/Submucous Resection

The turbinates exist as three or four bilateralextensions from the lateral nasal cavity. The infe-rior turbinate consists of highly vascular mucope-

riosteum covering a thin semicircular conchalbone.2,6,71,115,125 In combination with the internalnasal valve, the anterior extent of the inferior tur-binate can be responsible for up to two-thirds ofthe upper airway resistance.2,5,6,71 Posteriorly, theinferior turbinate diverges away from the nasalseptum, allowing for reduced upper airway resis-tance in this area.2,5,6,71,115,125

Inferior turbinoplasty is performed in patientswith nasal airway obstruction secondary to infe-rior turbinate hypertrophy refractory to medicalmanagement.2,5–7,71,126 In most cases, inferior turbi-

Fig. 6. Algorithm for correction of the deviated nose. ULCs, upper lateral cartilages. (From Rohrich RJ,Gunter JP, Deuber MA, Adams WP Jr. The deviated nose: Optimizing results using a simplified classifi-cation and algorithmic approach. Plast Reconstr Surg. 2002;110:1509–1523.)


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noplasty with outfracture of the inferior turbinateor submucous resection is adequate to achievesignificant improvement (Fig. 7).2,6,71 Overly ag-gressive surgical management may be complicatedby bleeding, mucosal crusting and desiccation, cil-iary dysfunction, chronic infection, malodorousnasal drainage, or atrophic rhinitis.2,6

Internal Nasal ValveThe important role of the internal nasal valve

in nasal airflow has been discussed in greatdetail.2,5,11–15,71,114 Iatrogenic internal nasal valveobstruction is frequently secondary to collapse ofthe midvault after composite dorsal hump reduc-tion or vestibular stenosis. Component dorsalhump reduction allows incremental control and

greater precision to reduce the risk of midvaultcollapse.112,113 Loss of cartilaginous support atthe midvault may require the use of spreadergrafts71,114,127–129 or autospreader flaps,71,130–132 andloss of lining secondary to vestibular stenosis mayrequire skin grafts or flaps.5,133

Autologous Grafts, Homografts, andAlloplastic Implants

Various grafts are used to augment deficient ar-eas to correct contour deformities and restore struc-tural support (Table 6).2,134 Autologous grafts arepreferential to homografts and alloplastic implantsbecause of their high biocompatibility and low riskof infection and extrusion.2,135,136 Their disadvan-tages include donor-site morbidity, graft resorption,and unavailability of sufficient quantities for graftmaterial.2,135,136 Autologous cartilage grafts are mostcommonly obtained from septal,137–140 ear,141–144 andcostal cartilage.145–157 Diced cartilage grafts have alsobeen used.158–166 Other donor sites for autologousgrafts include calvarial and nasal bone, and the olec-ranon process of the ulna.2,135 Concerns regardingdonor-site morbidity, graft availability, and graft re-sorption will necessitate the use of homologous oralloplastic implants.2,135,136,167–172

Nasal TipA graduated approach to nasal tip surgery requires

a combination of techniques (Fig. 8),2,173–177 includingthe cephalic trim (see Video 5, which demonstrates tipshaping with a cephalic trim in primary open rhino-plasty, available in the “Related Videos” section of thefull-text article on PRSJournal.com or, for Ovid users,at http://links.lww.com/PRS/A362), the use of a colu-mellar strut graft (see Video 6, which demonstrates tipshaping with a columellar strut graft in primary openrhinoplasty, available in the “Related Videos” section of

Fig. 7. Outfracture (above) and submucous resection (below) ofthe inferior turbinate. (From Rohrich RJ, Krueger JK, Adams WP Jr,Marple BF. Rationale for submucous resection of hypertrophiedinferior turbinates in rhinoplasty: An evolution. Plast ReconstrSurg. 2001;108:536 –544.)

