Aesthetic

Septorhinoplasty

Barış Çakır

123
Aesthetic Septorhinoplasty
Barış Çakır

Aesthetic
Septorhinoplasty
Barış Çakır
Private Practice Fulya Teras
Istanbul
Turkey

English translation by Ali Rıza Öreroğlu

ISBN 978-3-319-16126-6 ISBN 978-3-319-16127-3 (eBook)

DOI 10.1007/978-3-319-16127-3

Library of Congress Control Number: 2015949109

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In memory of my dear father Kemal Çakir
who passed away in 2012
Foreword

Dr. Baris Çakır has written a worthy successor to Jack Sheen’s monumental
text Aesthetic Rhinoplasty. As a resident, I remember reading Sheen’s text-
book and suddenly seeing rhinoplasty in a fundamentally new way. Sheen set
specific aesthetic goals and achieved them with a range of new techniques
which he had developed.
For the next 30 years, I learned a great deal in the operating room and from
lectures by my colleagues. However, I had not had that feeling of excitement
of witnessing a new era in rhinoplasty surgery until I attended the Combined
Rhinoplasty Meeting of the Turkish and American Rhinoplasty Societies held
in Istanbul in 2011. As usual, I was taking notes and trying to stay awake late
in the afternoon during the 5 min presentations. Suddenly, I became aware
that something dramatic was happening. A speaker was talking about new
concepts for tip aesthetics (polygons), bony vault remodeling (bony sculpt-
ing), and nostril sill excision. When the session was over, I went up to
Dr. Çakır and asked him if he would present the talk again for me the next
morning. He did and I had him repeat it three times. I was totally amazed at
his concepts, but wondered if he could really do in the operating room what
he was presenting. Therefore, I asked him if he could do a case for me. The
conversation went as follows: “I’d like to see you do a case.” “When?”
“Tomorrow.” “Okay.” The next day, Dr. Çakır did a rhinoplasty employing a
wide range of techniques which he had developed and achieved a superb
result. Later that day at lunch, my head was still reeling from trying to under-
stand the nasal polygons, his advanced tip suture techniques, and repair of
numerous ligaments that I had routinely cut. I reasoned that the only way I
could understand his concepts was to help Dr. Çakır write up his techniques
which he had thus far been unable to publish. Subsequently, he came to me
and said he had more ideas for journal articles. I told him that he would
always have too many ideas and too little time. I advised him to go ahead and
write a book as it would clarify his thinking and allow others to build on his
concepts. Naively, I thought he would be preoccupied for a couple of years.
Six months later, he sent me the manuscript and 3 months after that the
Turkish Edition was published to be followed by the English Edition.
In reading Dr. Çakır’s masterpiece, I am struck anew by how original and
advanced his concepts truly are. Something as mundane as nasal photography
and analysis suddenly becomes an art form and the use of preoperative
“shadow photographs” a brilliant break through. Some of his polygon
concepts require multiple readings before one fully understands them. For

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viii Foreword

example, the concept of a “resting angle” between the lower lateral and upper
lateral crura is totally new. At first one may think it is of little importance, but
when linked to the long lateral crus and herniation of the lateral crus into the
vestibule its relevance becomes obvious. One suddenly has an answer for a
previously inexplicable problem as well as a method of treatment and more
importantly a method of prevention. The discussion of multiple tip points and
definition of the soft tissue facets as well as their relation to specific tip
sutures is crucial information. In the surgical technique chapter, the impor-
tance of the continuous subperichondrial-subperiosteal dissection plane
becomes apparent. The novice surgeon should remember that many of his
techniques were perfected through the open approach before Dr. Çakır pro-
gressed to the closed approach. There are certain ideas with which I disagree,
including scoring of the septum, leaving a 2 mm gap between the septal base
and the anterior nasal spine, and resection of the membranous septum. I also
recognize that the book may prove daunting to some given the plethora of
new concepts and the quality of the English translation.
Yet, this is a book to be savored and read multiple times before returning
to specific chapters for greater insight into the challenges of rhinoplasty sur-
gery. For the younger surgeon, the book provides in-depth discussion of how
to analyze and photograph the patient while formulating an individualized
patient-specific operative plan. The linkage of surface aesthetics to nasal
anatomy to surgical techniques is the foundation of this text. For the experi-
enced surgeon, the book will be a revelation of how to set and achieve higher
aesthetic standards using the described methods. For the master surgeon, Dr.
Çakır challenges many of our accepted principles and techniques ranging
from the aesthetic dorsal lines to the need for lateral crural transposition.
Every surgeon performing nasal surgery should purchase a copy of Aesthetic
Septorhinoplasty as Dr. Çakır’s concepts, principles, and techniques repre-
sent the future of rhinoplasty surgery.

Newport Beach, CA, USA Rollin K. Daniel, MD

Preface to the Turkish Edition

Who is Barış Çakır?

After graduating from the Electronics Department of the Çukurova Technical

High School, I studied at the Faculty of Medicine upon my parent’s wish, and
during the fifth year of my studies I had to undergo rhinoplasty, followed by
revision surgery six months later. Within my own medical career in plastic
surgery, I focused on microsurgery and performed many such operations, but
my strongest interest has been in nose surgery because it requires both techni-
cal skill and aesthetic understanding. Even for someone like me who has both
undergone and then continually performed nose surgery, this specialization
continues to present interesting challenges because it is constantly develop-
ing. Several years of drawing and sculpting courses have contributed to my
own professional development, and in my own practice of eight years—
ninety percent of which consists of rhinoplasty—I have made changes to
almost half of all the techniques I learned in medical school. For instance, I
began nose remodeling surgery with the open technique, but since 2008
turned to closed technique instead—a rather unusual turn, as most surgeons
move in the opposite direction. Today, I am performing approximately 200 to
300 closed-technique rhinoplasties per year.
In 2012, at the ASAPS Congress, Dr. Rollin Daniel encouraged me to
write this book in the format of an instruction manual, so as to allow others to
benefit from my experiences with rhinoplasty as well as visual documenta-
tion surrounding this type of surgery, since in the framework of this book, I
have defined proper standards for surgical photography and technical draw-
ings. It is my hope that readers will find the present work most useful for their
own practice.

What Kind of Book is this?

This book describes closed rhinoplasty in which open rhinoplasty techniques

are used. In order to make the information presented here quickly and easily
accessible, the writing style has deliberately been kept simple and more
emphasis is put on the images, so that the book reads like detailed surgery
notes. No extensive explanation accompanies the photographs, but text, pho-
tographs, and drawings complement each other and the images illustrate the

ix
x Preface to the Turkish Edition

preceding text. Photographs of those patients who gave permission of use are
in standard format, while the photographs of those who refused permission
were cropped to make their faces unrecognizable. Since I wanted to illustrate
the effects of closed rhinoplasty, dissection and ostectomy techniques on
healing rates, I have also included images with early results.

Acknowledgments

Special thanks are due to Tayfun Aköz, MD, and Mithat Akan, MD, who
taught me about nose surgery; Ali Teoman Tellioğlu, MD, and Mithat Akan,
MD, who undertook the scientific revision of the book; my wife Çiğdem
Çakır; Metin Bahçivan for editing the Turkish text; and Nina Ergin for proof-
reading the English translation.

Barış Çakır, MD
www.bariscakir.com
Inquiries, comments and suggestions to the author can be sent to:
drbariscakir@gmail.com
Preface to the English Edition

Aesthetic Septorhinoplasty: The English Edition

The English edition of this book was planned while the author was still writ-
ing the Turkish original text. As with the original, the intent was to offer the
reader an introduction of aesthetic rhinoplasty similar to an instruction man-
ual, with abundant images but much less text. My task as translator was to
convey the original content of aesthetic concepts and surgical techniques,
while at the same time choosing plain language, keeping in mind that the
reader may be a junior plastic surgeon who is not a native speaker of English.
Being familiar with all the concepts and surgical techniques, I attempted to
make the instructions understandable, yet simple and practical. I hope that I
have achieved this goal and that the English edition will serve its purpose.

Ali Rıza Öreroğlu, MD

xi
Contents

1 Preoperative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1 Patient Photographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 The Photography System . . . . . . . . . . . . . . . . . . . . . . . . 5
1.2 Preoperative Photographs . . . . . . . . . . . . . . . . . . . . . . . 6
1.3 Light Cheats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.4 Fish-Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.5 Shooting with a Smartphone . . . . . . . . . . . . . . . . . . . . . 7
1.6 Camera Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.7 Paraflash Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.8 Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.9 Shadowing the Images . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2 Surgery Notes and Archiving . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.1 Photography Archive . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.2 Backup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
3 Skin Care and Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
3.1 Oral Vitamin A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
4 Menstruation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
5 Forehead Fat Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
5.1 Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
6 Jaw and Cheek . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
6.1 Importance of the Cheek . . . . . . . . . . . . . . . . . . . . . . . . 32
7 The Rhinoplasty Instrument Set . . . . . . . . . . . . . . . . . . . . . . . . 34
7.1 Dorsum Retractor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
7.2 Small Retractor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
7.3 Forceps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
7.4 Needleholder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
7.5 Scissors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
7.6 Bone Scissors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
7.7 Rasp and Saw . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
7.8 Osteotomes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
7.9 Elevators. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
7.10 Hook. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
7.11 Osteoectomy Chisels . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
7.12 Lateral Osteotomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
7.13 Arkansas Stone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
7.14 Sutures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

xiii
xiv Contents

2 How to Draw a Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

1 Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
1.1 Sketch from the Front . . . . . . . . . . . . . . . . . . . . . . . . . 40
1.2 Sketch from the Side . . . . . . . . . . . . . . . . . . . . . . . . . . 42
1.3 Sketch from Above and Below . . . . . . . . . . . . . . . . . . 44
2 Analysis of Patient Photographs . . . . . . . . . . . . . . . . . . . . . . . 48

3 Nasal Polygons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
1 Infratip Triangle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
2 Tip Defining Point . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
3 What Is a Facet? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
4 The Non-Mobile Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
5 The Mobile Tip Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
5.1 Mass Polygons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
5.2 Space Polygons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
6 Tip Breakpoints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
7 Dome Triangles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
8 Interdomal Triangle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
8.1 Dome Divergence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
9 Infralobular Polygon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
10 Columellar Polygon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
11 Footplate Polygons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
12 Facet Polygons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
12.1 Relation of the Facet and Dome Polygons . . . . . . . . . . 65
13 Lateral Crus Polygons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
14 Resting Angle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
14.1 Vertical Compression Test . . . . . . . . . . . . . . . . . . . . . . 67
14.2 Incorrect Resting Angle and its Effect on the Ala . . . . 70
14.3 Wide Lateral Crura. . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
14.4 Long Lateral Crura. . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
14.5 Convex Lateral Crura . . . . . . . . . . . . . . . . . . . . . . . . . . 78
14.6 Cephalic Malpositioning . . . . . . . . . . . . . . . . . . . . . . . 78
15 Scroll Facet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
16 Scroll Line. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
17 Dorsal Cartilage Polygon . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
18 Dorsal Bone Polygon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
19 Upper Lateral Cartilage Polygons. . . . . . . . . . . . . . . . . . . . . . 85
20 Lateral Bone Polygons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
21 Dorsal Aesthetic Lines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
21.1 Summary: Dorsal Aesthetic Lines . . . . . . . . . . . . . . . . 90
22 Lateral Aesthetic Lines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
23 The Polygon Model. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Contents xv

4 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
1 Patient Position and Tracheal Intubation . . . . . . . . . . . . . . . . 95
2 Local Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
3 Head Lamp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
4 Cleaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
5 Lighting in the Operating Room . . . . . . . . . . . . . . . . . . . . . . . 99
6 Drawings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
7 Basic Surgical Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
8 Concha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
8.1 Concha SMR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
9 Nasal Dorsum Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
9.1 Transfixion Incision . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
9.2 Intercartilaginous Incision . . . . . . . . . . . . . . . . . . . . . . 108
9.3 Entering the Nasal Dorsum from the Septal Angle . . . 108
9.4 Subperichondrial Dissection in the Open Approach . . 110
9.5 Periosteum Dissection . . . . . . . . . . . . . . . . . . . . . . . . . 114
9.6 Why the Subperichondrial Dissection? . . . . . . . . . . . . 122
9.7 Upper Lateral Cartilage Mucosa Dissection . . . . . . . . 124
9.8 Dorsal Cartilage Resection . . . . . . . . . . . . . . . . . . . . . 126
9.9 Dorsal Bone Resection. . . . . . . . . . . . . . . . . . . . . . . . . 128
9.10 Nasal Radix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
10 Septum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
10.1 Dissection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
10.2 Removing the Septum . . . . . . . . . . . . . . . . . . . . . . . . . 137
10.3 The “Gummy Smile” . . . . . . . . . . . . . . . . . . . . . . . . . . 138
10.4 When there is Extreme “Gummy Smile” . . . . . . . . . . . 138
11 The Footplates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
11.1 Narrowing of the Footplate Polygon . . . . . . . . . . . . . . 140
12 Tip Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
12.1 Incision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
12.2 Autorim Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
12.3 Lateral Crus Subperichondrial Dissection . . . . . . . . . . 162
12.4 Delivering the Domes . . . . . . . . . . . . . . . . . . . . . . . . . 168
12.5 Marking and Resections. . . . . . . . . . . . . . . . . . . . . . . . 175
12.6 How Did the Nose Break Down? . . . . . . . . . . . . . . . . . 177
12.7 Observation and Theory . . . . . . . . . . . . . . . . . . . . . . . . 177
13 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
13.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
13.2 How to Perform the Footplate Setback . . . . . . . . . . . . 187
13.3 Lateral Crus Steal Procedure . . . . . . . . . . . . . . . . . . . . 193
13.4 Dome Symmetry Test . . . . . . . . . . . . . . . . . . . . . . . . . 195
13.5 Cephalic Dome Suture . . . . . . . . . . . . . . . . . . . . . . . . . 196
13.6 Control 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
13.7 Control 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
xvi Contents

13.8 Medial Crus Overlap . . . . . . . . . . . . . . . . . . . . . . . . . . 205

13.9 Suturing the Domes . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
13.10 Columellar Strut Graft . . . . . . . . . . . . . . . . . . . . . . . . . 213
13.11 Infralobular Caudal Contour Graft. . . . . . . . . . . . . . . . 222
13.12 Columellar Polygon Stabilization . . . . . . . . . . . . . . . . 229
13.13 Closure of Tip Incisions . . . . . . . . . . . . . . . . . . . . . . . . 231
13.14 Tip Asymmetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
13.15 Cephalic Malpositioning . . . . . . . . . . . . . . . . . . . . . . . 238
13.16 Interdomal Graft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
14 Nasal Dorsum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
14.1 Setting the Dorsum Height. . . . . . . . . . . . . . . . . . . . . . 252
14.2 Osteotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
14.3 Osteoectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
14.4 Osteoectomy Technique . . . . . . . . . . . . . . . . . . . . . . . . 256
14.5 Bone Dust and Cartilage Paste . . . . . . . . . . . . . . . . . . . 276
14.6 Short Nasal Bones . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
14.7 Dorsal Reconstruction in Men . . . . . . . . . . . . . . . . . . . 280
14.8 Stabilization of the Nasal Tip. . . . . . . . . . . . . . . . . . . . 281
14.9 Reconstruction of the Scroll Line . . . . . . . . . . . . . . . . 283
15 Internal Splints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
16 Internal Valve Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
17 Drains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
18 The Pitanguy Ligament . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
19 The Superficial SMAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
20 Internal Taping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
20.1 The New SMAS Anatomy . . . . . . . . . . . . . . . . . . . . . . 291
20.2 Importance of the Pitanguy Ligament
in the Supratip Region . . . . . . . . . . . . . . . . . . . . . . . . . 292
21 Redrape . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
21.1 Dissection Borders . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
21.2 How to Use the Ligaments for Redraping . . . . . . . . . . 296
21.3 Why Internal Taping?. . . . . . . . . . . . . . . . . . . . . . . . . . 296
21.4 Camouflage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
22 Additional Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
22.1 Extra Columellar Strut . . . . . . . . . . . . . . . . . . . . . . . . . 297
22.2 Rim Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
23 Nostril Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
23.1 Problems and Solutions . . . . . . . . . . . . . . . . . . . . . . . . 299
23.2 Thick Alar Base: Simple Elliptic Resection . . . . . . . . 299
23.3 Big Nostrils: Avulsion Advancement Flap . . . . . . . . . 302
23.4 Big Nostril and Thick Alar Base:
Combination of Avulsion Advancement Flap
and Elliptic Resection . . . . . . . . . . . . . . . . . . . . . . . . . 307
23.5 Hanging Alae: Alar Rim Excision . . . . . . . . . . . . . . . . 311
24 Taping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
25 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
Contents xvii

26 How to Correct the Deviated Nose . . . . . . . . . . . . . . . . . . . . . 320

26.1 How Did the Nose Deviate?. . . . . . . . . . . . . . . . . . . . . 320
26.2 Reference Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
26.3 Nasal Dorsum Resection . . . . . . . . . . . . . . . . . . . . . . . 323
26.4 Septoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
26.5 Tip Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
27 Cartilage Grafts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
27.1 Septal Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
27.2 Rib Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
28 Columellar Show. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
28.1 Hanging Columella . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
29 Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349

5 Patient Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351

1 Case Analysis: A Common Patient . . . . . . . . . . . . . . . . . . . . . 351
2 Case Analysis: Thick Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
3 Case Analysis: Thick and Oily Skin . . . . . . . . . . . . . . . . . . . . 357
4 Case Analysis: Revision of My Own Case . . . . . . . . . . . . . . . 359
5 Case Analysis: Thick Skin and Large Hump . . . . . . . . . . . . . 362
6 Case Analysis: Closed Approach Healing Rate . . . . . . . . . . . 364
7 Case Analysis: Supratip Healing Period . . . . . . . . . . . . . . . . . 366
8 Case Analysis: Wide Dorsum, Wide Radix,
Bulbous Overprojected Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . 368
8.1 First Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
8.2 Second-Year Revision . . . . . . . . . . . . . . . . . . . . . . . . . 370
9 Case Analysis: Fractured Nose, Operated Twice . . . . . . . . . . 372
9.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
10 Case Analysis: Long Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
11 Case Analysis: Cephalic Malpositioning . . . . . . . . . . . . . . . . 376
11.1 Surgery Photos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376
12 Case Analysis: Closed Approach Revision. . . . . . . . . . . . . . . 378
12.1 Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380
12.2 Surgery Photographs . . . . . . . . . . . . . . . . . . . . . . . . . . 380
13 Case Analysis: Overrotated Saddle Nose . . . . . . . . . . . . . . . . 381
13.1 First Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
13.2 Second Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
13.3 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
14 Case Analysis: Thin Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386
15 Case Analysis: Thin Skin, Deviated Nose,
Tip Asymmetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388
16 Case Analysis: Tip Asymmetry . . . . . . . . . . . . . . . . . . . . . . . 389
17 Case Analysis: Thick Skin, Low Radix
and Cephalic Malpositioning . . . . . . . . . . . . . . . . . . . . . . . . . 390
17.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
18 Case Analysis: Saddle Nose, Notched Nostril . . . . . . . . . . . . 391
18.1 Surgery Photographs . . . . . . . . . . . . . . . . . . . . . . . . . . 393
xviii Contents

19 Case Analysis: Very Short Infralobule,

Very Narrow Facet Polygon . . . . . . . . . . . . . . . . . . . . . . . . . . 394
19.1 Surgery Photographs . . . . . . . . . . . . . . . . . . . . . . . . . . 395
19.2 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
20 Case Analysis: Saddle Nose, Hanging Nostril . . . . . . . . . . . . 395
21 Patient Example: Bulbous Tip . . . . . . . . . . . . . . . . . . . . . . . . 396
22 Patient Example: Thin Skin, Big Nose . . . . . . . . . . . . . . . . . . 397
23 Patient Example: Thin Skin, Pseudocephalic
Malpositioning and Tip Asymmetry . . . . . . . . . . . . . . . . . . . . 398
24 Case Analysis: Tension Nose . . . . . . . . . . . . . . . . . . . . . . . . . 399
24.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
25 Case Analysis: Thin Skin, Tension Nose . . . . . . . . . . . . . . . . 400
26 Case Analysis: Ideal Patient for the Closed Approach . . . . . . 401
26.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402
27 Case Analysis: Learning from a Patient . . . . . . . . . . . . . . . . . 402
28 Case Analysis: Bulbous Tip . . . . . . . . . . . . . . . . . . . . . . . . . . 403
29 Case Analysis: Thin Skin, Axis Deviation
and Breathing Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404
30 Case Analysis: Thick Skin, Bulbous Tip
and Deviated Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406
31 Case Analysis: Medium-Thick Skin . . . . . . . . . . . . . . . . . . . . 407
31.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407
31.2 Surgery Photographs . . . . . . . . . . . . . . . . . . . . . . . . . . 408
32 Case Analysis: Revision for Droopy Tip . . . . . . . . . . . . . . . . 411
32.1 Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412
33 What Not to Eat Before Surgery . . . . . . . . . . . . . . . . . . . . . . . 413
34 After Surgery: A Few Notes . . . . . . . . . . . . . . . . . . . . . . . . . . 414

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415
 Preoperative
1

1 Patient Photographs

My interview starts with taking photographs. I

designed one of the rooms in my office as a pho-
tography studio. I archive the photographs with
patient names. In addition to that I have a
“beautiful Nose” folder. I take photos of people
with beautiful noses. I ask my patients’ relatives
and my friends who have good-looking noses and
take their photo. I collect the photographs that
patients bring to me. Sometimes I look at them. I
suggest that you also do this. You can see a
female and a male nose that I consider beautiful
below. You can return to these photos for the aes-
thetic details to be explained further.

