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Rhinoplasty: Surface Aesthetics and Surgical Techniques

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DOI: 10.1177/1090820X13478968 · Source: PubMed

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Aesthetic Surgery Journal http://aes.sagepub.com/

Rhinoplasty : Surface Aesthetics and Surgical Techniques

Baris Çakir, Teoman Dogan, Ali Riza Öreroglu and Rollin K. Daniel
Aesthetic Surgery Journal 2013 33: 363
DOI: 10.1177/1090820X13478968

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 AL CON
ON

TR
INT ATI

IBUTION
ERN
Rhinoplasty

Aesthetic Surgery Journal

Special Topic 33(3) 363­–375
© 2013 The American Society for
Aesthetic Plastic Surgery, Inc.
Rhinoplasty: Surface Aesthetics and Surgical Reprints and permission:
http://www.​ sagepub.com/

Techniques journalsPermissions.nav
DOI: 10.1177/1090820X13478968
www.aestheticsurgeryjournal.com

Barış Çakır, MD; Teoman Doğ an, MD; Ali Rıza Öreroğ lu, MD;
and Rollin K. Daniel, MD

Abstract
Surface aesthetics of the attractive nose are created by certain lines, shadows, and highlights, with specific proportions and breakpoints. Our evaluation
of the nasal surface aesthetics is achieved using the concept of geometric polygons as aesthetic subunits, both to define the existing deformity and the
aesthetic goals. Surgical techniques have been developed and modified to achieve the desired surface appearance, and those are detailed in this article.
The principles of geometric polygons allow the surgeon to analyze the deformities of the nose, to define an operative plan to achieve specific goals, and
to select the appropriate operative technique. These aesthetic concepts and surgical techniques were used in 257 consecutive rhinoplasties performed in
the past 3 years by the principal author (B.Ç.).

Keywords
rhinoplasty, nasal surface aesthetics, nasal aesthetic polygons, lateral crus resting angle, cephalic dome suture, Libra graft

Accepted for publication September 3, 2012.

The primary objective of rhinoplasty surgery is to create
an attractive, functional nose without any surgical stig-
mata. However, this goal can only be achieved if the sur-
geon understands the direct linkage between surface
aesthetics, underlying anatomical structures, and func-
tional factors. The appearance of an attractive nose is cre-
ated by certain lines, shadows, and highlights covering the
nasal dorsum, tip, and base. During rhinoplasty surgery,
these surface aesthetics, with their proportions and break-
points, must be maintained, emphasized, and created
where they are absent. The following aesthetic concepts
and surgical techniques have been used in 257 consecu-
tive rhinoplasties performed in the past 3 years. Patients in
this series were 80% female and 20% male, with an age
range of 19 to 56 years (average, 27 years) and an average
follow-up period of 1.5 years. Two cases of bleeding
(0.78%) were observed, with no cases of infection. The
overall rate of revision was 5% for the whole series.
shadows and highlights, which are linked to the underlying
anatomic structures that can be modified surgically. Thus,
the goal of surgery is to modify, rearrange, and/or reconstruct
the nasal infrastructure, thereby creating nasal surface poly-
gons that are symmetrical and aesthetically pleasing.
Working from the glabella downward, we can define
the glabella polygon, the dorsal bone polygon, the dorsal
Dr Çakır and Dr Doğ an are plastic surgeons in private practice in
Istanbul, Turkey. Dr Öreroğ lu is a plastic surgeon in the Plastic,
Reconstructive and Aesthetic Surgery Department at Prof. Dr. A.
Ilhan Özdemir State Hospital, Giresun, Turkey. Dr Daniel is a Clinical
Professor at the Aesthetic Plastic Surgery Institute, University of
California, Irvine.
Corresponding Author:
Dr Barış Çakır, Terrace Fulya, Hakkı Yeten Cad., No. 11, Center: 1,
Apt. 5, Şiş li, Istanbul, Turkey.
E-mail: op.dr.bariscakir@gmail.com

Aesthetic Nasal Polygons

The nose can be analyzed as aesthetic units using the con-
cept of geometric polygons. A polygon is defined as a plane
figure with at least 3 straight sides and angles. Evaluation of Scan these codes with your smartphone to see the operative videos.
the nasal surface using polygons allows identification of Need help? Visit www.aestheticsurgeryjournal.com.