Table 6. Overview of Rhinoplasty Grafts by Region*

Dorsum Tip Alar Region Base

Dorsal onlay graft Anchor graft Alar batten graft Alar base graftDorsal sidewall

onlay graft(lateral nasalwall graft)

Cap graft Alar contour graft (alar rimgraft)

Columellarplumpinggrafts(s)

Radix graft Columellar strut (floating/fixed-floating) Alar spreader graft (lateralcrural spanning graft)

Premaxillary graft

Spreader grafts Columellar strut (fixed) Composite alar rim graftSeptal extension

graftsExtended columellar strut-tip graft

(extended shield graft)Lateral crural onlay graft

Onlay tip graft Lateral crural strut graftShield graft (sheen or infralobular graft) Lateral crural turnover graftSubdomal graftUmbrella graft

*Adapted from Gunter JP, Landecker A, Cochran CS. Frequently used grafts in rhinoplasty: Nomenclature and analysis. Plast Reconstr Surg.2006;118:14e–29e.


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Video 5. Video 5, which demonstrates tip shaping with a ce-phalic trim in primary open rhinoplasty, is available in the “Re-lated Videos” section of the full-text article on PRSJournal.com or,for Ovid users, at http://links.lww.com/PRS/A362. Used withpermission from the University of Texas Southwestern.

Video 6. Video 6, which demonstrates tip shaping with a colu-mellar strut graft in primary open rhinoplasty, is available in the“Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A363. Usedwith permission from the University of Texas Southwestern.

Fig. 8. Algorithm for achieving adequate tip projection and refinement. (From Ghavami A, Janis JE, Acikel C, Rohrich RJ. Tip shapingin primary rhinoplasty: An algorithmic approach. Plast Reconstr Surg. 2008;122:1229 –1241.)


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the full-text article on PRSJournal.com or, for Ovidusers, at http://links.lww.com/PRS/A363), nasal tip su-turing (Fig. 9) (see Video 7, which demonstrates tipshaping with nasal tip suturing in primary open rhi-noplasty, available in the “Related Videos” section ofthe full-text article on PRSJournal.com or, for Ovidusers, at http://links.lww.com/PRS/A364),178–190 and na-sal tip grafting (Fig. 10).191–199 Application of thesetechniques will help to correct tip deformitiesand improve tip shape and minimize deformi-ties secondary to loss of support. In addition,compared with the endonasal approach, theopen approach may cause mild loss of tip pro-jection because of disruption of ligamentoussupport and increased skin undermining.107 Acolumellar strut graft and nasal tip suturingtechniques will help maintain nasal tip supportfollowing open rhinoplasty.2,107,173

Alar RimsThe alar rims contribute to the alar-columellar

relationship, nasal tip support, and patency of theexternal nasal valve (Fig. 11).200–205 The presenceof deformities of the alar rims such as alar notch-ing or retraction, facets of the soft-tissue triangles,malposition of the lateral crura, or functionalproblems including external valve collapse shouldbe addressed during rhinoplasty.2 Various tech-niques to alter the length and strength of thelateral crura and the alar rims including lateralcrural horizontal mattress sutures,182,183 lowerlateral crural turnover flaps,206 alar contourgrafts (see Video 8, which demonstrates alarcontour grafts in primary open rhinoplasty,available in the “Related Videos” section of thefull-text article on PRSJournal.com or, for Ovidusers, at http://links.lww.com/PRS/A365),207 alarbatten grafts,208,209 and lateral crural strutgrafts210 –213 have been described (Fig. 12).Osteotomies

Nasal osteotomies are used to narrow a widebony vault, close an open roof deformity, or

straighten deviated nasal bones.2,71,214,215 The goalsof nasal osteotomies are maintenance or creationof smooth dorsal aesthetic lines and obtaining adesirable width of the bony vault.2,216 Osteotomiescan be classified by approach (external or inter-nal), type (lateral, medial, transverse, or a com-bination), and level (low-to-high, low-to-low, ordouble level) (Fig. 13).2,71 Relative contraindica-tions to the use of osteotomies during rhinoplastyinclude patients with short nasal bones, elderlypatients with excessively thin nasal bones, thosewith relatively thick nasal skin, and some non-Caucasian patients with extremely low andbroad noses.2,71,114,215–220 Multiple osteotomytechniques including intranasal, intraoral, andpercutaneous have been described.221–245 Percu-taneous lateral discontinuous osteotomies havethe advantage of producing a more controlled