© Springer International Publishing Switzerland 2016 1

B. Çakır, Aesthetic Septorhinoplasty,
DOI 10.1007/978-3-319-16127-3_1
2 1 Preoperative
1 Patient Photographs 3
4 1 Preoperative
1 Patient Photographs 5

You should employ a photographic standard.

The more importance you give to patient photog-
raphy, the more you will develop your own stan-
dards and make your patient feel valued. Do not
take photos just before surgery. Be done with
your photography and design work during patient
consultation.

1.1 The Photography System

Obtain an intermediate-level SLR camera. A

proper lens (e.g. macro) is more important than
the camera itself. I use a 100 mm macro lens.
Standard shots cannot be taken with zoom lenses.
If you use a zoom lens, try to take photos adjust-
ing the zoom to 100 mm. You should have a stan-
dard background. It’s better to select the correct
background color in advance, because you can-
not change it later. The best choices in my opin-
ion are black, grey, blue and dark blue. Black will
appear more artistic, but blue is a better choice
for scientific purposes.
Shadows will not occur if there is at least 1 m
distance between the patient and the background.
If you have a studio with paraflash system you
should be able to take good photos.
Take vertical (portrait) photos. Archiving and
photo merging will be much easier. If you take
horizontal (landscape) photos, you will be creat-
ing extra work for yourself later on.
Remember that, if you do not allow a distance
between you and your patient during photograph-
ing, you cannot take good photos. If you use a
macro lens, you should have at least a 2 m dis-
tance between you and your patient in order to
capture your patient’s face in the correct
quadrage. Another important issue is the position
of the patient in relation to light sources.
6 1 Preoperative

single flash for the preoperative photo and

paraflashs for the postoperative one is a common
cheat. A single flash exaggerates any deformity.
Half of the surgery can therefore be done by
light changes alone. For instance, no surgery is
documented in the photographs below. Both
photos were taken with a 10 s interval. The pho-
tograph on the left was taken with a single top
flash, and the photograph on the right using
paraflashs.

The location and intensity of light reflections

change as the patient changes positions. Because
of that, the location of the lights and patient posi-
tion must remain stable. In our photography stu- The same cheat occurred with these photographs
dio there is a circle on the ground, guiding the as well.
patient position. You can use self-adhesive foot-
prints for this purpose.

1.2 Preoperative Photographs

For years I have been taking photos of the carti-

lage structure during the operation, before and
after the surgery. Evaluating your first-year
results with preop photographs will accelerate
your development. In my practice, I use an SLR
camera with 100 mm macro lens for preoperative
surgical photographs in the operating room as
well.

1.3 Light Cheats

The lights, the patient and your position should

never change. Sometimes I look at patient eyes
in photographs presented at congresses. Using a
1 Patient Photographs 7

You can easily determine what kind of lighting

has been used by simply looking at the patient’s
eyes.

1.4 Fish-Eye

If you get close to the patient and zoom out with

the lens, the photograph will be fish-eyed. Photos
which are taken from the front will make the nose
look bigger and the ears smaller. Profile photos
make the ears look bigger and the nose smaller.
In the front view, you should look at how much of
the ears you can see behind the cheeks. In fish-
eyed photos, you can see less of the ears. The
nose tip will also look bulbous. You can correct 1.5 Shooting with a Smartphone
tip bulbosity just by changing the lens. If you use
a 100 mm macro lens without any zoom, you will You cannot take patient photos with a smartphone.
not experience any problems. Even the best phone on the market takes fish-eyed
The photos below do not document any sur- photos. People take their own photos with smart-
gery in between. I took the photo on the left by phones and evaluate their noses accordingly. Most
using a 35–85 lens set to 35’ and the photo on the of my patients complain that their noses are big in
right by using a 100 mm lens. There is no differ- photos. You should know what a fish-eye problem
ence in lighting either. is and be able to describe it to your patient.

1.6 Camera Settings

I am not a professional photographer, but I have

acquired all the knowledge necessary for my pur-
poses. You can take incredible photographs with a
few adjustments. It is unfair to receive criticism as
a surgeon because of bad photos instead of a com-
pliment for good surgical results. If you are going
to use the paraflash system, an intermediate-level
SLR camera will be sufficient.
8 1 Preoperative

1.6.1 Focus Settings

Photographers usually choose the eyes in portrait
photographs for focusing. In rhinoplasty photo-
graphs, it is better to choose the nose as the focus
point. The focus point can be set to the nose.

1.6.2 ISO
This is the camera sensitivity to light. 100 and 200
are appropriate. As ISO increases, the color qual-
ity of the photos deteriorates. Low ISO values
need intense light. If you have paraflashlights, you
can easily take photos with an ISO setting of 100.
1.6.3 Shutter Rate
It shows how long the diaphragm stays open. If the
shutter rate is longer than 1/125 the photo can be
affected due to shaking. I generally use a setting of
1/160. If you choose a shutter rate faster than 1/200
there can be disparity between your camera and the
paraflashlights. This can cause photos to have a dark
half.
1.6.4 F
You can take artistic photos with low “f” valued
focus distance. The front and back of the focus
point become blurry. We need a deep field of
depth. A value of 10 and above is adequate.
1.6.5 Skin Color
The patient’s skin reflects light in different amounts.
If the patient’s face is dark in photos, then decrease
the “f” value. If the patient’s face is bright in pho-
tos, then increase the “f” value. I take my all photos
by changing the “f” value between 10 and 13. In
order to take good photos in an “f” value of 11 you
need to adjust the power of the paraflashlight.
1.7 Paraflash Settings
You can show aesthetic lines better in front view
if one of the paraflashlights is more intense, but
then you will have problems with profile photos.
Since we make evaluations based on photos taken
from all angles, it makes sense to adjust the
paraflashlight intensity to the same level for all.
Taking photos in sunlight coming from windows
can give better reflections, but you cannot take
the same photo at different times of day. Therefore
a paraflash system is a must.
Since the light intensity of new video cameras
is high, it is possible to have great details in the
afternoon light from one angle. But it is difficult
to archive videos and have one standard for all
recordings.
Here you can see a patient example with stan-
dard settings.
1 Patient Photographs 9
10 1 Preoperative

1.8 Imaging

I am often asked about my photography tech-

niques and imaging. Therefore I will show
step by step how to design the nose in
Photoshop.

Open the file.

1 Patient Photographs 11

Choose the nose with Rectangular mask.

Practice it a few times and correct it over and

over again.
Open the Liquify filter.

Make a nose that fits the face.

12 1 Preoperative

Work on tip details. Add an “.....a” to the filename and save. You
can therefore save files with extensions such as
.....aa, .....aaa, .....aaaa and compare them easily.
Example: IMG_5643a, IMG_5643aa. When
you choose sorting photos in the folder by name,
your files will be aligned in order.

1.9 Shadowing the Images

Determine the work that fits the patient’s face.

You can use smaller masks for working in detail.
When you paste this photograph with 50 % den-
sity into the patient’s original photograph, you
can determine the differences between the origi-
nal nose and the nose you want.
You should choose the whole picture at the
beginning in order to copy the work you like.
Macintosh: cmd-A (Windows: CTRL-A): this
will select the entire picture.

Macintosh: cmd-C (Windows: CTRL-C): this

will copy the picture.
1 Patient Photographs 13

Go to the history and choose the original picture.

If we save this document as JPG, we can store it

With the paste command, the new nose will be
pasted on the older one as a new layer.
Macintosh: cmd-V (Windows: CTRL-V).
easily. The file that has more than one layer can
only be saved as PSD format and opened by the
Photoshop program. Because of this choose
merge down under the layers menu.
cmd-E: Pastes all layers.

In the following photograph, two layers are formed.

In the upper layer you can see our work. The origi-
nal photo cannot be seen as it is underneath. When
decreasing the contrast of the upper layer, the pho-
tograph in the lower layer becomes visible.

Now the file can be saved as JPG,

and you can see one layer on the right.

From the layer adjustment menu on the right,

set the opacity of the upper layer to 50 %. In this
way you can see the difference between the two
noses.
14
Add “....plan“ to the name of the photograph and
save.
Example: IMG_5643plan
The shaded picture gives information to the sur-
geon about the rotation and the amount of the
hump to be removed. You can use this picture in
order to determine the new tip point. We will use
a shaded picture in surgery drawings.
1 Preoperative
1.9.1 The Importance of
Photography and Imaging
Make your design yourself.
Do not undertake surgery without design.
For instance, you can get rid of a humped nose
illusion as a result of a low tip.
Make changes to forehead, chin and cheek.
The lowest point of the nose radix should be a
little in front of the eyelashes. In the profile view,
if the eyelashes of the other eye are visible, it is
more rational to fill the nose radix.
Note
It is not appropriate to have fixed rules for aesthetic
issues. You can choose to create a higher or lower
nose ridge, but you should not forget that, when
you lower the dorsum, the nasal body becomes
indistinct in frontal view. Thus, a low nose ridge
requires more infracture.
Work with Photoshop to determine if either
the nose radix is in front or the glabella is towards
the back. I should admit that I have made some
mistakes with this. In the profile view, if you can-
not have sufficient nose radix depth in spite of
lowering the base to the level of the eyelash tip, it
is reasonable to fill the forehead with fat. If you
cannot create a certain nose radix depth, the nose
can appear as if it starts from the forehead. Such
a result tends to make patients unhappy.
If your patient does not like your drawing and
results, do not operate. Your work should meet
your patients’ expectations.
Here you can see design and patient result.
Note
During surgery our perception makes a 90°
rotation.
1 Patient Photographs 15

Our perception of beauty develops through the

observation of other people. However, we decide
on the tip position and dorsal height during sur-
gery. I think that this is cause for serious confu-
sion. It takes time for our brain to rotate the
aesthetic perception by 90°. For me, it took about
one year. In order to accelerate this, rotate the pic-
tures of the noses that you find beautiful by 90°
and look again. Your brain can learn the appear-
ance of a beautiful nose in horizontal position.

Important
Aesthetic information feedback is very impor-
tant. You should avoid anything that may skew
your perception. For example, the head of the
patient should be parallel to the ground. If you
change the position of patient’s head at a differ-
ent angle in every operation, your chance of mak-
ing a mistake increases.
As I am left-handed, I stay on the left of the
patient to make my evaluation. Therefore, I set up
the computer to show the left view of the patient.
Right-handed surgeons should change position-
ing accordingly. You can rotate shadowed photo-
graphs by 90°.
16 1 Preoperative

Example
Our patient’s photos were merged and a final
photo created.

Note
Do not enter the operation room without a
photograph.
Do not operate by heart. I never operate with-
out my computer. Front, lateral views and shad-
owed photos should be open on your computer.
In the photo below you can see the lateral view
of the patient before surgery, the computer design
and the result after one month. The computer
design cannot show a perfect result, but starting
surgery without a design is similar to building
without a ground plan. Planning the main steps of
your operation with the help of computer design
is rational. If necessary, you can make small
changes.

The easiest way to put these views in one pho-

tograph is by opening all photos together and tak-
ing a composite photo of these views. With
Shift-Command-F4, you can take a photo of what
you want. With shift-Command-F3, you can take
a screen-shot. I also integrate my patient photos
with this method. Save the merged photo into the
patient’s folder. Choose all the photos and create
a preview. During surgery, when you want to see
other photos of the patient, your assistant can
show you photos via the left and right buttons.
2 Surgery Notes and Archiving 17

2 Surgery Notes and Archiving

I prefer to write surgery notes with words that a

computer can read. It is possible to record sur-
gery in drawings. But then it will not be possible
to search 1,000 patient files via a word search.
You should be able to access your patient and
surgery notes very quickly, even after a year. It is
a waste of time to ask for your patient’s file from
the archive. If you do not record what you did in
surgery, your development will be slow.
In nose surgery certain results appear after
about one year. Evaluate your first-year results
with the help of your surgery notes. In this way,
you can find your mistakes and correct them eas-
ily. Your recording program should be simple and
easily accessed. Do not spend too much on
patient archiving programs. You can have an
archive with your computer’s simplest program
without any technical support.
I use the address book program in my com-
puter. I have a pre-written surgery note. I copy
and paste this note and then change the surgery
note according to my patient’s operation. I e-mail
it to the hospital secretary. The secretary prints
the epicrisis report and gives it to the patient.
Before my patient is awake, I have already writ-
ten the surgery note and emailed it.
Another advantage of this system emerges
when preparing conference papers. For example,
you invented a new technique and want to submit
a paper. You want to find out on how many and
which patients you have used this technique.
18 1 Preoperative

Example 2.2 Backup

On how many and which patients did I use the
autorim flap technique? I write “autorim flap” in Make backups regularly. The photo archive of a
the address book. In less than a second I will get plastic surgeon is priceless. “Time Machine” is a
the patient names and see on how many patients I quick and automated backup application.
have used the technique. While writing this sec-
tion, I have done a search for this technique and
found out that I have used it on 178 patients. 3 Skin Care and Rhinoplasty

The skin shows everything that we do in nose

operations. Therefore, we have to help the skin to
change shape. Blackheads aggravate the skin and
makes redraping difficult. You should have an
esthetician who performs skin care without bruis-
ing the skin. In my office I have an esthetician
who performs skin care on the nose skin before
and after surgery. In the picture below you can
see a patient’s photo before the surgery on the
left, one month after the operation in the middle,
and after skin care on the right. There has been an
increase in the patient’s oily skin. In my opinion,
an increase in the skin’s oil negatively affects the
skin.

2.1 Photography Archive

I open a folder with the patient’s name during the

patient consultation and save the photos I take in
that folder. When my patient comes for a check-up
I enter the patient’s name into the search box and
easily access the folder. Do not lose time making
sub-folders, such as primary and secondary. I
archive all my patient folders in one folder. These
details can be archived by adding a key word to
your surgery note.
3.1 Oral Vitamin A

With oily skin you can often see inflammation

due to the sebaceous glands. In these patients
redraping will not be the same as in thin-skinned
patients. It is advisable to perform surgery on
these patients after they have used oral vitamin
A for some time. We offered Roaccutane treat-
ment before revision to a patient who had sur-
gery with open technique in another clinic.
Below you can see the effects of the treatment
on the skin.
5 Forehead Fat Grafting 19

4 Menstruation

Do not operate on your patients during their men-

strual period. Bleeding and edema can be more
significant during surgery, and your control can
decrease. After surgery swelling and bruising can
occur more often. The same problem can be seen
in patients who use oral contraceptive drugs.

5 Forehead Fat Grafting

In rhinoplasty, important reference points are the

cheek, chin and forehead. When planning nose
aesthetics, these reference points should also be
considered. Sometimes these reference points
should be changed as well. A small chin is cor-
rected via chin prostheses. In addition, the cheek
and forehead reference points can be changed. If
the malar and zigomatic area are not protruding
enough, the nose can seem bigger than it is.
Changing the forehead reference point is not a
well-known procedure, but we can change the
forehead, too. Selçuk Işık has published a most
useful paper on this issue. Işık uses intracath for
fat injection. I, however, think that fat grafting
using a cannula is safer.
Isik S, Sahin I. Contour restoration of the fore-
head by lipofilling: our experience. Aesthetic
Plast Surg 36(4), 2012:761–6.
Why is the forehead important in aesthetic
nose surgery?
My patients often say: “Please do not make
my nose start from my forehead, I see it else-
where, and it is very obvious.” It is not easy to
lower the radix; dissection is difficult, bone den-
sity is high and adapting skin to this area is not
easy. An important issue concerns the following:
when the height of the nose radix at its lowest
point is lowered more than 1.5 cm, the nasal body
starts to disappear from the front view. Lowering
the nose radix more than normal in order to pre-
vent the nose starting from the forehead is not
correct. It is more appropriate to correct the area
where the actual problem lies.
I learned fat injection to the forehead from
Oscar Ramirez. In Istanbul we performed rhino-
plasties together for three days. Ramirez performed
our first forehead fat injection to our patient.
20 1 Preoperative

5.1 Technique

Before starting nose surgery we take fat with a

2.1 mm cannula and 10 cc locked injector. We make
it homogenous and hold it perpendicular during
nose surgery. Thus for three hours the fat is filtered
by itself. After taping the nose we give the fat injec-
tion to the forehead. I use a 1.2 mm blunt cannula
for injection. It is possible to fill the glabella and
forehead by means of three holes which are opened
from the eyebrow edges and hair line with a blood
needle. We inject aqueous fat without centrifuging
it, so that the fat is distributed more homogenously.
In the two drawings below only the foreheads
are different. The noses are identical with each
other. I recommend fat injection for 10–20 % of
my patients.

The navel, waist and knee medial are appro-

priate sites for harvesting fat. I usually prefer to
take fat from the waist area.
5 Forehead Fat Grafting 21

Patient Example
We made a fat injection into the forehead and
chin of my patient who had rhinoplasty. Note the
effect of bringing forward the forehead and chin
on the appearance of the nose. In the first two
photos you can see the result of rhinoplasty sur-
gery. In the subsequent photos you can see the
fat-injected state of the forehead and chin. The
postoperative first-year results of rhinoplasty and
the first-month results of the fat injection can be
seen here.

Patient Example
Below you can see the photos of a patient who
has had a fat injection into her forehead 13
months before. Note the relationship between the
patient’s eyebrow tip and radix. The transition
between forehead and nose was corrected with-
out deepening the radix. As this patient’s skin is
very thin, the supra-tip break point became more
obvious than normal. A revision is planned.
Please note the reduced image of the
exophalmus.
22 1 Preoperative
5 Forehead Fat Grafting 23

Patient Example
With the fat injection into the forehead the nose
looks smaller. Seven months after the surgery.
24 1 Preoperative

Patient Example
Forehead fat injection. You are seeing the
patient’s first-year photographs.

Patient Example
Photographs of a patient with forehead fat injec-
tion. The skin is thin and the lobule short. Note
the dorsal aesthetic lines and the tip shadows in
the first-year photographs. Tip and dorsum sur-
gery will be discussed in detail in the chapter on
Surgery.
5 Forehead Fat Grafting 25

Patient Example
This patient has a blunt radix. This is why I
reduced the dorsum a lot. I did not think the fat
injection into the forehead would be efficient.
This is a good example showing the effect of a fat
injection into the forehead. Note how the rela-
tionship between the forehead and the radix, eyes
and eyelashes has changed. This patient also has
sagging alae. Alae rim resection was performed.
This topic will be discussed in the chapter on
Surgery. This is the patient photo one year post-
operative, after the fat injection into the nose.
There is no over-reduction. Note the even aug-
mentation of the radix. This result confirmed my
belief in the efficacy of fat injections.
26 1 Preoperative

Patient Example
As the patient’s forehead is back in relation to the
cheek and chin, the forehead was filled with fat
and the nose radix with cartilage. With this plan
less of the hump was removed. Note the relation-
ship between the eyebrow tip and nose radix. In
the shadowed photos below you can see the sur-
gical plan. These are the patient’s first-year
photographs.
5 Forehead Fat Grafting 27
28 1 Preoperative

6 Jaw and Cheek

When the chin is small, the nose seems to be big-

ger, the cheeks become obvious and the lower lip
seems erupted. I try to persuade patients who
have chin problems by showing many examples.
It is possible to make a 2–3 mm chin augmenta-
tion with fat injection. A chin implant is more
rational for patients who have a small chin that is
continuous with the neck. I prefer medpor
implants. The two-parted implant designed by
Yaremchuk fits the chin tip better. It is difficult
and to insert the implant through the mouth, as
this increases the risk of infection as well. When
we insert the implant through the mouth, it is dif-
ficult to close the mucosa. It is also possible to
insert the implant through an under-chin approach
with a 2–2.5 cm incision. Place the incision into
the mental line. When you open a pocket near the
mandibular edge for the implant, there is no need
for a screw. I usually need to shorten the tip of the
implant. It is possible to increase projection by
placing pieces under the implant. When the two
pieces align with each other I suture the two
implant parts to each other using a big-needled
Monocryl stitch. If you need a drain, use a gray
intracath.
6 Jaw and Cheek 29
30 1 Preoperative

Patient Example
This revision case had been operated on else-
where. I advised that the problem was not the
nose, but the forehead and the jaw. Note the effect
of the fat injection into the forehead and the chin
implant. The forehead fat injection was repeated
six months later.

Patient Example
For the big nose to appear smaller, fat injections
have been performed on the forehead and the
cheeks. The patient nose will be discussed in the
chapter on Surgery. These are the patient’s photo-
graphs after one year.
6 Jaw and Cheek 31
32 1 Preoperative

6.1 Importance of the Cheek

I learned about the illusion effect of the cheek on

the nose from Michael Esson in 2009. Esson gave
drawing lessons to 20 plastic surgeons in the
Istanbul Memorial Hospital.
Bringing forward the cheek makes the nose
appear smaller. In other words, a depressed cheek
makes the nose appear bigger than normal. With
a midfacelift and fat injections to the cheek and
lower orbital rim, you can make the nose seem
smaller than before.