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364 Aesthetic Surgery Journal 33(3)

cartilage triangle, the lateral bone polygons, the upper

lateral polygons, the dome triangles, the lateral crus poly-
gons, the interdomal triangle, the facet polygons, the
infralobular polygon, the columellar polygon, and the
footplate polygons (Figure 1). The intersection and juxta-
position of the polygons define the “lines” and “points”
that rhinoplasty surgeons use to analyze the nose. Although
somewhat tedious to define, these polygons are easily
sketched on standard nasal photographs and quickly mas-
tered for operative planning, as shown in the accompanying
video (Video 1), which is available at www.aestheticsur-
geryjournal.com. You may also use any smartphone to
scan the code on the first page of this article to be taken
directly to the video on www.YouTube.com.

Dorsal Aesthetic Lines

Classically, the nose is shown on frontal view with 2 diver-
gent concave lines that extend from the supraorbital rim
through the radix area and then continue as paired lines to
the nasal tip.1 However, these traditional dorsal aesthetic
lines are slightly different when viewed through the nasal
polygon aesthetic unit concept. As seen in Figure 1, the dor-
sal aesthetic lines should have a fusiform pattern starting at
the brows, with the nasal radix area being narrow, the key-
stone area wider, and the supratip region narrow again before
ultimately diverging at the tip. This fusiform pattern is impor-
tant in creating a natural-looking aesthetic dorsum. One can Figure 1.  Nasal surface aesthetics can be analyzed in terms
clearly see the natural widening of the keystone area on of geometrical polygons, including the glabella polygon,
oblique view (Figure 2). We define the dorsal aesthetic lines the dorsal bone polygon, the dorsal cartilage triangle, the
as corresponding to the lateral edges of the glabella polygon, lateral bone polygons, the upper lateral polygons, the dome
extending caudally in between the lateral bone polygons and triangles, the lateral crus polygons, the interdomal triangle,
the dorsal bone polygon, between the upper lateral polygons the facet polygons, the infralobular polygon, the columellar
and the dorsal cartilage triangle, and between the lateral crus polygon, and the footplate polygons.
polygons and the dome triangles (Figure 1).

Lateral Aesthetic Lines
These lines are created by combining the lateral edges of
the lateral bone polygons, the upper lateral polygons, and
partially by the lateral crura polygons (Figure 1). The
importance of the lateral aesthetic lines is to emphasize
the triangularity of the nose and to offset the nose from the
cheek. The lateral aesthetic lines are as important as the
dorsal subunit but not as complex. The nasal base on both
sides should also produce a highlight, creating 2 conver-
gent and convex lines extending from the supratarsal folds
toward the nasal alae, with the narrowest point being at
the nasal radix area.
The Scroll Line and the Lateral
Crus Resting Angle
The scroll line is a groove indicating the transition from the
upper lateral polygon to the lateral crus polygon (Figure 1).
The scroll junction between the upper lateral cartilage (ULC)
and the lateral crus marks the transition from the static nasal
body to the dynamic moving nasal tip.2 The groove over the
scroll area should meet in the center to create a supratip
breakpoint, especially in the female profile. The supratip
breakpoint corresponds to the common apices of the dome
triangles and the interdomal triangle.
The lateral crura have a position in space that can be
defined in 2 different planes. The first is the lateral crus
longitudinal axis, which represents a divergence of the
lateral crus relative to the contralateral lateral crus (ie, the
intercrural angle). This divergence can be described as a
lateral crus longitudinal axis, which intersects the lateral
canthus of the ipsilateral eye in its correct position. The
second is the axial rotational position of the lateral crus,
giving rise to the concept of the lateral crus resting angle,
which we believe should have a roughly 100° inclination
with the upper lateral cartilage (Figure 3). The lateral crus,
with a normal resting angle, essentially lies horizontal
with the cephalic margin slightly superior to the caudal
margin. When the cephalic edge is more superior when
compared with the caudal edge, both structure and aes-
thetics may be negatively affected.3