Fig. 9. Tip suturing techniques. (Left) Medial crural septal suture. (Center) Transdomal suture. (Right) Interdomal suture. (FromRohrich RJ, Janis JE, Kenkel JM. Male rhinoplasty. Plast Reconstr Surg. 2003;112:1071–1085.)

Video 7. Video 7, which demonstrates tip shaping with nasal tipsuturing in primary open rhinoplasty, is available in the “RelatedVideos” section of the full-text article on PRSJournal.com or, forOvid users, at http://links.lww.com/PRS/A364. Used with per-mission from the University of Texas Southwestern.


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fracture with less intranasal trauma and mini-mizing morbidity, including bleeding, ecchymo-sis, and edema.2,71,215–220,238 (see Video 9, whichdemonstrates percutaneous lateral nasal osteot-omies in primary open rhinoplasty, available inthe “Related Videos” section of the full-text ar-ticle on PRSJournal.com or, for Ovid users, athttp://links.lww.com/PRS/A366.)

IMPORTANT DETAILS OFPERIOPERATIVE MANAGEMENT

As with most aesthetic surgery procedures, rhi-noplasty is typically performed in the ambulatorysurgery setting. The American Society of PlasticSurgeons Patient Safety Committee evidence-based patient safety advisory provides an overviewof perioperative steps that should be completed toensure appropriate patient selection for the am-bulatory surgery setting.246 In addition, guidelinesfor perioperative cardiovascular evaluation,247,248

prevention of pulmonary complications,249,250 andvenous thromboembolism prophylaxis251,252 arealso available.

Fig. 10. Tip grafting techniques. (Left) Tip onlay graft. (Center) Infratip lobular graft. (Right) Combination graft. (From Rohrich RJ,Janis JE, Kenkel JM. Male rhinoplasty. Plast Reconstr Surg. 2003;112:1071–1085.)

Fig. 11. The length and strength of the lower lateral cartilageprovide support to the alar rims. The lateral crural complex issupported by the suspensory ligament of the tip, fibrous con-nections to the upper lateral cartilage, and its abutment withthe pyriform aperture. The posterior 50 percent of the alar rimthat is devoid of cartilage is composed of fibrofatty areolartissue and thick overlying skin. The tissue composition of thealar rim and the action of the nasal dilator muscles lend furtherbut much less significant support to the ala. (From Rohrich RJ,Raniere J Jr, Ha RY. The alar contour graft: Correction and pre-vention of alar rim deformities in rhinoplasty. Plast ReconstrSurg. 2002;109:2495–2505.)

Video 8. Video 8, which demonstrates alar contour grafts in pri-mary open rhinoplasty, is available in the “Related Videos” sec-tion of the full-text article on PRSJournal.com or, for Ovid users, athttp://links.lww.com/PRS/A365. Used with permission from theUniversity of Texas Southwestern.


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AnesthesiaRhinoplasty can be performed under general

endotracheal anesthesia or intravenous sedationwith local anesthesia, depending on the patient’scharacteristics and surgeon’s preference.71 Withgeneral endotracheal anesthesia, it is easier to securethe airway and, also, prevent intragastric blood leadingto postoperative nausea and vomiting by using a throatpack.2,111 Injection with lidocaine and epinephrine ofthe highly vascular areas of the nose including thecolumella, tip, dorsum, lateral sidewalls, alar base, andalong the caudal margin of the lower lateral cartilagesis important for hemostasis.2,111 Oxymetazoline-soakedcottonoid pledgets are inserted into the nasal cavities

for mucosal constriction. Comparable hemostasis canbe obtained using lidocaine with oxymetazoline andavoids the use of a controlled substance with potentialcardiac effects as seen with cocaine.253,254