Patient Example
Note the effect of the fat injection into the fore-
head and lower orbital rim on the nose. The pho-
tos show the patient ten days after the surgery.
6 Jaw and Cheek 33

Patient Example
Look at the relation between the eyelash and
nose. A reduction of only 2 mm was done to the
patient’s nose ridge. The reduction effect on the
nose was acquired with the fat injection to the
inferior orbital rim and forehead.
34 1 Preoperative

7 The Rhinoplasty
Instrument Set

If your speculum is not thin-legged, you can-

not see anything in closed surgery. Some specu-
lums close the nostril completely. A medium-sized
Because I had difficulties in preparing my rhi- speculum may be more appropriate. I bought sev-
noplasty set and needed to ask help from many eral of different lengths, but use only the medium-
colleagues, I am including here a section on sized ones.
the topic. Obtain the right tools from the begin-
ning. Habits of hand are also important. This is
why you should have your own set. With 7.1 Dorsum Retractor
approximately 25 surgical tools you can
accomplish almost every type of nose surgery. The body of the dorsum retractor should be thin.
For closed rhinoplasty, you should have special You must control the edges, making sure that
tools. If your tools are not suitable for closed they are not sharp. Check the edge of the retractor
surgery, you may have to turn to an open with your finger; it must be blunt. Sharp-edged
approach after you have already started the retractors can damage nostril margins.
closed rhinoplasty surgery.
A bad workman always blames his tools.
When you do not have the right tool you cannot
access the right plane. If your tools are not
appropriate, a successful closed surgery is
impossible to achieve. Since some of the
instruments have a thick body, they can obstruct
the working area when you insert them.
Traditional elevators are not appropriate for
subperichondrial dissection, so I changed the
shape of the elevators I had bought with a dre-
mel. I fashioned such an elevator for most of
my colleagues as well. With a gentle-tipped
elevator dissection can be done easily.
Following a surgery I undertook with Rollin 7.2 Small Retractor
Daniel, his interest in the elevator I fashioned
resulted in his passing this instrument on to The retractor must be thin and concave. Without
Medicon, which then started serial production this retractor, closed surgery is difficult.
of this tool. Especially in subperichondrial dissection, we
7 The Rhinoplasty Instrument Set 35

start dissection by opening small pockets. The 7.5 Scissors

retractor should be thin enough to fit into the
pocket and leave a working space.
– Long Curved Sharp Tip: For accessing the
subperichondrium plane.
– Short Sharp Tip: For opening pockets for
grafts.
– Long Curved Ragged: For cutting cartilage
and mucosa parts.
– Septum Scissor: For dorsum cartilage
resection.

7.3 Forceps

– Toothless: For placing grafts into pockets and

while stitching up cartilage, in order to hold
cartilage.
– Multiple Teeth: For stabilization while shap-
ing grafts.
– Superfine-Tipped Toothed: For holding the
perichondrium.
– Fine-Tipped Toothed: For holding the mucosa.

7.6 Bone Scissors

I remove the hump with a bone scissor, which

results in a very controlled maneuver.

7.4 Needleholder

A needleholder capable of managing a 6/0 suture

is sufficient.
36 1 Preoperative

7.7 Rasp and Saw 7.8 Osteotomes

It is possible to get inside and up to the osteotomy
area with a thin changeable tungsten tipped rasp.
– 2 mm: Concha SMR, for internal osteotomy.
– 1 mm: For external nose radix osteotomy, can
also be used to open a pocket for the rim graft
at the end of the surgery.
– 4 mm: For cutting the middle part of the hump.
– 90 degree angled 5 mm: Lateral and transverse
osteotomy.

7.9 Elevators

– Little Cottle: For septum dissection.

– Daniel Perichondrium: For upper lateral carti-
lage inner perichondrium and medial crus
perichondrium dissection.
– Çakır Periosteum: For bone periosteum
dissection.
– Çakır Perichondrium: For dorsum, upper lat-
eral cartilage and lateral crus perichondrium
dissection.
7 The Rhinoplasty Instrument Set 37

Left to right: Little Cottle, Daniel perichondrium, 7.11 Osteoectomy Chisels

Çakır periosteum, Çakır perichondrium.

7.12 Lateral Osteotomes

7.10 Hook 2 mm and 4 mm chisels should be in your rhino-

Dissecting the lateral crus requires fine hooks.
You should try to tuck the hook into the mucosa.
If the hook gets into the cartilage, it can tear the
cartilage.
plasty set. A strong straight lateral osteotome is
very useful for opening osteotomies in deviated
noses.
38 1 Preoperative

1 mm chisels can achieve an osteotomy exter- ”Degussit” (Al2O3) serves as a good sharpening
nally through a needle hole. stone.

7.14 Sutures
7.13 Arkansas Stone
These four types of suture are sufficient for
Sharpening stones help you extract better use closed rhinoplasty surgery.
from your chisels. Chisels become blunt after
five to ten uses. A blunt chisel breaks the bone
instead of cutting it. For osteotomy a newly
sharpened chisel is essential. Arkansas stones do
not create dust while sharpening the steel. You
can moisten it with saline while sharpening. You
should wipe the tip of the tool, if metal dust
remains; it can cause permanent pigmentation on
skin, especially in external osteotomies.
 How to Draw a Nose
You cannot perform good surgery unless you
draw the organ precisely with the pen. I have
been taking drawing courses since 2006, and I am
convinced that it has improved my surgery
results. Drawing increases awareness. You can-
not solve a problem that you cannot visualize.
Drawing allows you to analyze a beautiful nose
and imitate it well.
I strongly suggest you to draw noses with
pencil, using the methods mentioned in this
section.
© Springer International Publishing Switzerland 2016
B. Çakır, Aesthetic Septorhinoplasty,
DOI 10.1007/978-3-319-16127-3_2
2
1 Exercises
1. Learn to draw a nose.
Buy a computer drawing tablet (electronic
drawing notebook). There are various sizes on
the market, but a 10 × 15 cm tablet will be ade-
quate for our purposes. Make drawings of both
beautiful and ugly noses. Draw the nose contours
and add the shading. Draw the edges of the
cartilages.
During rhinoplasty courses in Turkey, we
organize sculpture classes. In these classes, basic
design knowledge is taught and nose drawing and
modeling applied. Based on their drawings, par-
ticipants sculpt noses from clay and apply them
to noseless busts. We use polygons as drawing
and modeling method.
39
40 2 How to Draw a Nose

nostril sill and footplate. Investigate the endpoint

of the nostril sill. If the scar of the alar surgery
aligns with the nostril sill anatomy, then the
human eye cannot recognize the scar.

– Investigate the fusiform structure that the nose

dorsum constitutes. In this way, you can
understand the dorsal aesthetic lines better.
– Shading is the next step. Investigate the rela-
tion between dorsal aesthetic lines and
shadows.
– Adding some highlights to the dorsal aesthetic
lines will make your drawing more realistic.

Note
Drawings below by Yusuf Başoğlu.

1.1 Sketch from the Front

– The nose tip consists of three circles. The mid-

dle circle includes more cartilage than the cir-
cles on the sides. There is a 3:2 ratio for these
circles.
– Investigate the borders of the nose-to-face
contact (nose footprint). Also draw the lateral
aesthetic lines.
– Investigate the relation between the lateral and
dorsum aesthetic lines, beginning and ending
points.
– Look at your colleague’s nose while drawing.
You will start to see details that you have never
recognized before. This will increase your
awareness.

Draw the nostril sill to understand its anat-

omy well. See the close relation between the
1 Exercises 41
42 2 How to Draw a Nose

1.2 Sketch from the Side

– Determine the length and height of the nose.

Determine the nasolabial angle.
– We will use the same circles again. The 3:2
ratio is the same. The line which passes tan-
gentially to the bottom edge of the circles
gives us the nasolabial angle.
– The lateral view of the nostrils is very impor-
tant. Examine the nostril peak point and the C
point relation.
– Examine the columella and lobule ratio. You
can copy from beautiful noses in these draw-
ings. It is easier to make drawings from photos
of beautiful noses.
1 Exercises 43
44 2 How to Draw a Nose

Important
The fundemantal rule for closed surgery is to see
the topography of the cartilages by following the
highlights in the skin.

1.3 Sketch from Above and Below

It is also important to draw the nose from top and

bottom. If you make drawings from all angles
using the same cubic forms, your brain will take
stock of the cartilages and make a three-dimen-
sional model of it.
1 Exercises 45

Following page: A sculpture made from

polygons.
Note how realistic a nose sculpture made of
polygons appears.
46 2 How to Draw a Nose
1 Exercises 47

Cartilage anatomy made from polygons.

48 2 How to Draw a Nose

2 Analysis of Patient
Photographs

There is no need to elevate the nasal skin in order

to see the nasal cartilage. Nose photos can pro-
vide more information. As you perform nose
drawing exercises, I suggest an additional exer-
cise for you. Below, you can see a drawing made
on an electronic drawing tablet within five min-
utes. Try to see the cartilage edges and draw the
main lines. Use thin lines for concave and convex
forms. Thus, you can see the cartilage anatomy
without elevating the skin. If you are going to
perform closed surgery, you should see the carti-
lage anatomy through the skin. Below, you can
see my computer and my electronic drawing
notebook. With this equipment, I created the
drawings for this book.

Study the examples below. I drew our patient’s

cartilage anatomy from different views.
2 Analysis of Patient Photographs 49

Let’s finish the nose design with detailed pho-

tos of a patient who is in the fourth year of sur-
gery. A rhinoplasty patient whose nose has been
remodeled based on a suitable design will not
encounter the question “Did you have your nose
done?” Even alar reduction surgery will go
unnoticed.
 Nasal Polygons
3

You can draw noses and make nose sculptures

with Çakır polygons. Moreover, you can use this
method for giving shape to the cartilages in nose
surgery. We developed these polygons together
with my sculpture teacher. Since 2010, my sculp-
ture instructor and I have been organizing rhinos-
culpture workshops at rhinoplasty congresses,
and plastic surgery assistants study nose draw-
ings and nose modeling. Polygons are one of the
main topics of instruction. For an article discuss-
ing this method in detail, see:
Çakir B, Doğan T, Öreroğlu AR, Daniel
RK. Rhinoplasty: surface aesthetics and surgical
techniques. Aesthet Surg J. 2013 Mar;33(3):
363–75.
What is the difference between Çakır
polygons and Sheen’s aesthetics?
Jack Sheen has described the ideal tip shape as
“two equilateral geodesic triangles with a com-
mon base formed by a line connecting both
domes. The highest projecting point of the tip
should lie along the apogee of the curved line that
connects both domes.” We all know the infratip,
supratip and soft triangles.
Sheen JH, Sheen AP. Aesthetic Rhinoplasty.
2nd ed. St Louis, MO: CV Mosby; 1987.

© Springer International Publishing Switzerland 2016 51

B. Çakır, Aesthetic Septorhinoplasty,
DOI 10.1007/978-3-319-16127-3_3
52
Shield grafts try to mimic the infratip triangle.
However, we see that this graft constantly changes
over time. Using a shield graft in a Y shape is an
increasing trend, because the short arms of the Y
graft and the gap between them gives more natural
3 Nasal Polygons
results. Placing a block cartilage to prevent the
shield graft from overturning is one of the least
common differences. The block graft both sup-
ports the shield graft and forms a second tip break-
point just 2–3 mm above the breakpoint formed by
5 The Mobile Tip Area
the shield graft. Thus, it protects thin-skinned
patients from pointed tip deformity. The aesthetic
concepts described by Sheen cannot meet the
needs of open rhinoplasty technique. In this book,
polygons, as they will be examined in detail, can
be considered as open rhinoplasty update of
Sheen’s aesthetic concept.
1 Infratip Triangle
We try to create this triangle with a shield graft. I
use a shield graft only for overly deformed noses.
I think that it has no place in primary rhinoplasty.
We described this area with the infralobule poly-
gon and added more details to the nose tip.
2 Tip Defining Point
When the shield graft is used for increasing pro-
jection, the tip becomes pointed. To prevent this,
a block cartilage has been used behind it. Toriumi
mentions this graft repeatedly. We have described
the nasal tip area with two dome triangles and an
interdomal triangle.
53
Note
I admire the approach based on an aesthetic con-
ceptual description from 30 years ago. Sheen
counts as one of the legendary surgeons for me.
Topographic anatomy is a more important concept
for closed rhinoplasty surgeons; we have to follow
the skin reflections created by means of cartilage
in the surgery.
3 What Is a Facet?
These are multi-edged flat areas which surround a
three-dimensional objects. This is the easiest
method for making a sculpture. You can imagine
round organic forms consisting of several facets.
Their sizes, angles, and the ratios between them are
important. Analyzing organic forms with the help
of cubic forms is a basic drawing method.
4 The Non-Mobile Nose
These polygons are mass polygons. They are cre-
ated from cartilage and bone.
Glabellar Polygon
Dorsal Bone Polygon
Dorsal Cartilage Polygon
Lateral Bone Polygons
Upper Lateral Cartilage Polygons
5 The Mobile Tip Area
5.1 Mass Polygons
Dome Triangles
Lateral Crus Polygons
5.2 Space Polygons
Interdomal Polygon
Facet Polygon
54 3 Nasal Polygons

Columellar Polygon 7 Dome Triangles

Footplate polygon (we do not elevate the skin in
this region) These are the triangles formed by the Ti, Ts, and
Infralobular Polygon Rm points. There are two dome triangles. Dome
polygons should look exactly towards the front.
These polygons cannot be seen when the skin
is raised.

6 Tip Breakpoints

In profile, the nose tip makes two breaking points

on the same vertical plane. We call the upper
refraction Ts (tip superior) and the lower one Ti
(tip inferior) points. Peak points of the dome tri-
angles form the Ts point. Bottom inner edges of
the dome triangles form the Ti points.

In 2008, the right dome of one of my patients

who had beautiful right dome highlights had a
triangular shape. In order to give it a similar
shape, I made the left dome triangular. The dome
triangle concept emerged with this photo.

Pay attention to the polygon drawings. If pos-

sible, draw them by yourself. It is easiest to begin
the drawing with the interdomal polygon.
7 Dome Triangles 55

makes the meeting point triangular. In some

patients, you can see this triangle clearly.
Generally there are more soft transitions between
these triangles.

Patient Example
Before surgery, let’s examine the cartilage anat-
omy of a patient with well-articulated nose tip
polygons. As the patient’s skin is thin, it is eas-
ier to see the cartilage anatomy underneath.
You can clearly see the facet polygon. As the
resting angle of the lateral crus is adequate, we
can see the light formed by the lateral crus cau-
dal edge.

The dome is the meeting point of the lateral

and medial crus. Lateral and medial crura are
not formed by the curve of a plane rectangle car-
tilage from the middle with one angle. If you
force it to curve on one plane with stitches, the
domes, lateral and medial crura can be malposi-
tioned. The infralobule polygon expands, the
apex of the facet polygon closes and the caudal The patient’s right dome shows the triangle
edges of the lateral crura turn towards the form more clearly. Examine how close the medial
nostril. crus and lateral crus are to each other on the
The lateral and medial crura meet each other cephalic edge of the dome. We are trying to copy
at a 15–20° angle. This angled articulation this form with tip sutures.
56 3 Nasal Polygons

Below, you can see the photograph of a patient

who has clear dome triangles.

However, the left dome of the patient does not

show the triangle form. The folding line near to
the lateral crus is more bent than the other one.
Moreover, the folding line close to the lateral crus
is folded more at the cephalic edge of the dome.
The common characteristics of the left and right
domes are that the medial and lateral crura on the
caudal edges of the dome which will form the tip
of the facet polygon are far away from each other.
Cephalic dome suture generates a form similar to
the right dome. Cephalic dome suture does not
generate a clear triangle, but this form can be
expressed with a triangle polygon. The triangle
form can be obtained with two different trans-
domal sutures that are positioned to each other at
a 30–40° angle, but a clear aesthetic achievement
cannot be obtained. It lasts longer, is more diffi-
cult and harder to achieve symmetry.
7 Dome Triangles
Below are the preoperative photos of one of
my patients who had an operation in 2007. I cre-
ated dome triangles by placing two different hori-
zontal mattress sutures at a 30–40° angle. Clear
triangle forms were given to the domes, but plan-
ning and performing the surgery was not easy.
I have not used this method since 2008.
Although the cephalic dome suture cannot make
the domes as triangular as above, it is a more use-
ful technique.
Important
While drawing, turn organic shapes into cubic
forms. This will make the analysis easier. The
base length of this triangle forming the dome is
approximately 3 mm, and this length constitutes
the root of the facet polygon.
57
Important
The horizontal mattress suture, named the dome
spanning, transdomal or dome-creating suture, is
not a suitable suture for dome anatomy. The
stitch that copies the trianguler dome anatomy
best and at the same time is the easiest one con-
sists of the cephalic dome suture. Cephalic dome
suture forms the dome by narrowing the top of
the triangle. Do not put any stitches from the
caudal edge of the domes. Below you can see an
example of a patient where I used a dome span-
ning or transdomal suture in 2008. I was trying
not to collaps the facet polygons by passing the
stitches to the cephalic edges of the dome. If you
contract the stitch too much, it can collapse;
however, if you do not tighten it enough, it does
not work. Technically, this is not an easy stitch.
It cannot correct the lateral crus resting angle
properly.
58
8 Interdomal Triangle
The interdomal triangle is the space between the
Ts point and both Ti points. Like the dome poly-
gon, it looks towards the front.
For the purposes of aesthetics, you should not
only see mass, but also the spaces in between.
The superior angle of the interdomal triangle is
80° in men and 100° in women.
Try to see the borders of the light reflected
through the tip of the nose. You will see that it
forms a triangle.
3 Nasal Polygons
Note
I discovered these angles through measurements
that I performed on beautiful noses in Photoshop.
Angles can vary between 5 and 10°. Based on my
findings, the peak angle of the interdomal poly-
gon in men is narrow.
Important
As the rotation of the nose tip increases, the cau-
dal edges of the domes drift apart. The angle dif-
ference between women’s and men’s noses is due
to the rotation differences.
Dome triangles only contact each other at the
Ts points. There should be space between the Ti
points. If you close this space with a suture, tip
aesthetics substantially deteriorate. Facet poly-
gons expand horizontally; hence you should con-
sider a rim graft. The incidence of a pinch nose
increases as the caudal edges of the lateral crura
also become medial.
8 Interdomal Triangle
As a result, never close the interdomal polygon.
8.1 Dome Divergence
This is a controversial issue that has not yet been
explained clearly. It has been discussed in theory,
but not yet performed in practice. Perhaps the
inadequate explanation of interdomal space
based on dome divergence has caused confusion.
In some drawings, dome divergence has been
59
shown as space between the cephalic edges of the
domes. However, the domes contact or stand
close to each other even if there are thin liga-
ments between them.
Important
Ti and Ts points should be on the same vertical
plane. In women, the Ti point could be 1–2 mm
anterior of the Ts point.
Does the Interdomal triangle make a pit
on the skin?
In naturally beautiful noses, the interdomal tri-
angle always exists. It is rare to see it on noses with
thick skin, but more obvious on thin-skinned
noses. The interdomal triangle can be seen from
the outside as a facet or litte groove. In the carti-
lage anatomy this groove is more obvious. The
superficial part of SMAS and the interdomal liga-
ments fill the space in between. The superficial
60
part of the SMAS should be protected during the
dissection. If you leave the superficial part of the
SMAS on the cartilages when you are elevating
the flap and make a resection while it gets between
the cartilages, that area will be empty when the
flap is closed again.
The strut graft should be fixed to the cephalic
edges of the medial crus. Otherwise, we cannot
protect the interdomal triangle. We should leave a
place for the superficial part of the SMAS
between the medial crura. In thick-skinned noses,
you can make this polygon obvious with small
resections from the perichondrium and SMAS.
Important
Do not resect too much because you may damage
the artery, vein and nerve.
3 Nasal Polygons
9 Infralobular Polygon
The infralobular polygon is the rectangle between
the Ti and C points, and it has been named by
Rollin Daniel. The infralobular polygon looks
downwards at a 45° angle. It is a space polygon.
The superficial part of the SMAS fills this space
and makes it a facet. The strut graft is also located
in this polygon. If the strut graft is close to the cau-
dal edge of the medial crus, the infralobule poly-
gon becomes round. The infralobule polygon is
constituted by the weakest part of the lower lateral
cartilage, named the middle crus. After dissection
this part weakens, and contour grafts will be
needed in order to strengthen it. We will describe
this topic in the chapter on surgery techniques.
10 Columellar Polygon 61

10 Columellar Polygon When the tip surgery is finished, the superfi-

cial SMAS and perichondrium may cause bulg-
The columellar polygon is a space polygon, ing on the columellar polygon. You can perform
between the C points and the footplate polygon. resections for the bulging on the columellar poly-
The columellar polygon looks downwards. The gon or make small flaps and turn them to the
space between the caudal edges of the medial space in the infralobular polygon. Below,
crus should be protected. A commonly occurring the bulging on the C point was treated with
mistake is the extreme grafting of this region or a perichondrium flap.
making the caudal edges too close to each other.
Extreme grafting expands the columellar polygon.
Suturing the caudal edges narrows the columel-
lar polygon. However, in a normal and beautiful
nose, the columellar polygon can be seen clearly.
A little groove seems to be natural and will not
disturb the patient. The medial crura turn laterally
and upwards in order to form the footplates. If the
columellar polygon is short, then it is possible to
lengthen the columellar polygon by suturing the
footplates to each other.
62 3 Nasal Polygons

The footplate polygon, columellar polygon

and lip may not be separated from each other
clearly. As in the examples below, the lip, colu-
mella or footplate can be dominant.