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Çakır et al 365

Figure 2.  The aesthetically pleasant and natural nose is shown in a 34-year-old woman. (A) The tip exhibits “double-light
reflections” when photographed with a paraflash. (B) The lateral profile shows that no real hump is actually present. (C) The
oblique view of the dorsum reveals the “natural hump” that is due to the fusiform structure of the natural dorsum.

the scroll groove and excessive fullness in the supratip

region, making the nose look as though the lower lateral
cartilages (LLC) were cephalically malpositioned. We
describe this abnormality as a pseudocephalic malposition
of the lateral crura, as seen in Figure 3A. A resting angle
of 180° or more results in medialization of the lateral crus
cephalic border compared with the ULC, hence creating a
“pinch nose” appearance.

The Nasal Tip

Figure 3.  The lateral crus “resting angle” determines the
position of the lateral crus rotational angle to the upper
lateral cartilage. This angle should ideally be 100° between
the lateral crus and the upper lateral cartilage. (A) An
abnormal lateral crus resting angle of 150° results in
excessive fullness in the supratip region and makes the lower
lateral cartilages appear cephalically malpositioned as in this
26-year-old woman. (B) One month after rhinoplasty with
correction of the lateral crus resting angle, reducing it to
100°. Note the well-defined scroll groove as well as a natural
supratip region.
Establishing a correct resting angle of the lateral crura
is vital to the surface aesthetics of the tip. A resting angle
of 100° or less creates a well-defined scroll groove. Lateral
crura with an abnormal resting angle will cause a loss of
Sheen and Sheen4 described the ideal tip shape as 2 equilat-
eral geodesic triangles with a common base formed by a
line connecting the 2 domes. They noted that the highest
projecting point of the tip should lie along the apogee of the
curved line that connects both domes. They defined the
intercrural distance as the distance between the domes,
which also represents the common base of the 2 geodesic
triangles. Daniel5 noted an angle of dome definition at the
domal junction line, with the most aesthetically pleasing
tips having a convex domal segment and concave lateral
crus. In contrast, our concept of tip surface aesthetics is
composed of 2 dome triangles, an interdomal triangle, a pair
of facet polygons, and an infralobular polygon (Figure 1).
The Nasal Tip Diamond
The nasal tip should show “double light reflections” when
photographed with a standard 2-flash technique on frontal
view (Figure 2A). These reflections create a “diamond”-
shaped highlight through combination of the dome triangles,

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366 Aesthetic Surgery Journal 33(3)

Figure 4.  (A, B, C) The tip surface structural anatomy: C′, columellar breakpoint; Ts, superior tip; Ti, inferior tip; Rm, medial
rim; and Rl, lateral rim. The Ts point corresponds to the combined vertices of the dome triangles. The Ti points correspond
to the inferomedial corners of the dome triangles, hence the 2 inferolateral vertices of the interdomal triangle. The Rm points
represent the medial ends of the lateral crura caudal border, and the Rl points correspond to the lateral ends of the lateral crura
at the caudal border.