AntibioticsFirst- or second-generation cephalosporins are

generally used for antibiotic prophylaxis inrhinoplasty.255 Patients at risk for methicillin-re-sistant Staphylococcus aureus colonization may re-quire alternate antibiotic prophylaxis.256,257 Thepatient should receive preoperative prophylacticintravenous antibiotics 30 minutes before surgery.Several studies258–261 have shown no difference in

Fig. 12. Techniques to alter the length and strength of the alar rims. (Left) Lateral crural turnover flap. (From Janis JE, Trussler A,Ghavami A, Marin V, Rohrich RJ, Gunter JP. Lower lateral crural turnover flap in open rhinoplasty. Plast Reconstr Surg. 2009;123:1830 –1841.) (Center) Alar contour graft. (From Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft: Correction and prevention of alar rimdeformities in rhinoplasty. Plast Reconstr Surg. 2002;109:2495–2505.) (Right) Lateral crural strut graft. (From Ghavami A, Janis JE, AcikelC, Rohrich RJ. Tip shaping in primary rhinoplasty: An algorithmic approach. Plast Reconstr Surg. 2008;122:1229 –1241.)

Fig. 13. Patterns of osteotomies. (From Rohrich RJ, Krueger JK, Adams WP Jr,Hollier LH Jr. Achieving consistency in the lateral nasal osteotomy during rhi-noplasty: An external perforated technique. Plast Reconstr Surg. 2001;108:2122–2130.)


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infection rate with the use of postoperative pro-phylactic antibiotics.

HOW TO AVOID AND WHAT TO DOWITH THE COMPLICATIONS

The reported incidence of significant compli-cations following rhinoplasty ranges from 1.7 to 18percent.262–267 Common complications followingrhinoplasty include bleeding, infection, nasal air-way obstruction, and deformities (Table 7).255,268

BleedingPatients with hypertension, a family history of

bleeding diatheses, and those taking aspirin andother nonsteroidal antiinflammatory drugs are atrisk for bleeding complications. Hypertensionshould be well controlled perioperatively.2,255 Thereshould be good communication with the anesthesiaprovider regarding intraoperative blood pressurecontrol. Patients with intraoperative hypertensionmay benefit from placement of a 0.2-mg clonidinetransdermal therapeutic system (Catapress-TTS-2;Boehringer Ingelheim Pharmaceuticals, Inc., Ridge-field, Conn.) for prevention of transient postoper-ative hypertension.2,255 Aspirin and other nonsteroi-dal antiinflammatory drugs should be stopped 10days before surgery and avoided for 2 weeks after.2,255

Epistaxis is one of the most common compli-cations following rhinoplasty.2,255,268 It is usuallymild and originates from the incisions or areas ofmucosal trauma. The patient should attempt headelevation greater than 60 degrees, oxymetazoline

nasal spray into the affected nostril, and gentlepressure for 15 minutes (Fig. 14). If bleedingpersists, the patient should be seen. Anteriornasal packing with saline-moistened ribbongauze or Surgicel (Ethicon, Inc., West Somer-ville, N.J.) lubricated with antistaphylococcal an-tibiotic ointment should be gently placed in theaffected nostril. Refractory bleeding may re-quire removal of nasal splints/packing and sa-line irrigation and suctioning to remove bloodclots and crusting to allow identification of theorigin of the bleeding; silver nitrate should beused to cauterize the area followed by anteriornasal packing. If bleeding continues, posterior na-sal packing should be considered along with hos-pital admission for observation. In less than 1 per-cent of patients, major epistaxis occurs andshould be addressed in the operating room withexploration and cauterization. Inferior turbi-nate resection is usually the source. If all of theabove measures fail, consultation for angio-graphic embolization should be obtained.