11 Footplate Polygons

These are the planes formed by the footplates.
They look at sideway and downwards.
It can be plumper in women. In men, it is not
uncommon to see it form a sharp angle with the
lip. In tension noses, the excess of the caudal pos-
terior part of the septum extends between the
footplates and expands this polygon. In patients
with short columellar polygons, it is possible to
make the columellar polygon longer by suturing
the footplates. The footplate polygon may be
wide enough to obstruct breathing. In surgery
this region should usually be narrowed.
12 Facet Polygons
In many of our patients, the footplate polygon
projection is excessive. This projection can be
decreased via dissection. However, if the foot-
plates are constricted too much, the footplate
polygon disappears and the columellar polygon
elongates too much. This creates an operated
look.
12 Facet Polygons
This is the polygon between the Ti, Rm, Rl and C
points. It looks downward and lateral 45°. One of
my essential objections is this region. This area is
not a triangle. There is a 2–3 mm edge between
the Ti and Rm points. The facet polygon is not a
space that has to be filled. This can be seen clearly
in beautiful noses. A thin-skinned nose without
the facet polygon significantly shows that it has
been operated on. It has an anatomy like a tent
formed between the middle and lateral crus.
63
For a good facet polygon,
1. A strong middle crus is required. If it is weak,
then I use contour grafts.
2. A right-sized infralobular polygon is needed. If the
infralobular polygon is constricted with stitches,
the facet polygon expands. In order to compensate
this mistake you have to use big rim grafts.
3. The dome polygon which is at the top of the
facet polygon should be appropriate to the
polygon concept. Non-anatomical sutures like
the dome-spanning suture or the transdomal
suture should not be used. Non-anatomical
sutures constrict the caudal part of the dome
and thereby the top of the facet polygon.
4. The caudal edge of the lateral crus should be
strong and elevated like the rod of a tent. The
lateral crus resting angle is important. The cau-
dal edge of the lateral crus should be anterior
to the cephalic edge. Thus, the caudal edge of
the lateral crus creates tension upwards and
sideways and stretches the facet polygon and
as a result sets up the tent. Otherwise a pinched
nose occurs. In a pinched nose, the caudal
edge of the lateral crus is collapsed inwards to
the nostril. Noses with obvious facet polygons
can breathe better. Below you can see a nose
with a clear facet polygon.
64 3 Nasal Polygons

Example
Below are the first-year photos of a patient with
open surgery technique. The pinched nose defor-
mity occurs especially on the right side. The car-
tilage which can be seen from the nostril is the
caudal edge of the lateral crus. The lateral crus
resting angle has been completely destroyed, and
the caudal edge contacts the septum. The patient’s
dome plane and lateral crus polygons have been
deformed consecutively. This nose cannot sup-
port deep inhalation. Additionally, the caudal
edge of the lateral crus also creates breathing
problems.
How can the facet polygon be destroyed?

1. The transdomal suture constricts the top of the

facet polygon. Because of that, the caudal edge
of the middle crus and the caudal edge of the
lateral crus interfere with the facet polygon.
2. If you use a lateral crus spanning suture, you
will obviously destroy the facet polygon. This
suture will impair the resting angle.

Note
The lateral crus spanning suture is a suture tech-
nique described by Tebbet. In order to correct tip
width, the suture passes through both lateral
crura and helps them to approach each other.

3. Extreme cephalic resection of the lateral crus

weakens the caudal edge of the lateral crus.

Below are photos of an operation I performed in

2007. Although I had tightened the suture, constric-
tion had occurred at the top of the facet polygon in a
patient on whom I used a transdomal suture.
13 Lateral Crus Polygons 65

13 Lateral Crus Polygons

12.1 Relation of the Facet I do not want to cause confusion by assigning

and Dome Polygons
In the front view, the height of the dome triangle
and the height of the facet should be similar. If
the facet polygons narrow or are not evident, the
aesthetic appearance deteriorates in the front
view.
numbers to the polygons’ corners. As it is very
difficult to explain the nose tip differently, I detail
it in the following way: The lateral crus polygon
is a mass polygon and made up from the body of
the lateral crus. The caudal edge of the lateral
crus is in front of the cephalic edge. This position
produces a clear facet polygon and a scroll line in
the skin.
It is necessary to explain the surgical impor-
tance of the lateral crus polygon.
66 3 Nasal Polygons

14 Resting Angle

This is the angle between the surface of the lateral

crus and the upper lateral cartilage surface. This
angle should be 100°. Surgical techniques that ruin
the nose tip also ruin the lateral crus resting angle.
This happens when the angle between the lateral
crus and the upper lateral cartilage starts to exceed
100°. The resting angle is an important topic on
which I will elaborate below. I have watched many
surgeons’ operation videos, but few surgeons care
about this angle. If this angle is regular, then the
need for a rim graft dramatically decreases. As the
resting angle broadens, the nose starts to become
pinched. If the resting angle is 100°, the facet poly- Below you can see how to correct the resting
gon appears well-formed. The section on techniques angle.
will discuss how the resting angle recovers with the
effect of the cephalic dome suture.

Important
Tip aesthetics are relevant to each other. When a
15–20° angle is formed between the medial crus
and the lateral crus planes, the resting angle will
be correct. As a result, the domes become trian-
gular. Below there is a simulation of the resting
angle. Examine the shape of the domes.
14 Resting Angle
14.1 Vertical Compression Test
The nose tip cartilages are very thin. Cartilage
thickness is not the only parameter affecting the
nose tip’s resistance to breathing. The mass gen-
erated from the angles of the two lateral crura on
the horizontal axis also produces an additional
resistance to respiration.
In order to produce horizontal resistance, the
lateral crura and transverse axis should be parallel
to each other. The angular relation between the lat-
eral crus and the upper lateral cartilages is very
important for breathing. As this three-dimensional
anatomy is both complex and important, I would
like to emphasize this point particularly. By con-
ducting this test with your patients, you can see
how the lateral crus affects breathing. Patients who
state that they breathe easily when they hold up
their nose tips are actually correcting the angle of
the lateral crus while doing so. With the vertical
compression test, when the angle of the lateral
crus is corrected, the patients state that they can
67
breathe easily. The horizontal mass effect formed
by the reclining of the lateral crus in a 4–5 mm
space between the septal angle and the domes also
stabilizes the internal valve. But the main effect of
the resting angle is on the external valve.
Below you can see the nose in resting position.
Nares of the patient close in deep inspiration.
Note
A collapse is more obvious in the nostril through
which more air passes. As the right side of the
nose is narrow because of septum deviation, the
collapse is obvious on the left side.
When the nose of the patient is compressed
between three fingers, the horizontal axis of the lat-
eral crus becomes parallel. The nares do not close
even when the patient takes a deep breath. In order to
make nares resistant to inspiration, a rim graft and
lateral crus strut grafts can be used. However, graft
application gives an unnatural rigor to the nose.
68 3 Nasal Polygons

The photo shows the transition of the lateral

crus to the horizontal plane during the vertical
compression test.

Resistance that originates from the right lat-

eral crus resting angle is the main reason for the
resistance generated by the nose tip against inspi-
ration. Examine the shape of the lateral crus in
the polygon model and the lateral crus shapes
after surgery.
14 Resting Angle 69

Example
An example of a corrupted resting angle, one of
the frequent rhinoplasty signs. Since the resting
angle is disturbed, the nose tip looks like a
cephalic malposition deformity.

The cartilage anatomy of this patient has been

drawn with the help of an electronic drawing
tablet.
70 3 Nasal Polygons

When the long and convex lateral crus prob-

lem is added to a wide lateral crus resting
angle, an appearance of a cephalic malposition
occurs. Techniques that we use for tip shaping
should aim to correct this shape in the simplest
way.

14.2 Incorrect Resting Angle

and its Effect on the Ala

In noses with disturbed resting angle, the caudal

edge of the lateral crus cannot support the nares
adequately. On the other hand, the caudal edge of
the lateral crus should be identified from the nose
skin. If the tip of the nose has a more rounded
look, the facet polygon is not clear. Patients with
a correct resting angle have a strong wing edge
and a defined facet polygon. In the following
drawings, examine the differences between lat-
eral crus resting angle, facet polygon and domes.
14 Resting Angle 71

4. And if you try to correct supra type fullness

resulting from a long lateral crus via sequent
cephalic resections, you will probably cause a
pinch nose.

Important
The length of the lateral crus should fit the nose
planned.

Below you can see a sample of patients in

which the lateral crus is kept long. The long lat-
eral crus is folded and the dome is deformed. The
surgeon has tried to weaken it by performing a
scoring to the lateral crus, but failed.

14.3 Wide Lateral Crura

Most of the patients’ lateral crura are wider than

normal. This causes a lateral supra-tip fullness
and narrow facet polygon. Making all resections
from the cephalic side is not correct. Do not for-
get that there is also width to the caudal side of
lateral crus. In the section on the autorim flap,
this topic will be discussed in detail.

14.4 Long Lateral Crura

This is an ignored topic. If you are planning to

increase rotation, lower the projection and make
a reduction in nose length, you should shorten the
lateral crus length. Long lateral crura are the
most important obstacle in correct tip surgery.
If you do not shorten a long lateral crus,

1. The long lateral crura will defeat you and the

nose tip will go back downwards. This is the
main reason for a polybeak deformity and
dropping of the nose tip.
2. It will be folded in some place. It folds most
frequently near the piriformis aperture and
herniates on the interior, causing breathing
problems.
3. And if the herniation occurs from the middle
of the lateral crus outwards, you will increase
bulbosity. If it is inwards, then collapse or
asymmetry occurs. I have even seen lateral
crus herniation of the right side inwards and
the left side outwards in the same patient.
Example
A closed technique rhinoplasty has been done in this
patient. Probably a rotation has been performed and
projection has been decreased. However, since the
lateral crus length was not changed, the lateral crus
has herniated through the airway. Possibly the
patient’s lateral crus was convex. Cephalic and cau-
dal excess of the lateral crus make convex deformity
more resistant. A convex lateral crus tends to herniate
to the airway. Its length and width should be treated.
You can see the herniation of the lateral crus below.
72 3 Nasal Polygons

The caudal excess of the lateral crus was left on
the skin as autorim flap.
The following image demonstrates a puff
4 mm medial to the herniated region in the air-
way. This puff recovers when the lateral crus is
stretched to the anterior with a forceps. This
means that the patient’s lateral crus was left long.
Some of the surplus in the length of the lateral
crus has made supra-tip bulging, and another part
has herniated to the airway.

The lateral crus has been dissected subperi-

chondrially. Even the dissection alone has cre-
ated some relaxation, but this is not adequate.

Important
Subperichondrial dissection makes the lateral
crus softer and hence it is shaped easier. With the
dissection of the perichondrium, the cartilage
may resist to the desired shape. It can protect its
convex shape even though the length of the carti-
lage has been shortened.
14 Resting Angle 73

Stretching the lateral crus corrects the herniation

of the cartilage to the airway.

When tip surgery is completed, since the

When I push the lateral crus posteriorly with a
forceps, the lateral crus herniates inwards from
the weakest point again.
length and width of the lateral crus suits the new
nose, herniation disappears. A lateral crus strut
graft is the most commonly used technique for
this problem. If the lateral crus is intact, a correc-
tion of length and width renders the crural strut
graft unnecessary. The main principle of the lat-
eral strut crural graft is separation of the lateral
crus from mucosa and skin. This procedure treats
the cartilage’s length and topographic shapes.
The graft serves as a plaster.

The herniation is corrected after stretching with

a forceps. This mechanism deserves further discus-
sion. In the open technique, the airway is not con-
stantly controlled. The surgeon should be able to
observe the nose’s interior when the nose is
enforced for rotation before shortening the lateral
crura.
74 3 Nasal Polygons

Compare the result with the herniation at the

beginning of surgery.

These are the patient’s tenth-day photos. A

depression is noticed where the lateral crus herni-
ates. This was improved significantly after
surgery.

The depression that occurred as a result of

herniation of the lateral crus inwards was also
corrected.
14 Resting Angle 75

Pay attention to the pit in the skin.

Patient Example
In the case of this patient who underwent surgery
ten years ago, the lateral crus has herniated
inwards into the nose.

In this photo the light sources was adjusted

from below to show herniation of the lateral crus
inwards.
76 3 Nasal Polygons

Postop second-year view. In these photos, a sin-

gle flash was used on the left. As a result, the
problem seems worse than it is.

Lateral crura were dissected from the skin and

mucosa and inserted again as grafts.
14 Resting Angle 77

Patient Example
This patient underwent rhinoplasty four times,
but in none of the surgeries the lateral crura were
shortened, and hence the long lateral crura cre-
ated a loss of rotation. Shortening the lateral
crura corrected the problem. Fat was also injected
to the upper eyelids.
78 3 Nasal Polygons

14.5 Convex Lateral Crura

The convex lateral crus problem is frequently

seen. Convex lateral crura can be found in both
the vertical and horizontal planes. The cephalic
and caudal parts of the lateral crura bend
inwards, because the borders of the lateral crus
are shorter than the midline axis. These parts
make the lateral crus convex geometry resistant.
Although the perichondrium which is connected
to the cartilage from both bottom and top is very
thin, it increases this resistance as well. This
effect is solely based on my observation.
Cartilages on which I have performed subperi-
chondrial dissection shape easier with the
sutures.
Do not forget that, when the convex or con-
cave plane becomes flat, its length and width
increases as well. Adversely, when a plane
becomes concave or convex its length and width
decreases. The main reason why the crura become
convex is the same as with the septum cartilage:
not fitting into the space and therefore folding.
With the principles used for correcting the warp
of the septum, we should also correct the lateral
crus. We should perform a wide dissection in the
subperichondrial plan and give shape with sutures
after removing the surplus cartilage. Most of the
convex lateral crus problems can be corrected 14.6 Cephalic Malpositioning
with subperichondrial dissection, caudal and
cephalic resections, lateral crura steal and Cephalic malpositioning has been described by
cephalic dome suture alone. Sheen as the longitudinal axis of the lateral crus
After the surgery is completed, if you are showing the medial canthus instead of the lateral
still seeing a puff in the middle of the lateral canthus. Since the problem is described in this
crus, open 1–2 mucosa sutures of the cartilagi- way, a lateral crus repositioning surgery is sug-
nous incision. If possible, dissect the mucosal gested. The lateral crus is dissected totally, a
side of the lateral crus on the subperichondrial pocket is opened inferior to the lateral end and the
plane. This dissection also decreases the resis- lateral crus is re-inserted. However, if you read
tance of the lateral crus. If you place 1.5 cm this book you will not need to use that procedure,
long and 1–2 mm wide cartilage grafts under because I believe that the problem is described in
the lateral crus, it can easily be adapted to its the incorrect way.
new shape.
Important
If there is a long lateral crus, wrong resting angle,
horizontal and vertical convex plane problems and
cephalic and caudal surplus problems at the same
time, then the nose will look as if cephalically mal-
positioned (parenthesis tip). The cephalic edge of the
14 Resting Angle 79

lateral crus becomes more significant than the skin,
so it shows the medial canthus. As the caudal edge of
the convex cartilage is folded into the nose, it cannot
be seen through the skin, and this creates the illusion
of insufficient cartilage in the alae.
chondrial dissection. Subperichondrial dissection
was applied to the mucosal side of the left lateral
crus, without any repositioning.

This idea is supported in the new anatomical

studies by Daniel, revealing the formation of a
ring by the lateral crura and turning of the crus
towards the nostril sill. Daniel argues that the lat-
eral crus ends at the same point in all people; all
changes take place in the body of the lateral crus.

Important
You can solve most of the problems if you
entirely mobilize the lateral crus by repositioning
it inferiorly. In my opinion, the main effect of the
repositioning technique is mobilizing the lateral
crus with dissection, rather than moving the car-
tilage inferiorly (once the lateral crus is dissected
from skin and mucosa, the convex shape softens,
hence solving the long lateral crus problem as the
cartilage spreads).

I met Rollin Daniel in Istanbul in 2011, and he

attended one of our surgeries. I was operating on
my own assistant on that day.

The lateral crus topography has become more sym-

metrical. If we had made a 2 mm autorim flap, we
would have obtained better results. I have been
using the autorim flap technique since early 2012.

The photos show my assistant two years after

the surgery. Her left lateral crus was convex and
her right lateral crus concave. The main difference
between these lateral crura caused a cephalic mal-
position view on the left lateral crus. During the
surgery, we talked about the effects of subperi-
80 3 Nasal Polygons

Why am I against the repositioning technique?

1. It is very aggressive and causes long-lasting

edema.
2. It can easily give an asymmetric result.

15 Scroll Facet

The scroll facet is the area near the cephalic side

of the lateral crus. The transition to the lateral
crus polygon is usually not clear. In some patients
it is possible to see a clear edge. In the patient
below, for instance, the scroll facet can be clearly In the same patient, a 3 mm steal of the lateral
seen. If the lateral crus resting angle cannot be crus is planned. A new dome is formed with the
achieved with the cephalic dome suture, a cephalic dome suture. The scroll facet is formed
3–4 mm cut can be made in order to form the with a 4 mm cut on the lateral crus.
scroll facet.
15 Scroll Facet 81

Patient Example
Below you can see the shape of the cartilages of
a patient with a beautiful nose. The highlights of
the dome on the skin look beautiful. However, the
dome cartilages of the patient do not form a clear
triangular form; the fold in the dome is more on
the cephalic and less on the caudal side. Pay
attention to the sharp edges on the cephalic edge
of the dome. Moreover, there is a separate 2 mm
area that can form the scroll facet. After using the
cephalic dome suture, we are going to copy the
shape by scoring the cartilage.
82 3 Nasal Polygons

In the following model, you can see the superfi-

cial cut for the scroll facet.

A 3 mm lateral crus steal was applied. The tip

was reshaped with cephalic dome sutures in
accordance with the original anatomy. The scroll
You can see the creation of the scroll facet in a
facet was rebuilt with a 4 mm incision.
patient on which I operated using the open tech-
nique. Making a 3–4 mm cut for the scroll facet
helps guarantee the correct lateral crus resting
angle. Compare the lateral crus resting angle in
this patient with the polygon model. In this photo,
the infralobule polygon had not been created yet.
The photo is from 2007. Transdomal sutures
were used for domes.

Note
This maneuver prevents the lateral crus from
overlapping and slightly narrowing the tip.
17 Dorsal Cartilage Polygon
16 Scroll Line
The scroll line is the area where the upper lateral
cartilage and the lateral crus meet, forming a
groove that is visible through the skin. If we do
not form this line, the nose becomes round. If the
lateral supra-tip skin does not fit completely onto
the cartilage skeleton after the rhinoplasty opera-
tion, the dead space fills with fibrosis and the
scroll line becomes indistinct. For a beautiful
scroll line, a correct resting angle is essential,
since the scroll line is formed by the pit where the
upper lateral cartilage and lateral crus connect.
In order to form the scroll line, we should
reconstruct the scroll area. This is also function-
ally important.
Important
If the upper lateral cartilage and the lateral crus are
sutured with the scroll ligament, the internal valve
is repaired and the scroll line becomes distinct.
83
17 Dorsal Cartilage Polygon
The dorsal cartilage polygon is the area from the
tip to the keystone region. It can be clearly seen as
a section looking anterior in thin-skinned patients.
In the cartilage anatomy, there is a groove in the
center of the cartilage; this groove is deeper at the
keystone. This groove is 1–2 mm deep and filled
by the dorsal perichondrium. The Pitanguy liga-
ment is on top of this perichondrium.
Note
The Pitanguy ligament was described by Pitanguy
in 1960. It was initially named the dermocarti-
laginous ligament. Pitanguy stated that this liga-
ment begins from the supra-tip dermis, passes
through the area between the dome and the septal
angle and is finally attached to the medial crura.
In terms of surgical importance, he has stated:
“Cut this ligament for nose rotation, if the liga-
ment is too much then resect.”
If you are making a subperichondrial dissec-
tion, forming this groove wherein the tissues
above fit will strengthen the dorsum highlights.
The drawing below illustrates a man’s nose
expressed with cubic forms. Therefore, the dor-
sum cartilage polygon is longer. As the dorsum
cartilage approaches the nose tip, the Pitanguy
tissue thickness increases. The dorsum cartilage
ends as it forms the septal angle after entering
between the lateral crura. Hence, I did not draw
the dorsum cartilage polygon adjacent with the
nose tip.
The shape of the polygon that we are going to
form with spreader grafts or flaps should be as
below.
84 3 Nasal Polygons

Important
Dorsum bone and cartilage polygon become
interconnected in the keystone area. The bone
lies on the dorsum cartilage with a 2–3 mm bone
shelf in the middle axis. The dorsum cartilage, on
the other hand, continues upwards for 2–3 mm on
both sides of the bone shelf. Ismail Kuran has 18 Dorsal Bone Polygon
determined that the left nasal notch is generally
larger. Because of this, the dorsum aesthetic lines The dorsal bone polygon is the area between key-
are formed by cartilages which extend up to stone and nose radix.
3 mm above the keystone region. Copying this
anatomy will cause better dorsum highlights. It
will decrease our responsibility in shaping the
bone on the nasal dorsum. We will examine the
relation between the cartilage and the bone in the
keystone region on the polygon model.
19 Upper Lateral Cartilage Polygons 85

19 Upper Lateral Cartilage

Polygons

The upper lateral cartilage polygon is the area

formed by the upper lateral cartilage.