the interdomal triangle, and the infralobular polygon. Proper
creation of this “diamond shape” light reflection is character-
istic of an aesthetic result following tip surgery.
Tip-Defining Points
The oblique and lateral views of the nose reveal important
breakpoints at the tip, which have been defined previously in
the literature under various nomenclature.6 Our approach to
the tip surface structural anatomy requires definition of spe-
cific points—namely, the superior tip (Ts), inferior tip (Ti),
medial rim (Rm), and lateral rim (Rl) points for precise
description of the tip polygons (Figure 4).
The Ts point corresponds to the combined vertices of
the dome triangles, which will be described later. The Ti
points correspond to the inferomedial corners of the dome
triangles—hence, the 2 inferolateral vertices of the inter-
domal triangle. These points should ideally be positioned in
the same vertical plane in the lateral profile view, to create an
aesthetically pleasing tip shape. The Rm points represent the
medial ends of the lateral crura caudal border, while the Rl
points correspond to the lateral ends of the lateral crura at the
caudal border (Figure 4). These landmarks and breakpoints
help define and evaluate the tip polygons, thus facilitating
analysis of the nasal surface aesthetics.
Dome Triangles and the Interdomal
Triangle
The dome triangles are a pair of isosceles triangles, in
between the Ts, Ti, and Rm points, each having their bases
in contact with the facet polygons. The interdomal trian-
gle, on the other hand, is the triangle in between the dome
triangles created by Ts and bilateral Ti points (Figures 1
and 4). The base of a dome triangle should ideally be half
the length of the 2 sides. The base of the triangle should
never be narrowed. Any attempt to narrow the caudal
base will result in widening of the infralobular polygon,
which results in medialization of the caudal edges of the
lateral crura and an unwanted notching effect on the nos-
trils. The base of the interdomal triangle is the widest area
of the tip, created by a line connecting the 2 Ti points
(Figures 1 and 4). The medial edge of each dome triangle
corresponds to the lateral edge of the interdomal triangle.
One can devise a relative ratio comparing tip width with
nasal width at the keystone area. In females, the tip-to-
keystone width ratio is wider, which accentuates femininity,
while the ratio is narrower in males (Figure 5). The superior
angle of the interdomal triangle, corresponding to the angle
formed by the 2 dome triangles, is also an important struc-
tural detail, with an ideal value of 80° to 90° in males and
a slightly wider 90° to 100° in females (Figure 5).
The Facet Polygon
The facet polygon is a critical surface structure in the
nasal tip that should be respected in tip plasty. Defined as
the polygon in between the Ti, Rm, and Rl and C′ points
(Figure 4), the distance between the dome triangles and
the rim should be at least equal to the length of the base
of the dome triangles, creating a well-defined facet poly-
gon in between (Figure 1). Caudal trimming of the lateral