Regardless of the location, all hematomasshould be drained following rhinoplasty. Hema-tomas deep to the skin will cause fibrosis, leadingto scarring and contour deformities, affecting thefinal nasal appearance. Septal hematomas can

Video 9. Video 9, which demonstrates percutaneous lateral na-sal osteotomies in primary open rhinoplasty, is available in the“Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A366. Usedwith permission from the University of Texas Southwestern.

Table 7. Complications of Rhinoplasty

HemorrhagicEpistaxisSeptal hematoma

InfectiousCellulitisSeptal abscessToxic shock syndrome

TraumaticL-strut fracturesLacrimal sac/nasolacrimal duct injury and epiphoraIntracranial injury and cerebrospinal fluid leak

FunctionalSeptal perforationIntranasal synechiaeVestibular stenosisInternal/external valve collapseSeptal deviationRhinitis

AestheticDeformities of dorsum or nasal tipDeviationAsymmetryAlar notching/retractionSupratip (“pollybeak”) deformity“Inverted-V” deformity“Rocker” deformity

Soft-tissueProlonged edemaVisible/depressed transcolumellar scarContact dermatitisSkin necrosisNasal cyst


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lead to septal perforations or necrosis of septalcartilage, leading to a saddle-nose deformity. He-matomas can usually be drained in the office withappropriate lighting. After drainage, the areashould be packed to prevent recurrence and thenreinspected the next day.2,255,268

InfectionInfections are rare following rhinoplasty.

Early diagnosis and initiation of treatment willprevent serious complications such as tissue ne-crosis, toxic shock syndrome,268 –272 and cavern-ous sinus thrombosis.2,255,268 In the event of an

Fig. 14. Algorithm for treatment of epistaxis.


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infection, internal nasal splints or packing mayneed to be removed.

Mild cellulitis usually responds to cephalospo-rins. Cellulitis refractory to this treatment after 24to 48 hours may be secondary to methicillin-resis-tant Staphylococcus aureus, and empiric antibiotictreatment should be selected based on local an-tibiotic resistance patterns.2,256,257 In cases of severecellulitis, admission for intravenous antibiotics

may be indicated.2,255 Abscesses are usually foundat the nasal dorsum, nasal tip, and the septum, andshould be drained and irrigated with cultures ob-tained to guide antibiotic therapy.2,255

Nasal Airway ObstructionIt is common for patients to experience tran-

sient nasal airway obstruction secondary toedema following rhinoplasty. This typically re-

Fig. 15. (Left) Preoperative frontal and oblique views of a 19-year-old woman with nasaldeviation and airway obstruction, a type IIa C-shaped dorsal deviation, a dorsal hump,and a bulbous tip. (Right) The postoperative result demonstrates a straight dorsum withrestoration of balanced dorsal aesthetic lines and improvement in her bulbous tip. (FromRohrich RJ, Gunter JP, Deuber MA, Adams WP Jr. The deviated nose: Optimizing resultsusing a simplified classification and algorithmic approach. Plast Reconstr Surg. 2002;110:1509 –1523.)


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solves over 2 to 3 weeks as edema subsides. Whennasal airway obstruction persists after 3 weeks,internal nasal examination using a topical vaso-constrictor should be performed to identify thecause. If it is secondary to edema, nasal decon-gestants can be used, but topical vasoconstric-tors should not be used for more than 7 daysbecause of rebound congestion following cessa-tion of these medications. If an anatomical causeof obstruction is identified such as internal nasalvalve collapse or synechiae, surgical treatmentwill be required but should be delayed for atleast 1 year to allow for complete resolution ofedema and maturation of scar tissue.2,255

DeformityMild deformities should be observed. If they

persist beyond 1 year, surgical treatment is re-quired. Significant deformities should be cor-rected as soon as they are identified to avoidpatient dissatisfaction.2,273 Certain deformitiesmay develop secondary to excessive scar prolif-eration; this is seen most frequently at the su-pratip and may benefit from corticosteroidinjections.255,268 Triamcinolone acetate (10 mg/ml) with plain 2% lidocaine at a 1:1 ratio ismixed, and typically a total of 3 to 5 mg oftriamcinolone acetate is injected using a 27-gauge needle into the area.255 Superficial injec-