The dorsal bone polygon has more round lines

compared with the dorsal cartilage polygon. It
does not give rigorous light as much as the dorsal
cartilage polygon. It is wider in the keystone
region and narrower in the radix. It is longer in
men and shorter in women. In other words, the
keystone is located higher in men when com-
pared to women. If the roof is completely closed
with osteotomy, the dorsum bone polygon
becomes very narrow. When spreader graft or
flaps are used for dorsum highlights, we have a
controlled open roof. When this area is left in this
way, you will see that the skin shows the 1–2 mm
opened framework. As the skin here is very thin,
you will experience collapses in the dorsum bone
polygon after a number of years. Therefore, I rec-
ommend you to use camouflage techniques as
standard. I most commonly use bone paste. Bone
paste can be prepared from the bone from the
nasal dorsum within one minute. I started using
this technique after I saw Fethi Orak using bone They face lateral, downwards and straight for-
shavings from rasping material, and I have been ward. As upper lateral cartilages are very thin,
very pleased with the outcome. they rarely have specific topographic problems.
If the dorsal cartilage polygon is shaped cor-
rectly, this section will not cause a problem. As
the height of the upper lateral cartilage is greater,
86 3 Nasal Polygons

we resect from the upper lateral cartilage while 20 Lateral Bone Polygons
removing the hump. One problem not adequately
discussed here is the case of a long upper lateral The lateral bone polygons are formed by bones.
cartilage polygon. In noses with a droopy tip, we They face lateral, upwards and straight forward.
make the nose tip rotation by means of septum
caudal resection and cephalic lateral crura resec-
tions. However, cephalic resection should be
done to allow lateral cephalic dome stitches. This
is usually 1–4 mm. If this resection is not enough
for rotation, the resection should be made from
the caudal part of the upper lateral cartilages. In
this way the upper lateral cartilage polygon can
be shortened.

They are generally convex and asymmetry can

often be observed. We can mobilize bones like
flaps. However, topographic problems of the
bone cause problems of asymmetry. You can cor-
rect these asymmetries with a rasp after a wide
dissection.
To correct this problem, double-leveled oste-
otomy is well advised, but I rarely use this
method. The bone base is formed by the maxilla
and is convex-shaped from the medial canthus to
the piriformis aperture. This convexity cannot be
changed with osteotomy, and narrowing the lat-
eral walls of the internal valves may impair
breathing. Bone thickness in some regions can
reach 4–5 mm. In such patients, it is not accept-
able to collapse 5-mm-thick bone into the nasal
cavity in order to constrict the airway for aes-
thetic purposes. This topic will be discussed in
the section on surgery.
21 Dorsal Aesthetic Lines 87

21 Dorsal Aesthetic Lines Patient Example

Let’s examine the two-year postoperative photo-
This section will cover concepts that are very dif- graph of a patient whose nasal dorsum was recon-
ferent from those discussed in other relevant structed with the Libra graft technique. Natural
books. Discussions and improvements are gener- rigorous light from the front was used. There is no
ally about techniques in nose aesthetics. hump from the lateral view, but a 1–2 mm hump
Concerning the nose aesthetic design issue, the at 45°. In the peak view, the fusiform structure
aesthetic concepts of well-known surgeons are can be clearly seen. Libra grafts copy the fusi-
accepted as correct and generally not further dis- form anatomy in natural noses. This issue will be
cussed. Personally, I am entirely against the dor- described in the section on surgery techniques.
sum aesthetic line concept in men and women,
since it has no anatomical basis. This is not a
matter of preventing reverse-V deformity, but of
the reconstruction of the nasal dorsum for correct
anatomical highlight design.
The colors of the sunlight and the skin are
similar. It may not be possible to make a com-
plete assessment regarding the anatomy. During
anatomical evaluation, since the light’s intensity,
arrival direction and our viewing angle are very
variable, the ideal angle for the dorsum aesthetic
lines is the peak angle. In the front view, the
paraflashlight shows the nasal dorsum better than
it is. On the other hand, with a single light source
it appears worse. As the lights wipe out shadows,
it is difficult to assess the dorsum. The dorsal aes-
thetic lines can be seen straight or concave,
according to the assessment and environmental
differences. From this point of view, it will be
wrong to shape the nasal dorsum as straight or
concave. Under more careful observation, we
will see the dorsal aesthetic lines as fusiform due
to the fusiform anatomy under the skin.

Important
In the oblique view, if you see a depression in the
keystone area, but the front view of the dorsum
appears perfect, then probably the studio lighting
improves the appearance. In the oblique view, a
small hump at the keystone level can be natural.
This hump is the result of the keystone region. It
is more obvious and higher in men. Examine the
natural noses at the beginning of this section. Try
to see this detail in noses that you like.
88 3 Nasal Polygons

Patient Example
Pay attention to the patient’s photos after
1.5 years; she had a nasal dorsum reconstruction
with a rib graft. In the oblique view, fusiform dor-
sal aesthetic lines are obtained.

The rib graft was prepared in a fusiform shape.

21 Dorsal Aesthetic Lines 89

Patient Example
Second-year photo of a patient on whom a fusi-
form-shaped rib graft was used. Gunter has deter-
mined the fusiform dimensions and defects for
the nasal dorsum and prepared rib grafts accord-
ingly. The rib grafts I use have concave bases in
addition and fit the defect easily, showing less
visible edges.
90 3 Nasal Polygons

21.1 Summary: Dorsal Aesthetic

Lines

1. The dorsal aesthetic lines are not straight.

2. The dorsal aesthetic lines are comprised of
leaning lines that are narrow at the supra-tip,
wide in the keystone, and narrow again in the
nose radix.
3. The difference between men and women is the
keystone width and keystone position.
4. The keystone is narrower in women and
located exactly in the middle of the nasal
dorsum.
5. The keystone is wider and closer to the nose
radix in men. It is located 3–4 mm higher in
men when compared with women.
6. The nose radix is at the supratarsal level in
men and the eyelash level in women.

In the drawings below, you can see both the

traditional dorsal aesthetic lines at the top and my
description at the bottom. The drawings on the
left show male dorsal aesthetic lines and those on
Important the right show female aesthetic lines.
We should develop a dorsal aesthetic line concept
compatible with the interior anatomy. Faulty con-
cepts will cause a wrong use of technique. We
should correctly understand the nasal dorsal anat-
omy and use more anatomical techniques
accordingly.
21 Dorsal Aesthetic Lines 91

I have selected the example below because the

nose skin is very thin. Examine the dorsal aes-
thetic lines from all angles.
92 3 Nasal Polygons

22 Lateral Aesthetic Lines Examine the same patient’s photos with single
flash on the left and without flash on the right.
Lateral aesthetic lines have also been defined by Abnormal lateral aesthetic lines reveals that the
Daniel. Since he was defining the base, he called nose has undergone an operation.
it basal aesthetic line, but published it as lateral
aesthetic lines.
The lateral aesthetic line points to the groove
in which the maxilla turns to the nose. It gener-
ates the nose’s footprint. This can be changed
with osteotomy. When the hump is removed, the
base becomes wider and can be constricted with
osteotomy. We should operate on the bone only
when knowing the aesthetic rules of this region.
The narrowest part of the lateral aesthetic line
is the level of the medial canthus. It becomes
wider while descending to the alar base. Lateral
aesthetic lines NEVER come down perpendicu-
larly. There are both functional and aesthetic rea-
sons for protecting Webster’s bone triangle.
When we perform low-to-low osteotomy, the If you do not change this approach you will
caudal edge of the bone mobilizes more. I think keep hearing complaints along the lines of “I was
that the bone rises somewhat after most osteoto- breathing better before.” The bone base should be
mies. After an osteotomy, if you infracture the narrowed while protecting a form in which it
base by compressing it with plaster and if the expands from top to bottom.
bone stays in that position, then the nose will Polygons help to examine the topographic
look like a pipe. You can see a sample of patients anatomy. Only reading this book will not be
whose lateral aesthetic lines narrow while enough to understand the topographic analysis.
descending. Draw noses with the help of polygons and aes-
thetic lines. If you do this, you can assess your
patients better before and after the operation. You
will start looking at areas you have never seen
before.
23 The Polygon Model 93

23 The Polygon Model

Nose tip cartilages have a complex three-

dimensional anatomy. Having a correct nose tip
anatomy model can make the surgery easier for
surgeons who are just starting to perform rhino-
plasty. Actually, Gruber’s model for the rhino-
plasty set motivated me to make a model of the
polygon model.
In Gruber’s model, the lateral crus resting
angle has not been shown clearly. Below you can
see a nose model prepared according to the poly-
gon concept. This model describes a surgery that
is performed according to polygon rhinoplasty
logic. Bones were reduced with osteoectomy.
Lateral aesthetic lines were protected. The nasal
dorsum was reconstructed with Libra graft tech-
nique. The nose tip was shaped with cephalic
dome sutures. The scroll facet was generated.
The facet polygon was relieved with an autorim
flap. The Pitanguy ligament was used as a cush-
ion between the septal angle and the dome.
94 3 Nasal Polygons
 Surgery
4

1 Patient Position
and Tracheal Intubation

The patient’s chin should be visible and the tube

should be positioned away from you at a 45°
angle. Be sure that the intubation tube is not pull-
ing the lip. This will prevent interference with
your work. If you place the tube in the midline as
reference, it can slip and mislead you. If the chin
can be seen, you will gain greater control of the
face.

In this section we will describe nasal surgery.

Each description is accompanied by numerous – Place a transparent band on his/her mouth.
photographs corresponding to that specific sub- Your little finger and the suture strand should
ject. Hence, once you read each description, a not enter the mouth. Closing the mouth is a
look at the photos will be sufficient for guidance. suggestion advanced by Ali Teoman Tellioğlu.

© Springer International Publishing Switzerland 2016 95

B. Çakır, Aesthetic Septorhinoplasty,
DOI 10.1007/978-3-319-16127-3_4
96
– A small gauze pad can prevent blood coming
from the mouth.
– Systolic blood pressure should not go beyond
80 mmHg. A stable blood pressure is impor-
tant: If the blood pressure decreases and then
increases, the vasoconstriction effect of the
local solution could decrease.
– After the patient becomes unconscious, spray
pseudoephedrine onto the nasal mucosa; two
puffs for each nostril is enough. I have not yet
tried cocaine for mucosal vasoconstriction.
– Raise the patient 20–30° from the waist and
by laying down the head position the face par-
allel to the floor. Be very careful about the par-
allel position of the face to the floor. The head
position will affect your decisions about nasal
tip rotation.
4 Surgery
– You should have a foot-controlled adjustable
chair. Profile assessment is required fre-
quently. In addition nose tip sutures are per-
formed more easily while seated.
Important
Check the position of the tube from time to
time since the tube can pull at the upper lip
and the nose. Connecting the intubation
tube to the anesthesia circuit with an exten-
sion hose decreases the possibility of such
pulling.
Important
Do not put adrenalin-soaked cotton or
gauze pads into the nose. The pseudo-
ephedrine spray will give the same result.
In order to prevent posterior bleeding, it is
adequate to place a gauze pad on the
tongue. In a complex surgery of this kind, it
is a great risk to forget gauze inside the
patient. Prefer gauze with strings. In my
opinion there is no difference between
pseudoephedrine spray and pseudoephed-
rine-soaked gauze for mucosa vasocon-
striction. I use gauze if there is an active
bleeding in the posterior.
2 Local Anesthesia 97

2 Local Anesthesia 3. Internal valve peak point 0.5 cc,

Infiltrate the local anesthesia, then clean nostril

hair and prepare the patient. In this way you will
have waited 15 min for the local anesthesia to
take its effect without losing any further time. Do
not postpone the infiltration to after patient prep-
aration. You will not gain any time and your sur-
gery will be more bloody.
Formula: Prepare fresh

– 10 cc saline solution
– 5 cc 2 % Lidocaine
– 5 cc Bupivacaine
– ¼ adrenalin
4. Both sides of the maxillary spine 0.5 cc,
While injecting, keep an eye on the patient’s 5. Septum posterior bilateral 0.5 cc,
pulse and blood pressure. If the pulse or pressure 6. An artery passes from the bone mucosa peak
increase, stop the infiltration. point. A 0.5 cc local solution infiltration
there decreases bleeding.
1. Both sides of the septum caudal cartilage 7. Infiltrate 1.5 cc solution into the nasal ridge.
0.5 cc, Making this injection from the septal angle
down to the perichondrium facilitates subp-
erichondrial dissection.

2. Anterior maxillary spine 1.5 cc,

98 4 Surgery

8. To both sides of the upper lateral cartilages 10. Inject 1–2 cc to the septum hump and upper
and the bone near the cartilage 1.5 cc, lateral mucosa planned to be removed.

Important
If you only use Lidocaine, the analgesic
effect decreases after two hours and as the
patient feels pain, his/her blood pressure
increases. If you add Bupivacaine, you will
not encounter any blood pressure increases
due to pain.

Important
Do not inject into the nose too much. This
can result in a loss of the surface details.
9. To the rim incisions and the lateral crura You should be aware of the side effects of
0.5 cc, local anesthetics. A total of 10–15 cc solu-
tion should be sufficient.

Important
I no longer perform infraalveolar and
supratrochlear blocks. Although I control
the injection by pulling on the piston, in
3–4 of my patients I made the injection into
the vessel. The face turned white very
quickly. Now, I make injections only into
the nose.
5 Lighting in the Operating Room 99

Important
In the nasal dorsum dissection, there can be
bleeding from the bone. These are gener-
ally venous and difficult to control.
Infiltration inside the mucosa of the bone in
the region of bleeding with local anesthet-
ics can decrease bleeding.

Now take a break as your nurse prepares the

patient. Adjust your head lamp and scrub.

3 Head Lamp As my nurse prepared the patient and made the

aspirator and cautery connections, I scrubbed and
Closed nose surgery is done with a head lamp. In had the above patient photo taken. You can see
this way you can even see the medial canthal the vasoconstrictive effect of the local infiltration
periosteum. A head lamp with a battery can give solution.
you more freedom to move when compared with
cabled lamps. You can walk around your patient.
This will allow you to assess the patient in the
correct manner, from many different angles.

4 Cleaning

Clean the nostril hair with a blade. Applying

poviodine can facilitate cleaning. Do not struggle
with oiled cream and scissors.

5 Lighting
in the Operating Room

Perform surgery in a brightly lit environment. If

Clean the inside of the nose with a poviodined
cotton bud and wash with saline solution.
the lights in the room are not adequate, turn the
top lamps to the ceiling. Do not point the top
lamps directly towards the nose, or you will not
see the details. I have learned this information
from Micheal Esson, an Australian artist who
attends plastic surgery operations and arranges
workshops for plastic surgeons. He organized a
100 4 Surgery

course in Istanbul in 2009. As Esson said:
“Operating room lights prevent you to see the
form.”
the cheek. These lines guide me while adjusting
the tip position. I determine the amount of steal-
ing from the lateral crus according to these lines.
I determine the correct dome positions perform-
ing the lateral crural steal until the tip rotates to
my previously marked points.

A photo from Esson’s course in Istanbul in 2009.

6 Drawings

For years I have been marking lines on the cheek

that show my new tip point, and this effectively
facilitates my job. Performing surgery without
planning makes me nervous as I want to control
every step. Operating according to my drawings
in Photoshop is safe. I look at shadowed photos.
I mark my planned nose tip on the current nose.
I draw two to three lines that show this point onto
8 Concha 101

reduced. I am performing an outfracture only to

the concha, which can contract sufficiently with
pseudoephedrin spray. If the spray does not cause
contraction, I remove the concha’s bone.
Hypertrophic concha can also cause a relapse of
the septum deviation. Do not cauterize the concha
mucosa. There is no such treatment. It is rarely
successful if you cause necrosis and make it
detach. Cauterization of the mucosa impairs
breathing and usually causes adhesions. Moreover,
it causes large crusts inside the nose, which are
very uncomfortable for the patients. A large con-
cha’s bone is also big. Radiofrequency cauteriza-
tion is a temporary solution. It was performed on
me twice and its effect is only temporary.

8.1 Concha SMR

1. Apply a small amount of local anesthesia to

the big concha and wait for a few minutes.

Important
Do not expand the concha with local infil-
tration. As conchae have a rich capillary
network, this can cause tachycardia or
arrhythmia. A 0.3 cc of local solution is
adequate for conchal surgery.
7 Basic Surgical Steps

1. Concha
2. Nasal dorsum dissection 2. Expand the concha with 10 cc saline
3. Nasal dorsum resection solution.
4. Septum surgery
5. Tip dissection
6. Tip surgery
7. Nasal dorsum reconstruction
8. Nasal tip stabilization
9. Scroll ligament repair
10. Closure of incisions

8 Concha

Compensatory concha hypertrophy due to sep-

tum deviations does not regress when correcting
the septum. Therefore, a big concha should be
102 4 Surgery

4. Cut out the cavernous tissue in between the

mucosa and the bone. This procedure is useful
even when applied to a depth of 3–4 cm only.

3. Cut the head of the concha 4 mm with a sur-

gical blade in a C shape (the body of the C
should look towards the nasal cavity). You
can also start concha surgery by making
elliptic resections starting from the concha
head.
8 Concha 103

5. With a 2-mm chisel, dissect on both sides of

the bone. Turn the chisel 90°, get into the
bone and try to fracture the bone with con-
trolled back and front movements. Aspirate
the free pieces.

6. Take the bone pieces out with a thin punch.

104 4 Surgery

7. Control the bleeding for 5–10 s with electro

cautery. Be careful not to tear the mucosa.

The inside of the concha.

8. With the blunt elevator push on the concha,

folding it to open the nasal airway passage.
Close the wound with a 6/0 Monocryl suture
and put in place the silicon splint.

The procedure is finished without tearing the

conchal mucosa.
8 Concha
Here you can see the airway after the concha
SMR procedure has been completed.
I perform conchal SMR in about 20 % of my
patients. Even if there is a mild deviation at the sep-
tum base, I always remove a 1–3 mm wide cartilage
piece from this area. After osteotomy, in cases with
low resistance, an asymptomatic septal deviation on
the interior can cause total axis deviation after sur-
gery. I make resections from the septal cartilage in
about 90 % of my patients. In septum surgery, I
leave a 1–2 mm space between septum and maxil-
lary spine. I want the periosteum and perichondrial
segments in the intersection of the septum base
bone cartilage to get into this space. I prefer to insert
a silicon splint for two days in cases with concha
and septum surgery. If a procedure has been done
on the septum base, I prefer to cut the silicon. This
increases patient comfort.
105
Note In the picture below, you can see a conchal
bone which was removed in one piece. It is impos-
sible to take out a bone this size without tearing
the mucosa. Therefore, I prefer not to remove the
concha bone in one piece. I included this photo in
order to illustrate how big the conchal bone can
be. You can imagine how this bone could obstruct
the airway. It is more logical to take the concha
bone in pieces. Radiofrequency and laser cannot
reduce the bone in size because they are effective
on cavernous tissue only. Conchae of this size also
have large mucosa. After bone reduction and
bleeding control by means of electro cautery, the
conchal mucosa can be contracted. I have previ-
ously used Tebbett’s technique for excising con-
chal bone and mucosa, repairing with 6/0
Monocryl continuous sutures. This is a time-con-
suming and a difficult technique. The concha
SMR technique satisfies my needs.
106 4 Surgery

8.1.1 Normal Anatomy

This is how the conchal bones are removed

usually.
8.1.2 Inward Collapsed Maxillary
Base

My experience as a patient for my allergic

conchae hypertrophies included electrocautery,
radiofrequency (twice), steroid injections into the 8.1.3 Segmental Outfracture
conchae, acupuncture and concha SMR. I wasted
much time before the concha SMR. The shaver is
not a controlled way of bone removal. It is easier
to take out the bones under visual control. Finally
I had concha bone reduction and outfracture of
the Webster triangle. As a result I can now breathe
much better.
In secondary patients and sometimes in pri-
mary patients, the bone to which the concha is
attached is either infractured or naturally narrow.
If you outfracture a 3–4 mm long segment of this
part with a Çakır V or a 4 mm chisel, your patient
will remember you with gratitude (Webster
triangle outfracture).
9 Nasal Dorsum Surgery 107

Important
In patients with outfracture, the bone
should be supported for at least 4–8 days.