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Çakır et al 367
Figure 5.  Differences in surface aesthetics between (A) men
and (B) women. The female nose (35-year-old woman) has a
tip-to-keystone width ratio that is wider than the ratio in the
male nose (38-year-old man). In addition, the superior angle
of the interdomal triangle has an ideal value of 80° to 90° in
men and a slightly wider 90° to 100° in women.
crura instead of cephalic trimming may be necessary for
creating a well-defined facet polygon.
The Infralobular Polygon
The infralobular polygon is formed between the inter-
domal triangle and the columellar polygon. The superior
edge of this polygon corresponds to the interconnection of
the Ti points. The base of the infralobular polygon is at the
columellar breakpoint, represented by the interconnecting
line between the C′ points (Figure 4), which is ideally
placed at the apical edge of the nostrils. A lower columel-
lar breakpoint will result in a more exposed nostril on
frontal view. The infralobular polygon has a relatively
wider superior edge in females than in males.
Columellar and the Footplate Polygons
The columellar polygon is located between the infralobu-
lar polygon and the footplate polygon. It begins at the
columellar breakpoint and continues down until the diver-
gence of the medial crura. The footplate polygon begins at
the divergence of the medial crura footplates and ends just
above the lip junction. These 2 polygons reflect the under-
lying division of the medial crura into a columellar seg-
ment and a footplate segment.2,5
Surgical Techniques
Analysis of surface aesthetics allows the surgeon to define
the deformities, establish goals, and then determine how
to modify the underlying structures. Two examples of uti-
lizing the polygon concepts in rhinoplasty surgery occur in
tip surgery and dorsal reduction.
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Tip Suture Technique
Tip modification is one of the most complex steps in rhi-
noplasty due to the tip’s 3-dimensional (3D) structure and
the interrelationships of the alar cartilages. Many suture
techniques have been developed to narrow and define the
nasal tip,1,3,7-9 in addition to various grafts that have also
been designed and proposed for tip modification.6 The
nasal tip is formed in part by the middle crura in a vertical
plane and the lateral crura in a horizontal plane, with their
junction being a 2-dimensional axis that includes a rota-
tional position. The lateral crus has a 3D spatial position
with relation to the nasal anatomy and the contralateral
crus. A 3D reconstruction of the whole structure is essen-
tial to achieving the desired surface aesthetics.1,3
The cephalic dome suture is a lateral crus-angling
suture that, when placed properly, can adjust the lateral
crus in the correct spatial position with the desired resting
angle (Figure 6). This suture stabilizes the middle and the
lateral crura in different planes, thereby correcting the
resting angle of the lateral crura, everting it onto the cor-
rect surface polygon. The suture can be placed using
either an open or closed approach, the latter through the
dome delivery technique. A video of this technique (Video
2) is available at www.aestheticsurgeryjournal.com. You
may also use any smartphone to scan the code on the first
page of this article to be taken directly to the video on
www.YouTube.com.
The lateral crura, domes, and middle crura are dis-
sected in the subperichondrial plane. This maneuver
results in a more pliable lateral crus cartilage that is easier
to shape with sutures. The lateral crura are separated from
each other and cephalic resection is performed to reduce
the lateral crural width if necessary. The amount of
cephalic resection required when using the cephalic dome
suture is usually less than the resection required when
classical transdomal sutures are used. In fact, resection
should be just enough to enable rotation of the lateral
crus, hence correcting its resting angle. A wide lateral crus
can limit this movement, preventing the cephalic dome
suture to correct the resting angle. On the other hand, too
much resection results in an empty space between the
lateral crus and the ULC, which is not favorable. Caudal
resection of the lateral crura is performed to adjust and
manipulate the facet polygon. The location of the new tip-
defining point is determined and marked. The cephalic
dome suture is then inserted at this point to increase tip
definition and projection, as well as stabilization of the
lateral crus resting angle. The cephalic dome suture is
applied through the cephalic edges of the medial and the
lateral crura, 2 to 3 mm posterior to the dome, using a 6-0
PDS suture on a 10-mm round needle. Extra care is taken
to keep the suture knot posterior. If the deformity is severe
or the cartilages are too rigid to reshape easily, extra
sutures can be added. If a sharp dog-ear deformity is pro-
duced at the cephalic edge of the new dome, it can be
resected as a small wedge excision. The cephalic dome
suture is the only single-tip suture to create and manipu-
late this ideal anatomy. This procedure also produces a
368 Aesthetic Surgery Journal 33(3)
Figure 6.  The cephalic dome suture (A) adjusts the lateral crus resting angle, stabilizing the middle and the lateral crura in
different planes. The figure-of-8 dome-equalizing suture (B) stabilizes both cartilages in an ideal position (C).
4- to 5-mm area of contact between the medial and lateral
crura of both sides that stabilizes the tip complex in a very
firm way. Functionally, this stability of the lateral crura
significantly reduces the need for columellar struts, alar
rim grafts, and lateral crural strut grafts. On lateral view,
the cephalic dome suture elevates the Ts point and posi-
tions it 1 to 2 mm anteriorly. In contrast, a partial dome
division and dog-ear resection lowers the Ts point. This
maneuver can help to maintain the same-plane position of
both the Ts and Ti points on the lateral profile view.
In conclusion, correcting the resting angle of the lateral
crus using a cephalic dome suture has the following
effects: it (1) moves the lateral crus caudal border antero-
laterally, (2) moves the cephalic border posteromedially,
(3) preserves or enhances the facet polygon, and (4)
improves formation of the dome triangles, the infralobule
polygon, and the interdomal triangle surface polygons by
preserving the dome divergence angle.
Dorsal Modification—The Libra Graft
Reducing the nasal dorsum is a common surgical maneu-
ver performed in primary rhinoplasty. It is often achieved
by rasping the bony vault and excising the cartilaginous
vault. Currently, reconstitution of the dorsum can involve
narrowing the defect with osteotomies, insertion of