Fig. 16. (Left) Preoperative lateral and submental views of the patient in Figure 15. (Right)The postoperative result demonstrates a straight dorsum with restoration of balanced dorsalaesthetic lines and improvement in her bulbous tip. (From Rohrich RJ, Gunter JP, Deuber MA,Adams WP Jr. The deviated nose: Optimizing results using a simplified classification andalgorithmic approach. Plast Reconstr Surg. 2002;110:1509 –1523.


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tion should be avoided, as it may lead to sub-dermal atrophy.255,268 Deviations are managedsimilar to deformities. Mild deviation may becorrected using nasal molding techniques.2,255

The patient is instructed to apply controlledpressure using his or her thumb along the nasalsidewall three to four times per day for 4 to 6weeks postoperatively. If the deviation is signif-icant or persistent beyond 1 year, surgical treat-ment is required.2,255

EXPECTED OUTCOMES FOR THEPATIENT AND THE SURGEON

OutcomesResults following primary rhinoplasty are

shown in Figures 15 through 17. At this time,there are no standardized measures for assessingthe aesthetic or functional outcomes followingrhinoplasty.2 Several authors have described out-come measures to assess patient satisfaction,274–278 andhave reported significantly improved quality oflife for patients following rhinoplasty regardless ofwhether the indication was cosmetic orposttraumatic.275,277 Attempts to quantify bothaesthetic279–288 and functional results289–292 alongwith the impact of various maneuvers have alsobeen reported.

Revision RhinoplastyAlthough it is difficult to determine an exact

revision rate following primary open rhino-plasty, a recent survey of plastic surgeons andotolaryngologists revealed that 58 percent ofthose surveyed cited their revision rate as lessthan 5 percent, whereas another 33 percent re-ported their revision rate to be between 6 and 10percent.89 This survey also revealed that theopen approach was preferred by 73 percentcompared with 20 percent preferring the endo-nasal approach for revision rhinoplasty.

Revision rhinoplasty poses a significant chal-lenge because of the complex nature of anatomicalor functional abnormalities, alteration of native na-sal anatomy, presence of scarring, and depletion ofautogenous cartilage needed for grafting. Severalauthors have described strategies for successful re-vision rhinoplasty along with considerations andtechniques.11,90,95–97,293–297

CONCLUSIONSAccurate preoperative systematic nasal analysis

and evaluation of the nasal airway, along with iden-tification of both the patient’s expectations and thesurgeon’s goals, form the foundation for success.

Intraoperatively, adequate anatomical exposure ofthe nasal deformity; preservation and restoration ofthe normal anatomy; correction of the deformityusing incremental control, maintenance, and resto-ration of the nasal airway; and recognition of thedynamic interplays among the composite of maneu-vers are required. During postoperative recovery,care and reassurance combined with an ability torecognize and manage complications leads to suc-cessful outcomes following rhinoplasty.

Rod J. Rohrich, M.D.Department of Plastic Surgery

University of Texas Southwestern Medical Center1801 Inwood Road

Dallas, Texas [email protected]

Fig. 17. Gunter diagram demonstrating operative plan: compo-nent dorsal reduction; submucous septal resection; septal L-strutstraightening with inferior, full-thickness, 50-percent cuts; and bi-lateral spreader grafts. Tip rotation was achieved with a caudal sep-tal reduction, and tip reconstruction was performed with suturetechniques. (From Rohrich RJ, Gunter JP, Deuber MA, Adams WP Jr.The deviated nose: Optimizing results using a simplified classifica-tion and algorithmic approach. Plast Reconstr Surg. 2002;110:1509–1523.)


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PATIENT CONSENTPatients provided written consent for the use of

their images.

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