9 Nasal Dorsum Surgery

9.1 Transfixion Incision

Do not make the transfixion incision on the mem-

branous septum, or you will disturb the Pitanguy
midline ligament and destroy the integrity of this
ligament. Make the transfixion incision leaving a
3 mm edge of the septal cartilage on the columel-
lar side. This cartilage can be called the “poste-
rior strut.” Cut the cartilage full thickness with a
no. 11 blade. Cut the periosteum of the anterior
nasal spine. Dissect through the maxillary ante-
rior wall. If the projection of the footplates is
high, dissect anteriorly on the maxilla to decrease
it. This dissection mobilizes the nasal tip. This
also increases your field of vision during nasal
dorsum dissection.
108
9.2 Intercartilaginous Incision
The incision is continued in between the upper
lateral and the lateral crus 1–2 mm above the
internal valve peak point with a no. 15 blade. If
you are a planning a large reduction of the nose,
make the incision 2.5 cm, otherwise a 2 cm length
should be adequate. Incise the mucosa 2 mm
deep. Take care not to cut any cartilage during the
intercartilaginous incision. Closed rhinoplasty
can be done infracartilaginous, without intercarti-
laginous incision. The exposure is smaller, but the
mucosa at the internal valve area heals better.
Note Erol Benlier et al. have published a paper
noting that the caudal part of the septum should
be left adjacent to the Pitanguy ligament and
sutured back to the septum.
Benlier E, Top H, Aygit AC. Management of
the long nose: review of techniques for nasal tip
supporting structures. Aesthetic Plast Surg. 2006
Mar-Apr;30(2):159–68.
4 Surgery
9.3 Entering the Nasal Dorsum
from the Septal Angle
Take your sharp tipped scissor. Separate the pos-
terior strut completely from the septal angle.
After a 3–4 mm separation with your scissors,
head towards the nasal dorsum from the septal
angle. Dissect up to the upper lateral cartilages.
At this point you will see the caudal edge of the
nasal dorsum perichondrium. This is an impor-
tant region, the most appropriate area for getting
under the perichondrium. If your scissors are not
sharp enough, you will have difficulty getting
under the perichondrium.
With your scissors, advance 2 mm under the
perichondrium. Get under the perichondrium
with the Çakır perichondrium elevator and
advance along the midline for 1 cm.
9 Nasal Dorsum Surgery
By moving the elevator sideways, dissect the
perichondrium of the upper lateral cartilages.
Extend the dissection and combine this plane
with the intercartilaginous incision, hence
dissecting the upper laterals completely.
109
Important
It is difficult to get under the dorsum
perichondrium from the intercartilaginous
incision. It is easier to access the subperi-
chondrial plan from the septal angle. When
you arrive at the right plane, dissection will
be faster than with the sub-SMAS plan.
Once you have achieved this, it is likely
that you will find it an indispensable
technique.
In the scroll area, detach the upper lateral carti-
lage and lateral crus from each other completely.
You can see that the upper lateral cartilage peri-
chondrium stays on the skin side without
tearing.
110 4 Surgery

9.4 Subperichondrial Dissection

in the Open Approach

After the columellar incision, enter between the

medial crus without cutting the cartilages. Cut
the superficial SMAS. Open a perichondrium
window on the medial crus and start to scrape
upward.

When putting a small retractor under the peri-

chondrium, the dissection becomes much easier
if you compress the skin and perichondrium
between your fingers, with the retractor pulling
them down. This will also increase your field of
vision.
9 Nasal Dorsum Surgery 111

Continue with the subperichondrial dissection on The Pitanguy midline ligament can be visualized
the lateral crus. easily in the middle when the tip cartilages are
You can begin the dissection from the lateral crus dissected subperichondrially.
and cut the columella later. Some surgeons find
dissection from the lateral crus towards the dome
more practical.

In order to repair it more easily later on, tie

two marking sutures and cut in between them to
reach the septal angle. Find the perichondrium at
the septal angle level and enter beneath it, using
the Çakır perichondrium elevator.
112
Dissect the upper lateral cartilages perichon-
drium by making right and left swiping move-
ments similar to the closed approach.
4 Surgery
When you reach the bone, cut the periosteum and
perichondrium with a blade. There is a sharp
bone corner at the lateral bone defect. You can
scrape that corner with the Çakır periost elevator
and start to elevate the periost easily.
9 Nasal Dorsum Surgery 113

Dissect the bone starting laterally with the Çakır

periosteum elevator. Important
There is a second subperichondrial plane
entering under the bone rack 1 cm caudal to
the septal angle. Find it with your sharp
tipped scissors.

The scroll and Pitanguy ligaments as seen in an

open approach subperichondrial dissection.

Enter beneath this perichondrium with the

perichondrium elevator and dissect it under the
bone for 1 cm forward. With right and left move-
ments, dissect the dorsal cartilages from the over-
lying bone in the midline.
114 4 Surgery

9.5 Periosteum Dissection

Do not try to enter beneath the subperiosteal plane

from the keystone area. This will damage the
periosteum. Take your small retractor and insert it
through the intercartilaginous incision. Using the
Çakır perichondrium elevator, get up to the bone
above the upper lateral cartilage laterally.

Attention
The subperichondrial plane continues
beneath the bone. If you are in the subperi-
chondrial plane, stop when you feel the
bone. Otherwise you will separate the upper
lateral cartilages from the bone laterally.

Make a small incision into the perichondrium and

the periosteum using a blade by feeling the bone.

With this dissection it is possible to leave the

perichondrium at the keystone level on the flap.
At the keystone region the skin is thinner, a rea-
son why we should preserve the soft tissue in this
area.
9 Nasal Dorsum Surgery 115

The dissection starts with the Çakır periosteum

Attention elevator.
After cutting the periosteum with the blade,
be careful when taking the blade out. If you
do not pay enough attention you may easily
cut the nostril or columella.

Visualize and dissect the lateral walls of the bone

using the Çakır periosteum elevator. Do not open
a tunnel without clear visualization. Create a
wide pocket for visual clarity. Dissect until the
maxillary base, the medial canthus and the nose
radix. In the picture below, the maxillary bone
periosteum was cut with a blade.

The periosteum is dissected under wide

visualization.

In this endoscopic view, the cut at the left maxil-

lary periosteum can be observed.
116
I try to dissect the periosteum very delicately.
Dissection of the right nasal bone. The perios-
teum is cut with the blade.
The right nasal bone and maxillary periosteum
are dissected.
4 Surgery
At the sides of the keystone region generally
there is no bone. In this region the cartilage
merges into the bone like a wedge. Carefully pro-
tect the perichondrium in this region. This is one
of the regions in which dorsal irregularities can
be seen most.
9 Nasal Dorsum Surgery 117

Incise the periosteum of the dorsal bone shelf in You can see the transition from the perichon-
the midline. Raise the dorsal periosteum. In this drium to the periosteum.
way, the planes will combine.

Although the periosteum of the nasal bone is

slightly injured, the dorsal periosteum is intact.
A straight tipped elevator is useful in this region.
118 4 Surgery

Here you can see the borders of the soft tissue

dissection. Important
Do not perform the periosteum dissection
without clear visualization. Otherwise the
periosteum will be damaged. Using a little
retractor and head lamp, it is possible to see
and dissect easily up to the nose radix.
9 Nasal Dorsum Surgery 119

There should be no soft tissue in the material

extracted from the nasal dorsum. If you do not
perform a good dissection, after cutting the bone
hump you will have to pull out the bone with a
clamp instead of a bayonet forceps. This is
because of the incomplete dissection of the bone
periosteum. Skin ecchymosis usually occurs at
this stage. A good dissection, however, rarely
results in ecchymosis of the skin. Below you can
see the photos of five consecutive patients after
surgery. In all five of them there occurred an inter-
vention to the bone and the average surgery time
was three hours. Note that dissection, resection
and intervention to the bone have had no signifi-
cant effect on the skin. The last patient’s nose skin
was sensitive because of using oral Vitamin
A. Note the rash on the nasal dorsum.
120 4 Surgery
9 Nasal Dorsum Surgery 121

With this dissection it is possible to elevate the

periosteum all the way up to the osteotomy
borders.

Important
If you are performing a wide dissection for
all nasal bones, do not use the lateral oste-
otomy. The bone can collapse into the nasal
cavity since the bone and periosteum have
been separated completely. Instead you can
perform osteotomy with a 2 mm chisel or
osteoectomy with a Çakır 90 chisel.

Attention
In surgery with correct dissection, ecchy-
mosis of the skin is not common. If it
occurs, you may have damaged the perios-
teum or even the SMAS, or you may have
compromised a vessel during local injec-
tion. If the SMAS and subcutaneous fat tis-
sue are damaged, nasal skin will look shiny
for months. This is the result of inflamma-
tion related to soft tissue injury. If you per-
form a delicate subperiosteal and
subperichondrial, you will not see any shin-
ing of the skin. If the skin shines, this is a
sign that the nose will go on changing.
122
Ahmet Karacalar has used lateral based
perichondrium flaps for coverage of dorsal
irregularities.
Karacalar A, Korkmaz A, Içten N. A peri-
chondrial flap for functional purposes in rhino-
plasty. Aesthetic Plast Surg. 2005 Jul-Aug;29(4):
256–60.
Nazım Çerkeş has also elevated the nasal dor-
sum perichondrium as a flap and repaired it at the
end of the surgery.
Cerkes N. Concurrent elevation of the upper
lateral cartilage perichondrium and nasal bone
periosteum for management of dorsum: the
perichondro-periosteal flap. Aesthet Surg J. 2013
Aug 1;33(6):899–914.
9.6 Why the Subperichondrial
Dissection?
One of the new approaches in this book is the
subperichondrial dissection of nasal tip carti-
lages and the nasal dorsum. I have used this
plane since 2006. This dissection accelerates
nose healing. In addition it has been possible for
me to see, protect and reconstruct the ligaments
that we only see in anatomy papers. For further
reading, see:
Cakir B, Oreroğlu AR, Doğan T, Akan M. A
complete subperichondrial dissection tech-
nique for rhinoplasty with management of the
nasal ligaments. Aesthet Surg J. 2012 Jul;32(5):
564–74.
9.6.1 Subperichondrial Dissection
and Healing
As a rule we have performed subperichondrial
dissection for the septum, resulting in less inflam-
mation and fibrosis. The same principle is valid
for nose surgery. If we damage the muscle and
fatty tissue during dissection, our fears become
real. Progressive thinning occurs in nasal tissue,
the main reason being soft tissue injury. The sim-
plest indicator is shining of the skin in the first
months. If the skin shines, this shows soft tissue
injury with a possibility of changes to the nose in
the long term.
4 Surgery
Important
1. Entering the subperichondrial dissec-
tion is difficult, but dissection is easy.
2. Dissection is easier when a previous
subperichondrial dissection was applied
on that nose. Similarly, once dissected,
the septum can be dissected more easily.
3. Yet, in a sub-SMAS surgery patient, the
subperichondrial dissection plane has
been kept intact. You can perform subp-
erichondrial dissection under the previ-
ous sub-SMAS without any fibrosis.
9.6.2 Subperichondrial Dissection
and Muscle Function
A person with facial palsy breathes with more
difficulty from the paralytic side. The nasal mus-
cle helps keeping the internal and external valves
open. Since the muscle functions stop when the
human dies, the external and internal valves
close. (See “Functional Rhinoplasty”).
The nerves of the facial muscles enter the
muscles from below. A sub-SMAS dissection
plane hence is adjacent to the nerves. Therefore,
if we cause nerve injury, the muscle function
decreases. Another reason for impaired muscle
function is muscle tissue injury itself. If you see
fat in the dissection, then you are progressing
inside the muscles. In addition to the sub-SMAS
dissection damage, our retractors also damage
muscles during surgery.
Seyhan Çenetoğlu calls the muscle function
impairment due to rhinoplasty a “paralytic nose,”
which is an excellent expression. Muscle function
is impaired due to subsequent dissections. In
patients who have had three or four surgeries,
examine the valves and look for their resistance
against inspirium. You are going to see that the
functions of the nose have iatrogenically decreased.
Structural rhinoplasty aims to treat this side effect
by solidifying the nose. If you protect the nose
muscles, your need for structural graft decreases.
If you dissect the nasal cartilages entirely in
the subperichondrial plane, you will never see fat
and muscle tissue.
9 Nasal Dorsum Surgery
Perform surgery in the subperichondrial
plane, the nose is not aware that it is being oper-
ated on.”
9.6.3 Subperichondrial Dissection
and the Camouflage Effect
In primary rhinoplasty, if you think there is a
need for putting acellular dermis or fascia onto
the dorsum, think about your dissection again.
The nasal dorsum perichondrium is a 1-mm-thick
great covering and healing tissue. Do not look for
camouflage material in any other place. With a
little attention paid to dissection and the correct
tools, you can benefit from the advantages of sub-
perichondrial dissection. In the photo below, a
dorsum reconstruction was performed. Examine
the covering tissue of the perichondrium above.
Important
Cartilages are surrounded with perichon-
drium. When you make a sub-SMAS dis-
section you resect the cartilage with the
perichondrium on it. Especially at the nasal
dorsum, the cartilages left over will be in
direct contact with the overlying soft tissue
without the perichondrium barrier.
123
9.6.4 Effect of Subperichondrial
Dissection on Bleeding
This book includes many preoperation patient
photos. I start tip surgery after finishing dorsum
reduction. Examine my dorsal skin surfaces. You
will see very little edema and ecchymosis.
Likewise pay attention to how the surgery causes
very little bleeding. If you perform a subperi-
chondrial dissection, there will only be bleeding
from the mucosa cuts, the Pitanguy ligament dis-
section and the veins from the bones. I rarely use
cautery. Before I started paying attention to dis-
section, I used to see hematoma under some of
my patients’ nose skin. When you pay attention
to dissection and insert a drain, a hematoma will
become a rare complication. Below you can see a
patient with 1 cc of hematoma drainage from the
radix.
9.6.5 Effect of Subperichondrial
Dissection on Ligaments
The Pitanguy and scroll ligaments are in fact
thickenings of the SMAS. These ligaments can
tear if you pass the suture through them. The
perichondrium and sesamoid cartilages on the
other hand are tough tissues adequate for holding
the suture. If you perform a subperichondrial
124 4 Surgery

dissection, you can see the sesamoid cartilages Dissect the cartilage dorsum from the one dor-
attached to the scroll ligament. In sub-SMAS dis- sum with an elevator. In this way you can remove
section, however, these scroll ligaments and the the cartilage and bone dorsum separately.
attached sesamoid cartilages stay on the cartilage
and are cut off with the lateral crura cephalic
resections. The perichondrium is a strong tissue
for repairing the Pitanguy in the open approach.
In the closed approach, however, surgery is done
without cutting the Pitanguy ligament. I use the
sesamoid cartilages while repairing the scroll
ligaments.
As a result, subperichondrial dissection allows
you to protect the ligaments and reconstruct them
effectively.

9.7 Upper Lateral Cartilage

Mucosa Dissection

After separating the upper lateral cartilages from

the septum, it is difficult to dissect the upper lat-
eral cartilage inner mucosa. Upper lateral carti-
lages become extremely mobilized because they
are thin, and while separating the mucosa can be
damaged. Dissect the mucosa of the upper lateral
cartilages before separating them from the sep-
tum. Incise the perichondrium in the mucosal
side of the upper lateral cartilages from the septal
angle using a surgical blade. While holding the
soft tissues with a forceps and stretching them,
open a tunnel with the Daniel elevator. From the
septal angle, dissect the perichondrium of the
septum and take down the internal valve mucosa.
9 Nasal Dorsum Surgery 125

Stretch the mucosa with a forceps. Incise the Dissection of the contralateral upper lateral carti-
inner perichondrium of the upper lateral cartilage lage mucosa.
with a surgical blade.

While stretching the mucosa with a forceps, dis-

sect the mucosa using a Daniel perichondrium
elevator.

After taking down the upper lateral cartilage

mucosa, dissect the septum mucosa subperichon-
drially connecting the septum and upper lateral
cartilage dissection planes.
126
The internal valve mucosa was taken down with-
out damage.
9.8 Dorsal Cartilage Resection
Cut the upper lateral cartilages and the septum
respectively, at the same level. With mild dissec-
tion, the cartilage hump can be taken off easily
since we have dissected the cartilage hump from
the bony hump during dissection.
4 Surgery
If the nasal body is deviated to one side, asym-
metric resections should be made. Less upper lat-
eral cartilage is resected from the deviated and
more from the contralateral side. In the example
below, there is an axis deviation to the left; hence,
more resection is made from the right cartilage
and nasal bone when compared to the left side.
9 Nasal Dorsum Surgery 127

Attention
In deviated noses, less upper lateral cartilage
is removed from the deviated side and more
from the other side. Take out the dorsum
cartilage in one piece. If you are going to use
spreader flaps, you should not make resec-
tions from the upper lateral cartilages.
Separate the upper laterals from the septum
using a blade and fold them inside. I prefer
to use the Libra graft technique if the dorsal
cartilage is strong. I could not achieve strong
dorsal aesthetic lines with the spreader flap
technique when compared with the Libra
graft. If I have to use spreader flaps, I try to
give a fusiform shape to the upper laterals
folding inside. I get the fusiform shape by
suturing tight near the septal angle and loose
in the keystone area.
128 4 Surgery

9.9 Dorsal Bone Resection Left nasal bone is being cut using bone scissors.

When you remove the cartilage dorsum, the bone

will show its slim edges.

1. Cut the bone from both sides with bone

scissors.
2. A few taps to the midline with a 4 mm chisel
will get the bone out easily. It is easy to make
additional 1–2 mm resections using the bone
scissors. You can rasp irregularities. Since the
bones of Turkish patients are thick, it can take
plenty of time rasping.

Below, the right nasal bone is being cut using

bone scissors.

Bony dorsum is removed in this patient without

using a 4 mm bone chisel.
9 Nasal Dorsum Surgery 129

Bone and cartilage dorsum removed with clear

sharp edges.

In the example below, you can see the right and

left nasal bones cut with bone scissors and the
dorsum removed by a 4 mm chisel. Make sure
your chisel is not blunt.
130 4 Surgery

In the example below, there is an axis deviation to important. If the periosteum gets damaged,
the left; more resection is done at the right upper bleeding can occur, leading to glabellar edema.
lateral cartilage and the nasal bone when Tissue injury in the glabella and nose radix area
compared with the left side. cause long-term edema.

9.10 Nasal Radix

If you are going to reduce the nose radix, a curved

8 mm chisel will be sufficient. Removing the
bone via grating is a very controlled procedure.
Take down the radix by making 1 cm back and
forth movements with an 8 mm chisel. A curved
8 mm chisel will grate when moving forward and
not backward. Press the chisel to the bone when
moving forward. Take out the piled bone parti-
cles with bayonet forceps. In order to create a
sharp nose starting point from the radix, a hollow
pit should be formed in this area. Curved nose
radix rasps are unsuccessful for creating this hol-
low radix. In addition, radix rasps can damage
the periosteum and hence expand the glabella.
Protecting the periosteum in the radix area is very
10 Septum 131

It is possible to perform bone resections as shown

in the following photo by pushing the chisel
forward five to six times.

You can use a 90° osteoectomy chisel in the nose

radix area. It removes bone when moving both
forward and backward. Removed bone is like
dust, not in in the form of particles. The removal
is slow but more controlled.

When a posterior strut is created, the cephalic

septum part is very thick and an easy place for
entering the subperichondrial plane.

10 Septum

10.1 Dissection

The caudal part of the septum is tough and there-

fore easy to get under the perichondrium. Incise
the perichondrium with the blade’s blunt side.
132 4 Surgery

Dissect the perichondrium with a thin Cottle

elevator. Important
Do not perform an L-strut septoplasty. The
excess part of the septum is usually the base.

Important
There is usually a group of patients that
come for revision rhinoplasty. The open
approach has been usually preferred, and
the posterior septum cartilage removed via
L septoplasty; aggressive tip surgery was
performed and no spreader grafts were
used. It is not wrong to assume that in these
patients excess cartilage has been disposed
of. I do not know whether L septoplasty is
The Daniel-Cottle elevator was inspired by a den-
taught as a routine step in rhinoplasty such
tist’s tool. By rubbing this ragged tip to the carti-
as lateral crus cephalic excision, but I
lage, you can check whether the perichondrium is
believe these patients were treated wrongly.
there or not.
L-septoplasty is not an effective method for
the correction of septal deviation or axis
deviation treatment. These patients’ axis
deviations generally are not corrected
either. If you plan a revision in these cases,
you now have to harvest rib cartilage. The
excess cartilage storage place should be the
septum. The deposited cartilage size should
be recorded in the surgery note. A more
rational technique is to take only as much
cartilage graft as needed. The excess part in
the septum base usually meets the graft
requirement in 90 % of the patients.