spreader grafts, or turning over of the upper lateral crura
as spreader flaps.10-17 The natural fusiform dorsal lines of
the nasal dorsum are created anatomically by the spread
of the cartilaginous vault and its overlying cap of bony
dorsum, with the widest point at the keystone area (Figure
2). In addition, the dorsal septum is 1 to 2 mm below the
ULC in the keystone area. This difference in height results
in a longitudinal groove, which is filled with fibrous tissue.
Previously, the excised dorsal cartilaginous hump has
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been used as spreader or dorsal grafts.18,19 Our approach
to dorsal reconstruction is to recreate the fusiform anat-
omy using rotated halves of the excised hump to produce
a natural, aesthetic dorsal appearance.
A transverse section of the keystone area resembles the
shape of the Libra scales; hence, we coined the term Libra
spreader graft (Figure 7). The operation can be performed
through an open or closed approach via a subperichon-
drial/subperiosteal dissection. A video of this technique
(Video 3) is available at www.aestheticsurgeryjournal.
com. You may also use any smartphone to scan the code
on the first page of this article to be taken directly to the
video on www.YouTube.com. The ULC and septum are
dissected in the subperichondrial plane with a blunt eleva-
tor to keep the septum’s transverse segments intact. The
cartilaginous hump is removed en bloc with angled scis-
sors, followed by careful elevation of the bony septum
using a straight 4-mm osteotome. It should be noted that
dorsal resections exceeding 5 mm require concurrent exci-
sion and repair of the underlying mucosa to prevent dorsal
opening.
The excised cartilaginous vault is then split longitudi-
nally with a #15 blade and the 2 pieces rotated 90° to
create Libra spreader grafts. Rotating the split halves pro-
duces a smooth, straight dorsum and facilitates trimming
the final graft shape before insertion. The grafts are placed
between the septum and the ULC, which are then stabi-
lized caudally with 2 horizontal sutures to the septum
(Figure 7). Creation of the graft from the dorsal hump
makes graft harvesting unnecessary from any other site,
which is another major benefit of this technique. Use of
the Libra spreader grafts results in a groove in the center
of the middle vault, as in natural anatomy, making it pos-
sible to create the adequately sharp dorsal aesthetic lines
(Figure 7). Anatomically, the Libra spreader grafts’ antero-
lateral wings increase the dorsal height by 1 to 2 mm
Çakır et al 369
Figure 7.  Composite cartilaginous and bony hump removal (A) is followed by longitudinal splitting of the graft (B) and 90°
rotation of the 2 pieces (C) to create the Libra spreader grafts. The grafts are then placed between the septum and the upper
lateral cartilage (D) and stabilized with 2 horizontal sutures to the septum.
while also widening the dorsal width at the keystone area
yet tapering rapidly toward the tip. The reconstruction
achieved with this technique recreates a more natural
anatomy and results in natural fusiform dorsal aesthetic
lines.
Clinical Cases
Two clinical cases demonstrate utilization of the surface
polygon concept for assessment of the clinical deformities
and selection of the appropriate surgical techniques.
Case 1
The patient was a 30-year-old woman who underwent a
preoperative frontal nasal analysis that revealed a sym-
metric nose with thin skin. The lateral crura were wide
and convex. The lateral crura resting angle was about
145° bilaterally, as measured in the preoperative photo-
graph. The lateral view analysis exhibited a tension nose
with an increased tip projection, a short and blunt
infralobule polygon, and a high, wide footplate polygon.
The dorsal bone and cartilage polygons were displaced
anteriorly (Figure 8).
The operation was performed through the closed
approach via the dome delivery technique. High transfix-
ion and intercartilaginous incisions were made and dissec-
tion performed in the subperichondrial plane. Mucosal
tunnels were created and the dorsal component resected
by 3 mm. The septum was not dissected. Rim incisions
were made and the LLC were dissected in the subperi-
chondrial plane. The lateral crura were resected cephali-
cally by 3 mm, leaving a 6-mm crural strip. The lateral
crural steal procedure was applied with 3-mm advancement
of the lateral crura to the middle crura for both domes.
Cephalic dome sutures were used to internally rotate the
lateral crura, setting the intraoperative resting angle to
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100° and establishing the dome and interdomal triangles
as well as the infralobule and columellar polygons. The
dog-ears created at the cephalic edges of the triangles
were resected, shifting the Ts point to a more posteroin-
ferior position. Care was taken to place the Ts, Ti, and Rm
points in the same vertical plane. The dome triangles
were sutured together at their apices with a figure-of-8
suture, setting the interdomal triangle superior angle at
100°.
A columellar strut graft was prepared and placed in its
pocket. The medial crura were then sutured to the caudal
septum 5 mm below the domes to create the columella or
C′ breakpoint. The footplates were set back 4 mm each
and sutured to each other, narrowing the footplate poly-
gons. The lateral crural steal also increased the infralobule
and facet polygon heights, enhancing the facet polygon
silhouette. Lateral internal osteotomies were made in a
high-low-high manner using a V-pointed, straight 3-mm
osteotome combined with external osteotomies using a
1-mm osteotome. The Libra spreader grafts were then
used for dorsal reconstruction. Pitanguy’s midline liga-
ment and the bilateral scroll ligaments were preserved and
plicated at the end of the procedure. A total reduction in
nasal projection caused widening of the nostrils, and a
3-mm nostril resection was done.
The 1-year postoperative photographs reveal clearly
defined surface polygons (Figure 8). The fusiform dorsum
was created using the Libra grafts, with a small 2-mm
hump seen on the 45° oblique view where the dorsal car-
tilage and bone polygons join. The lateral crus polygons
were shortened through cephalic trimming of the cartilage,
setting the scroll groove closer to the tip. This can be seen
clearly in the 45° oblique view. The dome triangles can be
visualized clearly on the frontal view, whereas the lateral
crura shading can be clearly defined via the Rm and Rl
points on the lateral view. This distance also defines the
well-enhanced facet polygons. A natural triangular nasal
shape can be clearly seen on the basal view, without any
use of rim grafts or lateral crural strut grafts, thanks to the
370 Aesthetic Surgery Journal 33(3)

Figure 8.  (A, C, E, G) This 30-year-old woman presented with tension nose, wide and convex lateral crura, a resting angle of
about 145° bilaterally, increased tip projection, a short and blunt infralobule polygon, high and wide footplate polygons, and
anteriorly displaced dorsal bone and cartilage polygons. (B, D, F, H) One year after rhinoplasty through the closed approach
via the dome delivery technique, with the resting angle set to 100° bilaterally, establishing the tip polygons and creating a
fusiform dorsum.

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Çakır et al 371

Figure 8. (continued)  (A, C, E, G) This 30-year-old woman presented with tension nose, wide and convex lateral crura, a
resting angle of about 145° bilaterally, increased tip projection, a short and blunt infralobule polygon, high and wide footplate
polygons, and anteriorly displaced dorsal bone and cartilage polygons. (B, D, F, H) One year after rhinoplasty through the
closed approach via the dome delivery technique, with the resting angle set to 100° bilaterally, establishing the tip polygons
and creating a fusiform dorsum.

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372 Aesthetic Surgery Journal 33(3)

Figure 9.  (A, C, E, G) This 25-year-old woman presented with a left axis deviation, bulbous tip, indistinct domes, short and
convex right lateral crus, resting angle of about 150° bilaterally, inadequate tip projection and rotation, short infralobule
polygon, high footplate polygons, and anteriorly displaced dorsal bone and cartilage polygons. (B, D, F, H) One year after
rhinoplasty through the closed approach via the dome delivery technique, which corrected the axis deviation and set the
resting angle to 100° bilaterally, establishing the tip polygons and creating a fusiform dorsum.

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Çakır et al 373

Figure 9. (contineud)  (A, C, E, G) This 25-year-old woman presented with a left axis deviation, bulbous tip, indistinct
domes, short and convex right lateral crus, resting angle of about 150° bilaterally, inadequate tip projection and rotation, short
infralobule polygon, high footplate polygons, and anteriorly displaced dorsal bone and cartilage polygons. (B, D, F, H) One
year after rhinoplasty through the closed approach via the dome delivery technique, which corrected the axis deviation and set
the resting angle to 100° bilaterally, establishing the tip polygons and creating a fusiform dorsum.