Important
Cartilage presence in the septum is impor-
tant for secondary surgery. The amount of
cartilage available in the septum area can
be determined easily by touching the sep-
tum with a cotton bud while examining
with a speculum and light.

Without removing the excess part in the sep-

tum base, no procedure (not even L-septoplasty)
can correct axis deviation.
10 Septum 133

Do not completely dissect the septum. Only dis-

sect on the two sides of your resection area. If you
need to score the cartilage, dissect accordingly.

Reveal the excess part of the septum, cut it with a

blade and 4 mm chisel and take out the cartilage
with a Cottle elevator and perichondrium eleva-
tor, taking care not to break it.

After removing the curved or excess cartilage,

dissect the maxillary crest periosteum. Do not
dissect completely before resection as you might
hurt the mucosa.

Important
You can cause mucosa tears anytime.
Defects larger than 2 cm heal with diffi-
culty. Repair these tears with a locking
microsurgical needle holder and a slim
tipped bayonet forceps. A 6/0 Monocryl
suture mounted on a small needle is suffi-
cient. It is difficult to suture with big
needles in the nasal cavity.
134 4 Surgery

Dissect the soft tissue with a Cottle elevator. As

the amount of dissection increases, the footplate
height decreases.

Incise the anterior maxillary spine periosteum.

Correct the maxillary spine deviations. Do not try

to centralize it in the midline. The bone is tough
there and would mobilize, and you will have to
resect it. Trim the excess parts on both sides
using a 4 mm chisel or cut the bone with bone
scissors.
10 Septum
Leave a 2 mm space between the septum base
and the anterior maxillary spine. Periosteum and
perichondrial tissue left on the mucosa will fill
the space.
135
Correct deviations of the ethmoid bone.
Attention
It is dangerous to advance too far superior
in this region. If you apply excess force on
the ethmoid bone, it can fracture from the
cranial base and result in CSF leakage. The
ethmoid bone portions that cause breathing
problems and are in contact with the mid-
dle conchae should be resected. There is no
rationale for correcting superior deviations
of the ethmoid bone. Deviations of the eth-
moid and vomer should be resected using
bone scissors to cut little pieces rather than
using a chisel. If the bones are removed in
big parts, they can easily tear the mucosa.
These bones generally have sharp edges
and can tear the mucosa completely when
taken out. In the picture below, note the
sharp edges in the excised vomer bone.
136 4 Surgery

At this stage stabilize the septum to the

maxillary spine midline using 5/0 PDS. Since we
have used blunt dissectors while removing the
excess cartilage from the nasal base, enough soft
tissue remains on the anterior maxillary spine for
this stabilization. If the septum mobilizes later
during surgery, fixing it to the base will become
more difficult. The transfixion incision is a good
incision for fixing the septum to the base. If the
PDS knot remains between the septum and spine
in the 2 mm space, it will not cause any suture
reaction. If the space is bigger than 2 mm, you
can fill this space by tying more knots.
10 Septum 137

When septum surgery is completed, check the

nasal passage. If there is no problem, insert the
silicon splint. When septoplasty is completed,
you should check the nasal passage as it can still
be plugged. Sometimes a bone or cartilage piece
can tear the mucosa and be exposed to the nasal
passage. This kind of spur will not easily be epi-
thelized and can cause bleeding, crusting and
smell in the patient’s nose.

Important
We have already put in the silicon splint at
the beginning of the surgery in patients
who have had a concha intervention. You
can perform septoplasty without removing
the splints. If you have difficulty, then
remove them, finish your septoplasty and
finally insert the silicon back again. If you
insert the silicon at the end of the surgery,
the blood accumulated under the septum
perichondrium can move to the nasal dor-
sum and mobilize the grafts.

10.2 Removing the Septum

The septum should rarely be reconstructed extra-

corporeal. If the septum is broken badly, it is not
logical to repair it inside the nose. It is more rational
to take it out after the septal base and nasal dorsum
resections are complete, because it is more difficult
to make resections from the septum corrected with
grafts. Drawing the silhouette of the septum on the
exterior can be a guideline for us. Spreader grafts,
ethmoid bone with holes drilled and horizontal
mattress sutures can be used for extracorporeal
septum deviation corrections. In my view, this
approach is too aggressive and should be employed
no more than 2–3 times per 1000 patients.
138 4 Surgery

10.3 The “Gummy Smile”

The lips move upwards while smiling; however,

this upward movement is limited by the nose. In
cases with anteriorly placed footplates, I fre-
quently see the “gummy smile” deformity.
Dissection of the periosteum inferior to the ante-
rior nasal spine towards the teeth results in repo-
sitioning the footplates superior to the orbicularis
oris muscle and a barrier to the upper lip move-
ment. Hence the lips do not elevate when smiling
due to the footplates’ positions and reduction or
complete correction of the “gummy smile”
deformity.

10.4 When there is Extreme

“Gummy Smile”

Dissect wider at the inferior of the anterior maxil-

lary spine and fill this space with grafts. If you do
not have enough material for this purpose, break
and use the bones removed posteriorly. Debris
from the lateral osteoectomy material can also be
a great filler for this region.
10 Septum 139

As an alternative, you can plan and design a colu-

mellar strut thicker at the base.
Yet another method could be the placement of
3–4 pieces of cartilage struts 10 × 1 mm in size on
the columellar base.

In the photograph below, you can see bone dust

material removed via osteoectomy with a 90°
angled chisel. This material can be used for fill-
ing the lip nose junction.

Important
Filling under the periosteum inferior to the
maxillary spine can increase nose projection.
Setting the footplates back via dissection on
the other hand decreases projection. The
footplates are generally set back in combina-
tion with the lateral crural steal procedure. It
is important to note that the loss in tip projec-
tion due to dissection of the periosteum infer-
olateral to the anterior nasal spine is much
larger than the gain in projection caused by
filling under the maxillary periosteum.
140 4 Surgery

Here you can see the one year photographs of a 11.1 Narrowing of the Footplate
patient whose “gummy smile” deformity has Polygon
been corrected with this approach.
1. Mark the footplates externally; symmetry is of
great importance.

11 The Footplates 2. Pass a 5/0 Prolene suture through the

transfixion incision under the mucosa, out
The footplate polygon is frequently wide and through the footplate marking.
should be narrowed in most of our patients
because of the septum cartilage getting in between.

Important
In normal anatomy, there is a space between
the footplates and the septum, which is
filled by the Pitanguy ligament. We pre-
serve this anatomy with the help of the pos-
terior strut technique.
11 The Footplates 141

3. Pass the suture back though the hole going 4. Pass the suture back though the needle hole
through the contralateral footplate. under the mucosa and back through the trans-
fixion incision.
142 4 Surgery

5. Tying the knot caudal to the posterior strut

will narrow the footplate polygon.

Important
Footplate suturing results in a lowering of
the footplates since the septum does not get
in between the footplates, hence pushing
them downwards. This results in a lowering
of the nasolabial angle for 3–4 mm. Even if
not planned, one may have to shorten the
septum caudal region at this level. If caudal
resection of the septum is not sufficient,
resection from the maxillary spine should
be performed.
A 4 mm chisel can be used for anterior maxillary
spine resections.
12 Tip Surgery
However, some patients may need this effect.
Suturing the footplates in the patient below will
result in blunting of the nasolabial angle and a
better-looking nostril shape.
143
12 Tip Surgery
Now we have come to the most exciting subject,
i.e. tip surgery. The key point to nasal tip surgery
is to find the correct lateral crural length.
Important
It is not enough to make only cephalic exci-
sions from the lateral crura via the intracar-
tilaginous incisions in the closed approach.
The length of the lateral crura may need to
be changed in addition. Hence, in my opin-
ion, it is not correct to perform rhinoplasty
without visualizing the domes.
1. Sit on your chair. Lower it to the level that can
exactly show you the lateral profile.
2. In the shadowed photo, determine the location
of the nasal tip that you have planned.
Determine the new tip location.
3. Mark the new tip position on the nose of the
patient by drawing three lines that show this
point. Do this before starting the surgery since
the nose shape will change after dissection
and resections. If you have a tip reference
point in surgery, you can make your decisions
more easily.
Important
You may have a wonderful surgical talent,
but you also need a well-trained eye for
aesthetic surgery. You should be familiar
with the beautiful nose and be able to make
the right decisions throughout surgery.
Important
We will begin with tip surgery after finish-
ing nasal dorsum and septal surgery.
Dorsum reconstruction should be done
after tip surgery. If you completely recon-
struct the nasal dorsum prior to tip surgery,
you cannot make the correct tip to dorsum
adjustments. In addition, an early interven-
tion of the nasal base can cause the nose to
swell while working on the delicate tip
adjustments.
144 4 Surgery

12.1 Incision 3. Place a double hook on the nostril peak point

and evert it. Now connect the two incisions. In
If there is no caudally excessive lateral crura, we this way you decrease your chance of making
will cut from the edge of the cartilage (infracarti- a mistake.
laginous incision). If however there is a caudal
excess, we will plan an autorim flap (inferior
intracartilaginous incision).

12.1.1 Infracartilaginous Incision

1. Place the double hooks and evert the nostril tip

with your finger. The lateral crus edge can be
seen. Make an incision throughout the lateral
crus edge for 1.5 cm length and 1 mm depth.
When you get close to the domes, the cartilage
edges can be visualized only with difficulty.
Do not cut here based on chance.

2. Turn the columella with your finger and incise

it throughout the medial crus edge.
12 Tip Surgery 145

4. Make a 3 mm incision mark perpendicular to Caudal resection in thin-skinned patients can

the infracartilaginous incision near the dome. easily cause ala retractions.
In this way you can decrease the chance of
sliding the incision edges at closure. If you
slide the edges of the incision, nostril asym-
metry can occur.

12.2 Autorim Flap

Steven Denenberg has made lateral crural caudal

resections for bulbous tip cases on his website.
This is a powerful technique. I have utilized it as
well.

12.2.1 My Experience

1. In most patients there is caudal excess of the

lateral crura.
2. In thin-skinned patients, direct resections can
cause retractions of the alae.
3. I incised the excess and left it on the mucosa:
some of my patients had asymmetry.
4. Finally I left the cartilage on the skin. I am
happy with this technique and have been using
it since 2012.
5. It is not correct to leave a cartilage more than
3 mm in width. A big cartilage piece will not
rotate towards the nostril. I want the auto-
rim flap to turn inside and support the facet
polygon.

In the example below you can see a patient

with lateral crus caudal resections. In the first-
year postop photos you can see that the tip is well
narrowed, but the facet polygon is not clear.
146 4 Surgery

12.2.2 When to Apply the Autorim

Flap
If the lateral crus polygon is getting over the facet
polygon narrowing the facet region, you should
do an autorim flap. 80 % of my patients have this
indication. Let’s look at the drawings of a thin-
skinned patient. In the oblique view you can
clearly see the caudal edge of the lateral crus
which is curved towards the facet polygon. We
make the incision by leaving this part of the car-
tilage on the skin. You can see the photos of the
patient ten months after surgery. Note the changes
of the facet polygon.
12 Tip Surgery 147

If the lateral crus polygon is facing down, get- To clarify the indications, let’s take a look at a
ting into the facet polygon, and has caused nar- thin-skinned patient. The excess caudal edge of
rowing of the facet polygon, there is an indication the lateral crus can clearly be seen to turn into the
for the autorim flap. Ali Murat Akkuş proposed facet polygon in the operative views.
the idea of classifying the indications for autorim
flap. Therefore we classified 30 of my conse-
quent patients according to the distance between
the lateral crus and the nostril edge:
1 % of the cases had a normal lateral crural
width. 20 % had excess cephalic width. 20 % had
excess caudal width. 59 % had both cephalic and
caudal width excess.
There is no autorim flap indication in the first
two groups. Cephalic trimming is contraindi-
cated in the third group. If you try to correct the
caudal excess using cephalic trimming, you will
create a defect between the upper lateral cartilage
and the lateral crus. If the skin is thin, the lateral
crus will retract cephalically until it contacts with
the upper lateral. Since this will change the alar
position as well, nostril asymmetries or notches
can appear. The autorim flap and 1–2 mm cau-
dal resection will be more appropriate for these
patients. The final group consists mostly of my
cases. The lateral crura are usually convex in
shape. You can treat this group efficiently with
the autorim flap, 0–1 mm caudal resection and
2–3 mm cephalic resection combination. In this
group, if you just perform a cephalic trim, you
will face problems as well.
From left to right: normal, only cephalic
excess, only caudal excess, cephalic + caudal
excess.
148
The incision is placed on the cartilage in order to
keep this part of the cartilage on the skin flap.
The new caudal edge of the lateral crus now cre-
ates a distinct highlight. The autorim flap is left to
the skin and now part of the facet polygon.
4 Surgery
The case below is a case of my own with caudal
and cephalic excess that was treated only with
cephalic resection before starting to use the auto-
rim flap technique. As a result, the nostrils are
retracted.
The case below is another one of my cases with
caudal excess that was also incorrectly treated
with cephalic resection only. As a result, the facet
polygon has not changed. Notice the tip high-
lights being very close to the nostril edges.
12.2.3 Is the Autorim Flap Difficult
to Perform?
The only difficult part is cutting in the right place.
I do not recommend you to use this technique on
your first 100 rhinoplasty patients. When junior,
try to incise a 1 mm autorim flap. You can increase
the autorim flap size as time goes by.
12 Tip Surgery 149

12.2.4 What is the Rationale An additional 2 mm caudal resection was per-

for the Autorim Flap?
All of us resect the curved cephalic piece of the
lateral crus in surgery. However, the caudal part’s
curved portion is left behind. It is very difficult to
designate the lateral crural polygon lower edge
using this curved caudal cartilage. We cannot
have a good light reflection with this cartilage in
the lateral view. It is then logical to leave this
curved piece in the skin. The incised 3 mm cau-
dal cartilage piece is inverted inwards when cut,
creating the autorim flap. Since the autorim flap
is attached to the skin, it is stronger than a normal
rim graft. The remaining lateral crus relax as a
result of horizontal shortening, and bulbosity
decreases. With cephalic resection, the bulbosity
decreases even more. Thus the flat middle part of
the lateral crus is used effectively.
formed. Thus 5 mm narrowing of the lateral crus
was achieved.
Important
In patients with the autorim flap, an addi-
tional caudal resection facilitates angling
of the autorim flap into the facet polygon.
This is not always necessary; however,
some patients require this additional caudal
resection. In patients with thin nasal skin,
you can incise the 1 mm caudal edge of
the lateral crus and leave it attached to the
mucosa to prevent retraction.

Important
Convex lateral crura have a more resistant
shape because of their short cephalic and
caudal curved parts. The autorim flap
technique decreases this resistance, hence
enabling the suture techniques to work
better on the lateral crus.

In the example below, the lateral crura are dis-

sected while creating a 3 mm autorim flap. There
is still caudal excess. Pay attention to the curved
cartilage piece marked on the caudal edge.
The flat region in the middle of the lateral crus is
now available by making a 2 mm cephalic resec-
tion as well. The lateral crura convexity is
decreased easily without the use of any sutures.
150
The domes are relocated 5 mm superiorly.
Here you can see the completed tip surgery.
4 Surgery
Making repetitive cephalic resections for treating
the bulbous cartilage creates nothing but trouble.
A defect is created between the upper lateral car-
tilage and lateral crus. The remaining caudal crus
shows cephalic migration over time, causing alar
retraction. Equal resections from both the
cephalic and caudal parts can prevent this migra-
tion and hence alar deformities. A defect will not
be created between the upper lateral cartilage and
the lateral crus, allowing reconstruction of the
scroll area.
Note that how the autorim flap supports the facet
polygon.
12 Tip Surgery 151

The patient’s lateral crura are close to the nostril

edges. The facet polygon width is not more than
2 mm. Here we will lengthen in a controlled man-
ner the facet polygon using the autorim flap
technique.

3 mm autorim flap, 2 mm lateral crus caudal

resection and 4 mm lateral crus cephalic resec-
tion were planned.

12.2.5 How to Perform Autorim Flap

Evert the nostril wing with a doubled hook, mark
the caudal edge of the lateral crus and the inner
curve 3 mm from the lateral crural edge. Make
the incision from there. Forget the remaining part
and continue surgery as usual. From now on the
caudal piece will behave like a rim graft. At the
end of the surgery, there is a possibility of puffi-
ness in the infralobule polygon in 5 % of the
patients. Stealing from the lateral crus can cause
the tip of the autorim flap which is normally
placed laterally to extend into the infralobule
polygon. In this case, you can shorten the medial
part of the autorim flap 2–3 mm. Surgery using
the in situ cartilages is more controlled and easier
than using plenty of grafts.
152 4 Surgery

Narrow facet polygon. The autorim flap is created from the curved cau-
dal part of the lateral crus.

Desired facet polygon width is marked. The lateral crus caudal edge is marked.

We will let this portion turn inwards. The incision mark is drawn 3 mm cephalic to the
lateral crus caudal edge. This incision will be the
new border of the facet polygon.
12 Tip Surgery 153

A clear 2 mm deep incision is made. The two incisions are connected.

The hook is placed.

The edge of the medial crus is incised.

The nurse gently everts the mucosa using a
forceps.
154 4 Surgery

The cartilage surface is cut with a blade’s blunt Dissection is extended up to the footplates,
edge. while the deep and superficial SMAS planes are
divided.

The subperichondrial plane is entered using

scissors. The domes are connected while preserving the
Pitanguy ligament.

The lateral crus is dissected in the subperichon-

drial plane. You can see the autorim flap left over on the skin.
12 Tip Surgery 155

The caudal edges of the lateral crus are trimmed. A 3 mm cephalic resection is made.

Important
Do not make resections more than 2 mm
from the lateral crus caudally. Generally
1 mm will be enough. The lateral crus
width can be narrowed easily up to 4–5 mm
using the autorim flap and an additional
1–2 mm caudal resection. Therefore, less
cephalic resection will be required.
156 4 Surgery

New dome points are planned. Domes are connected with a figure-of-eight suture.

Cephalic dome sutures are placed. The columellar strut graft is placed.
12 Tip Surgery 157

AC suture is used. Incisions are closed by only stitching the mucosa

without passing through the cartilages.

Important
If your suture is passed through the carti-
lage, the autorim flap cannot rotate into the
facet polygon.

See how the facet polygon enlarges. Our autorim

flap is now inside the facet polygon in between
the two markings.

The suture is passed from the medial crus’ caudal

side and turned back from the caudal edge and
then from the caudal edge of the other medial
crus.
158 4 Surgery

You can clearly see the change in the facet poly- Convexity of the lateral crus has been signifi-
gon when comparing this picture to the preopera- cantly decreased.
tive photograph.

Alar support has also been increased as the facet

The patient’s one-year photos. Clear acceptable polygon size increases.
facet polygons have been created when compared
to the almost indistinguishable preoperative
photograph.

Important
If excessive puffiness is noted on the facet
polygon at the end of the surgery, you can
make a cephalic resection from the autorim
flap.
12 Tip Surgery 159

Case Example
In the front view, note the dome lights get-
ting farther away from the nostrils.

Let’s take a look at some patient examples. Note

the changes in the facet polygons in the photo-
graphs below. In the basal view, the excess on
both domes has been used as autorim flaps.
Remember how many structural grafts are usu-
ally employed to form this triangular shape in the Case Example
basal view. The heights of the dome and the facet poly-
The excessive puffy region of the dome is now gons should be similar. In this example, the
part of the facet polygon as the autorim flap. dome triangle has been shortened and the
facet polygon widened. Ten-month postop
Case Example photo.
In the patient below, you can see the effects
of a decrease in nose tip projection and
use of the autorim flap technique on the
nostrils.
160 4 Surgery

Lateral crus caudal excess has been reduced,

while a strong facet polygon has been obtained.
12 Tip Surgery 161

I have presented the autorim flap technique at the

Turkish Aesthetic Surgery Society in winter
2014. After the presentation I had the chance to
talk to the surgeon Ahmet Seyhan. He told me:
“Barış, the cartilage you left behind gets under
the dome at the end of the surgery due to the steal
and therefore supports both the dome and the soft
triangle. This is an important advantage and you
should talk about this.” I am indeed indebted to
Seyhan. Examine the autorim flap-dome relation-
ship in the drawing below.
162 4 Surgery

12.2.6 The Effect of the Autorim Flap In the example below, you can see the controlled
on the Nostril superomedial movement of the nostrils with the
In bulbous nose tips, we want the nostrils’ peak autorim flap.
points to turn superomedially. Our standard
weapon, i.e. the cephalic resection, can cause nos-
tril retraction. With the autorim flap technique,
the peak points of the nostrils move superome-
dially while the mucosa is sutured. The autorim
flap which was left behind in the rim prevents the
notching while the mucosa is sutured. Below you
can see a patient photo who had 3 mm autorim
flap and 2 mm caudal resection. Note the space
between the lateral crus and the autorim flap.
If this patient did not have an autorim flap per-
formed, notching of the ala could have occurred
when the mucosa was sutured. This is one reason
one could be in need of a rim graft or cutting the
mucosa sutures just to correct the notching at the
end of the operation.