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374 Aesthetic Surgery Journal 33(3)
correct lateral crural resting angle that strengthens the
rims. A high starting osteotomy prevented narrowing of
the lateral aesthetic lines at the middle vault level, creating
a natural nasal shape. Plication of Pitanguy’s midline liga-
ment and the scroll ligaments resulted in a maintained
supratip breakpoint despite a total reduction in tip projec-
tion in the 1-year postoperative period.
Case 2
The patient was a 25-year-old woman who underwent a
preoperative frontal nasal analysis revealing a left axis
deviation, bulbous tip, and indistinct domes. The right
medial crus was situated lower than the contralateral
side, and the right lateral crus was short and convex. The
lateral crura resting angle was about 150° bilaterally as
measured in the preoperative photograph. The lateral
view analysis exhibited inadequate tip projection and
rotation with an acute nasolabial angle. The dorsal bone
and cartilage polygons were displaced anteriorly. The
facet polygons were indistinct and the infralobule poly-
gon was short. The footplate polygon heights were also
increased (Figure 9).
The operation was performed through the closed
approach via the dome delivery technique. High transfix-
ion and intercartilaginous incisions were made and dissec-
tion performed in the subperichondrial plane. Mucosal
tunnels were created and the dorsal component resected
by 3 mm. The septal base was reduced by 2 mm, and scor-
ing was applied to attain middle line axis. Rim incisions
were made and the LLC were dissected in the subperi-
chondrial plane. The lateral crura were resected cephali-
cally by 3 mm, leaving a 6-mm crural strip. The lateral
crural steal procedure was applied to the right side, with
3-mm advancement of the lateral crus to the middle crus
and 4-mm advancement on the left side. Cephalic dome
sutures were used to internally rotate the lateral crura, set-
ting the intraoperative resting angle to 100° and establish-
ing the dome and interdomal triangles as well as the
infralobule and columellar polygons. The dog-ears created
at the cephalic edges of the triangles were resected, shift-
ing the Ts point to a more posteroinferior position. Care
was taken to place the Ts, Ti, and Rm points in the same
vertical plane. The dome triangles were sutured together
at their apices with a figure-of-8 suture, setting the inter-
domal triangle superior angle at 100°.
A columellar strut graft was prepared and placed in its
pocket. The medial crura were then sutured to the caudal
septum 5 mm below the domes to create the columella or
C′ breakpoint. The footplates were set back 2 mm each
and sutured to each other, narrowing the footplate poly-
gons. The lateral crural steal also increased the infralobule
and facet polygon heights, enhancing the facet polygon
silhouette. Lateral internal osteotomies were made in a
high-low-high manner using a V-pointed straight 3-mm
osteotome combined with external osteotomies using
a 1-mm osteotome. The Libra spreader grafts were
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then placed for dorsal reconstruction. Pitanguy’s midline
ligament and the bilateral scroll ligaments were preserved
and plicated at the end of the procedure.
The 1-year postoperative photographs reveal clearly
defined surface polygons (dome, interdomal, infralobule,
columellar) as well as a corrected lateral crural resting
angle (Figure 9). Correction of the resting angle between
the ULC and the lateral crura also enhanced the scroll
groove. This can be seen clearly in the 45° oblique view.
The facet polygons were enhanced and the fusiform dor-
sum was created using the Libra grafts, with a small
2-mm hump seen on the 45° oblique view. The dome
triangles can be visualized clearly on the frontal view
(not seen in the preoperative photographs), whereas the
lateral crura shading can be clearly defined via the Rm
and Rl points on lateral view. This distance also defines
the well-enhanced facet polygons. A natural triangular
nasal shape can be clearly seen on basal view, without
any use of rim grafts or lateral crural strut grafts. A high
starting osteotomy prevented narrowing of the lateral
aesthetic lines at the middle vault level, creating a natu-
ral nasal shape. Plication of Pitanguy’s midline ligament
and the scroll ligaments resulted in a maintained supratip
breakpoint that was enhanced in the 1-year postoperative
period.
Conclusions
Nasal aesthetics can be defined in terms of polygons and
triangles, with new emphasis on the lateral crus spatial
position and the proper lateral crus resting angle. For
example, the critical “tip diamond” is created by the
interrelationship between the dome triangles, the inter-
domal triangle, the facet polygons, and the infralobule
polygon. This type of analysis has led to new surgical
techniques. The cephalic dome suture is used to create
the desired tip by emphasizing the dome triangles, the
infralobule polygon, and the interdomal triangle aes-
thetic subunits. The Libra graft is used to create a natural
fusiform dorsum with reconstruction of the dorsal bone
polygons and the dorsal cartilage triangle. Utilization of
the aforementioned techniques enables manipulation of
the surface aesthetic polygons, facilitating reconstruction
of proportions and aesthetic subunits associated with an
attractive nose.
Disclosures
Dr Daniel receives book royalties from Springer Publications
and surgical instruments royalties from Medicon Instruments.
There are no commercial associations or financial disclosures
to be made by the other authors.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
 Çakır et al 375
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