12.3 Lateral Crus Subperichondrial

Dissection

Lateral crus subperichondrial dissection can

sound fantastic, but one may say that it is already
being done in that plane. (See, for example,
Gruber’s comment on the following paper: Çakır
B, Öreroğlu AR, Doğan T, Akan M. Rhinoplasty:
A Complete Subperichondrial Dissection with
Management of the Nasal Ligaments. Aesthet
Surg J. 2012 Jul;32(5):564–74). Subperichondrial
dissection can make use of the autospreader flap
technique easier for the dorsum; however, all sur-
geons say that they are already dissecting in the
subperichondrial plane on the lateral crus. If you
make a true subperichondrial dissection, you can
clearly write on the cartilage, like writing on a
12 Tip Surgery 163

paper with a pen. When you dissect subperichon- 12.3.2 How to Dissect the Lateral
drially on the lateral crus, as in the septum subp- Crus in the Subperichondrial
erichondrial dissection, you can clearly see the Plane
perichondrium on the flap. Since muscle and
perichondrium stay on the cartilage when subp-
erichondrial dissection is not used, your writings
with a marking pen disperse. Subperichondrial
dissection is extremely easy with the correct sur-
gical tools and appropriate technique. It takes
10–15 s to get into the correct plane and dissec-
tion is much quicker.

1. Place the hook onto the mucosa without get-

ting through the cartilage.

Important
If the hook plunges into the cartilage, it can
break it. Because of this, you should use a
hook not penetrating more than 1 mm.
12.3.1 Tools Needed for
Subperichondrial Dissection
2. Your nurse should pull the hook down gently.
1. A 1 mm hook. You can use fine doubled hooks
as well.
2. Perichondrium elevator. Traditional elevators
will not be delicate enough to perform the
subperichondrial dissection. I have used my
own elevators for years. I was buying eleva-
tors and thinning them. Medicon produces
these tools now.
3. Sharp tip long dissection scissor. Use this
scissor for entering the subperichondrial dis-
section plane.
4. Retractor that will compress both the peri-
chondrium and the skin with mild traction.
This retractor should be minuscule as well. A
concave shape will enhance your field of view.
5. Sharp tip forceps. This is used for holding and
stretching the perichondrium. It is needed
when entering the subperichondrial plan for
the first time.
164 4 Surgery

3. Retract the skin to see the cartilage edge using

the sharp tip forceps. Important
4. Cut using the blade until you reach the You may not succeed at first. But remem-
cartilage. ber that you were also disappointed while
suturing your first vein. It is similar to
scraping adventitia with your fingertips.
You will get used to it, so do not give up.
By using the subperichondrial plane, you
can protect the nasal muscles and nerves.

5. When you reach the cartilage, hold the knife

reversely and incise the perichondrium of the
cartilage.
6. Hold the perichondrium and its overlying tis-
sues tightly using the forceps.
7. Try to get into the subperichondrial plane 8. After entering 2–3 mm into the subperichon-
without bleeding by using your sharp tipped drial plane, place in the small retractor, hold
scissor through the long axis of cartilage for a and compress with the ala and stretch it.
length of 2–3 mm.
Important
Perichondrium or cartilage can tear with
sharp dissection. Use a blunt perichon-
drium elevator.
12 Tip Surgery 165

9. While stretching the perichondrium with one
hand, move forward with the elevator in the
subperichondrial plane. The perichondrium
can be dissected easily through the dome. Be
careful about lateral dissection. The peri-
chondrium can tear easily in this region. You
can perform lateral dissection after deliver-
ing the domes.
11. Place the hook closer to the dome and, while
protecting the perichondrium, approach the
dome using subperichondrial dissection.
12. Attach the hook to the dome’s mucosa, cre-
ate traction and move forward by cutting the
tight junctions of the perichondrium to the
caudal side of the lower lateral cartilage.

10. When you come to the scroll region, you can

reach the nasal dorsum dissection plane by
pulling the elevator gently. Connect the two
planes, and the lateral crus will be totally
freed from the skin. Wide dissection of the
lateral crus facilitates redraping of the skin
flap.

Important
If you have done everything correctly to
this point, you will see sesamoid cartilages
attached to the scroll ligament under the
flap. We will use these cartilages for inter-
nal bandaging while closing.
166 4 Surgery

13. After passing the dome, medial crural subp- 14. Apply the same procedure to the other side.
erichondrial dissection becomes easier. After
stretching the nose ala with a hook, dissect
this region with the Daniel elevator.
12 Tip Surgery 167

Important
Cartilage with subperichondrial dissection
applied is softer than sub-SMAS dissection
applied cartilage. 6/0 PDS is enough for
shaping the cartilage.

12.3.3 Subperichondrial Dissection

in Secondary Rhinoplasty
It is possible to perform subperichondrial dissec-
tion on patients who have had surgery before.
This is because surgeries are generally made in
the sub-SMAS, i.e over the perichondrium. This
means you can perform your surgery in an
untouched plane.

Important
In secondary rhinoplasty, if you use the sub-
perichondrial dissection, you will not see
the previous operation’s grafts. In order to
reach the tip grafts, you should cut the peri-
chondrium and reach the sub-SMAS plane.

Important
It can be difficult to dissect the domes in
secondary rhinoplasty. In such cases you
can approach from the medial crus and join
both dissection planes at the dome. Below
you can see the secondary dissection of an
open rhinoplasty patient.
168 4 Surgery

12.4 Delivering the Domes

1. Grab the dome mucosa bilaterally using hooks

while your nurse pulls them equally.
2. Insert the little retractor to allow you to see the
medial perichondrium of the dome.

3. With a sharp-tipped scissor, dissect to the

other dome from the end point of the peri-
chondrium transversely. Do not cut more than
2–3 mm.
12 Tip Surgery 169

4. Separate the superficial SMAS and the

Pitanguy ligaments on the columellar and
infralobule polygons. The superficial SMAS
should stay on the columellar skin.
5. Start splitting the Pitanguy ligament from the
middle while the domes are being held firmly
on both sides. With 2–5 mm of splitting, the
domes will be mobilized and stay out of the
nostrils. With this procedure, the Pitanguy mid-
line ligament can be seen clearly. Do not spoil
the integrity of this system. After having per-
formed 100 rhinoplasties, you will no longer
need to split the Pitanguy to access the tip car-
tilages, and you will not have to suture it again.

Emrah Aslan has introduced a flap from the

Pitanguy midline ligament, using it to control the
supratip skin. Without disturbing the integrity of
the ligament, controlling the supratip skin
becomes easier.
Arslan E, Gencel E, Pekedis O. Reverse nasal
SMAS-perichondrium flap to avoid supratip
deformity in rhinoplasty. Aesthetic Plast Surg.
2012 Apr;36(2):271–7.
170 4 Surgery

Below is an endoscopic view of the dissected sesamoid piece to the septum perichondrium.
Pitanguy midline ligament and the superficial I use the long sesamoid piece for the reconstruc-
SMAS. At position 8 o’clock you can see the left tion of the scroll region.
medial crus, at 10 o’clock the left medial crus
perichondrium and superficial-SMAS, and at 4
o’clock the Pitanguy midline ligament.

Note the vascular structures passing through the

Pitanguy midline ligament.

The Pitanguy midline ligament attaches to the

right and left scroll ligaments. In the middle you
can see the left scroll ligament. Generally there is
one long and another short sesamoid cartilage on
the scroll ligaments. I use the short sesamoid
for internal bandaging by suturing the short
12 Tip Surgery 171

In the photograph below, you can see the left lat- The Pitanguy ligament can be split into two equal
eral crus at 4–7 o’clock, the short sesamoid carti- parts from the midline or close to either dome,
lage at 11 o’clock, the long sesamoid cartilage at but if possible you should not split the Pitanguy
12 o’clock, and the septum at 9 o’clock. The lat- midline ligament at all.
eral crus perichondrium can be seen on the near
side of the long sesamoid cartilage and the peri-
chondrium of the upper lateral on the far side.

In the photo below the Pitanguy ligament has

been separated from the domes without splitting
from the midline.
Note that the Pitanguy midline ligament is a thick
structure similar to the palmaris longus tendon.
172
With appropriate dissection, the lower lateral
cartilages have been delivered from the nostrils.
Important
If you do not sufficiently separate the two
domes from each other, you cannot perform
a lateral crural steal. You should separate the
domes without disrupting the Pitanguy sys-
tem. You should free the cartilages as much
as you are going to change the shape of the
cartilages. If the lateral stealing is not going
to be more than 1–3 mm, a dissection allow-
ing the domes to get out will be enough.
Important
One of the advantages of the closed tech-
nique is to be able to perform surgery with-
out the need to cut the Pitanguy ligament.
In the open approach you can suture the
ligament back. This will have a similar
effect, but you should be careful about a
symmetric alignment.
Tellioğlu has stated that, after repairing the
Pitanguy ligament, the droopy nose rises when
smiling. When we repair the Pitanguy ligament,
we enable the nasal muscles to show their elevat-
ing effect.
4 Surgery
Important
While separating the domes, leave the
Pitanguy system intact for a width of
2–3 mm. When you do an excess splitting,
the Pitanguy ligament can be cut.
Therefore, you should split the ligament
all the way up to the posterior strut. The
tip subperichondrial dissection plane and
the dorsum subperichondrial planes
should not be joined. If the planes join, the
Pitanguy midline ligament can rupture
and escape under the supratip skin, creat-
ing a supratip fullness. This is the main
reason of supratip deformity. Projection
decreases equal to the Pitanguy ligament
thickness (2–4 mm). This is because the
Pitanguy tissue is like a pillow on which
the domes fit.
Important
In thick-skinned, long interdomal distanced
and bulbous noses, only removing the car-
tilage will not be enough. Soft tissue should
be removed as well. Do not assume this
procedure as a skin reduction. If you want
to narrow the nasal tip in such cases, leave
2–3 mm of perichondrium on the Pitanguy
ligament while entering between the
Pitanguy and superficial-SMAS with scis-
sors. Then resect the perichondrium and
soft tissue that you leave on the Pitanguy
ligament. Take care not to disrupt the
Pitanguy ligament during this procedure.
In the patient below, soft tissue removal
from the interdomal space is planned.
12 Tip Surgery 173

The region between the superficial and deep

SMAS was entered such that on both sides 3 mm This perichondrium left below was then resected.
of domal perichondrium is left below.
174 4 Surgery

First-month photos of the patient.

If you have projection problems, you can suture

the perichondrium which you left on the Pitanguy
ligament under the domes instead of removing it.
Thus you will be adding a 2 × 2 mm tissue vol-
ume to the soft tissue pillow.
In the example below, the perichondrium below
the mark was added to the soft tissue pillow
between the domes and the septal angle.
12 Tip Surgery
12.5 Marking and Resections
If you are performing surgery with the closed
technique, always have a marking pen with you.
Do not operate with an imaginary sense of
proportion only. You should always do many
175
markings, and your pen tip should be thin. If the
pen tip is thick, thin it yourself.
1. Enter beneath the domes with an unserrated
pickup forceps and bring the domes together
by creating upward traction in the midline.
Mark the exact contact point. This point will
be the reference point.
2. Check the symmetry of the caudal edges of
the lateral crus and perform caudal resection if
necessary.
3. Using serrated and unserrated pickup forceps
perform a lateral crural steal simulation. Place
a mark on the estimated new dome point.
4. We will shape the tip cartilages with the
cephalic dome suture. Cephalic dome suture
makes the lateral crus rotate towards the
medial. Surplus in the cephalic part of the
176 4 Surgery

lateral crus prevents this rotation. Resection Mark the part that prevents the lateral crus from
that allows rotation towards the medial is rotating inwards and remove it.
enough. More than 3–4 mm cephalic resection
is rarely needed. If the resection is not suffi-
cient for rotation, we will perform an addi-
tional resection from the caudal part of the
upper lateral cartilage. Do not adjust the rota-
tion amount with cephalic resection. In the
photo below, cephalic resection will be made
to the lateral crus.

5. For cephalic resection, you should have a

serrated super-cut scissors. Stabilize the lat-
eral crus with a multitooth forceps, hold your
scissors crosswise and cut the cephalic surplus
of the lateral crus.

Imitate the lateral crus resting angle with a

pickup.
12 Tip Surgery
6. Check whether the remaining parts of the lat-
eral crus are equal.
Examine the determination of the cephalic resec-
tion amount of another patient.
The lateral crus is curved inwards with a pickup.
The part that prevents this rotation is marked and
removed.
Before discussing how to shape the tip with
sutures, I want to turn to another very important
issue. The concepts discussed here will allow for
a deeper understanding of tip surgery.
177
12.6 How Did the Nose
Break Down?
I often investigate my patient’s families.
Sometimes two siblings come for consultation,
one with a wonderful nose with a perfect lateral
crus resting angle nose tip. However, the other
sibling who wants surgery, has a hump, septum
and axis deviations and parenthesis tip. How can
the nose of two siblings be so different? Another
question in my mind is: How can one sibling
have beautiful nose tip polygons, while the other
has a cephalic malposition?
12.7 Observation and Theory
12.7.1 Observations
1. Cephalic malposition occurs more often in
humped noses.
2. Fracture in the vomer occurs more often in
humped noses.
3. Patients with axis deviation and hump have a
trauma history before adolescence.
4. There is a relation between the septal angle
and the position of the dome. The dome is
located at the bisector angle of the caudal
septum and dorsum edges, hence the septal
angle indicates the dome.
178 4 Surgery

5. These patients have weak dome cartilages. The patient’s nose tip cartilages have been
dissected.

6. Sometimes we can see a folding line that is

2–3 mm away from the domes on the lateral
crus. It appears as if the dome should be on Note the symmetric notches 9 mm away from the
that point, but it is in fact on the middle crus. current dome.

Patient Example
12 Tip Surgery 179

Overlap has been applied to the medial crus.

As the coordinates which we have drawn on the

cheek show these notches, the dome was created
on these notches. You can see the finished state of tip surgery. A
steal of 9 mm is very rare. Generally, a steal of
4–5 mm is sufficient.
180 4 Surgery

Below are the patient’s first-month photographs.

12 Tip Surgery 181

7. In some patients, when the footplate setback

and lateral crural steal surgery are completed,
the location of the dome at the beginning of
surgery becomes the columellar breakpoint
now. Examine the example below. The
domes in the first photo have now become
the C point in the second.

12.7.2 Theory

1. All cartilages are connected to each other.

2. Trauma occurs in the vomer as a result of an
impact, and blood circulation increases
because of wound healing in that region.
3. A broken vomer produces more cartilage.
4. Septum cartilage grows up towards caudal
and anterior.
5. As it cannot fit into the nose, it causes right
and left deviations in the nose.
6. Dorsal cartilage is connected to the upper lat-
eral cartilage and pulls it anteriorly as well.
7. Upper lateral cartilage is connected to the
cephalic part of it lateral crus, and because of
this upper cartilage, it
(a) pulls the cephalic edge of the lateral crus
anteriorly,
(b) makes an external rotation in the lateral
crus, and
(c) expands the lateral crus.
8. Septum cartilage moves to the caudal and
8. Most of these patients have a short infralobule pulls the columella to caudal and anterior.
lenght and the nose is affected by depressor The distance between the upper lateral carti-
and orbicularis oris muscles. lage and medial crus increases.
182
9. Footplates expand with the entering of
septum cartilage.
10. Footplates move anteriorly.
11. As depressor and orbicularis oris muscles are
attached to the footplate, they pull the lip
upwards. Muscles cause more movement on
the nose while laughing and talking when
compared with a normal situation.
Example
The photo taken in 2008 is the most important
source of inspiration for me to think about lateral
crus surface problems. While my patient’s nose tip
had a deformity, her sister had a beautiful nose tip.
How can the noses of two siblings be so different?
My patient fell down and broke her nose while she
was a child. Her nose shape was deformed in ado-
lescence. The nose tip seems like a cephalic mal-
position, but the nostrils of the two sisters were the
same. The nostril crease produces the lower edge
of the lateral crus. As a result their lateral crura end
at the same point. Parenthesis view occurs as a
result of lateral crus surface problems and is not
related to the lateral crus long axis. Thus, repairing
surface problems will be more logical than reposi-
tioning the lateral crus.
12. The weakest point of the nose tip cartilages
Examine the patient’s cartilage anatomy. Pay
attention to the relation between the lateral crus
cephalic edge and the anterior-caudal located
septum and upper lateral cartilages. It would not
be incorrect to state that the septum seems to be
responsible for the deformity in the lateral crus.
4 Surgery
Important
In nose tips moving downwards when
laughing, if we diagnose the problem as
strong or short depressor, we have to per-
form a muscle resections. I think that the
problem is the forward movement of the
footplates because of the overgrowth of the
septum. If we dissect the footplates and
move them towards the anterior maxillary
spine, they will not pull so much. I have not
made any depressor intervention for a long
time.
Example
Taking footplates posteriorly is similar to
loosening your dog’s collar. It cannot pull
you anymore.
is the middle crus. As the septum growth is
abnormal, the septal angle goes down and
forward. With the pushing power of the sep-
tum, the lower lateral cartilages bend at the
middle crus which is the weakest point. This
is a possible reason for having very weak
cartilages in the dome. We are not seeing the
real domes, but the middle crura that are
12 Tip Surgery
forced to become the dome by the septum. If
we accept the current dome as real and
resume surgery, we have to insert tip grafts
and perform a lateral crus shortening
procedure.
The tension nose is one of the most fascinat-
ing topics for me. See the following article stat-
ing that most patients have a tension nose:
Johnson CM Jr, Godin MS. The tension nose:
open structure rhinoplasty approach. Plast
Reconstr Surg. 1995 Jan;95(1):43–51.
However, I do not agree with performing a
reprojection (i.e increasing the projection), usu-
ally with grafts. Generally, the total length of the
medial and lateral crus is sufficient for having a
beautiful nose. When we use lateral crus length
for infralobule height—that is, when we perform
a steal from the lateral crus—a graft is rarely
needed for projecting the tip.
12.7.3 Discussion
We should repair the nose in the same way in
which it was damaged. I perform deprojection by
taking footplates to the posterior as described in
the above-mentioned article. However, I perform
reprojection by the lateral crural steal technique,
not by tip grafts.
1. Taking footplates posteriorly removes the
active depressor effect.
2. When you take footplates to the posterior, tip
projection and nose rotation decrease. Thus,
our patient becomes an ideal patient for the
lateral crural steal procedure. This gives us the
opportunity to perform a lateral steal for
patients who have excessive tip projection. We
can also elongate the infralobule in this way.
3. When we perform the lateral crural steal, the
infralobule extends and rotation increases.
4. Stealing from the lateral crus without chang-
ing the position of the footplates just makes
the nose uglier. If you combine the lateral cru-
ral steal with footplate setback, everything
will fit in place. If you do not combine them,
you will never perform the lateral crural steal
or make it less than needed.
183
Important
Consider the issue in the following way:
How can we combine the lateral crural steal
and a footplates setback? Try to imagine the
effects of the following combinations.
– Footplate setback for 2 mm, 3 mm stealing
from lateral
– Footplate setback for 4 mm, 4 mm stealing
from lateral
– Footplate setback for 5 mm, 6 mm stealing
from lateral
– Footplate setback for 3 mm, 5 mm stealing
from lateral, 3 mm medial crus overlap
If we can organize these combinations prop-
erly, tip graft or camouflage techniques will
rarely be needed. If we can understand the
puzzle, we can solve it.
Important
The key point of this puzzle is the lateral
crus length. If we can find the right lateral
crus length, everything else will fall into
place easily and quickly.
Important
Examine the ellipse model. Stealing from
the lateral has several effects at the same
time. Because of mixed results, it is not
very popular. If you can control the lat-
eral crural steal technique, you will rarely
use the tip graft. The lateral crus expands
as it moves away from the dome, and it is
difficult to fix the new dome on this big
cartilage. It is however easier to make a
new dome on the lateral crus which is
narrowed with an autorim flap from the
caudal edge.
184
12.7.4 The Ellipse Model
We first investigated the geometry of the lateral cru-
ral steal technique with my father, who was a math-
ematics teacher, on millimetric paper in 2010.
4 Surgery
He said that this technique can be explained
with an ellipse model.
The Ellipse is a curve on a plane surrounding two
focal points, such that a straight line drawn from
one of the focal points to any point on the curve
and then to the other focal point has the same
length for every point on the curve.
Ali Rıza Öreroğlu has designed and integrated
into an Excel program the mathematical formula
of the ellipse model. We examined the standard
lateral poses of 70 patients, marking the starting
and ending points of the lateral crura on the pho-
tographs. Medial and lateral crura lengths were
measured with Photoshop. Nasolabial angles
were measured. Using the formula Excel pro-
gram, rotation and projection changes related to
the amount of steal were simulated and
examined.
13 Results 185

Thus, the steal procedure cannot increase pro-

jection while the footplates are stable. After
1–2 mm it decreases projection. This result
especially astonished me. I was expecting that
the lateral crural steal would increase
projection.
3. A 1 mm steal from the lateral crus causes an
approximately 8.78° increase in rotation. The
first millimeters create more rotation and there-
after each mm causes less parabolic rotation.
4. Footplate setback changes the axis of the
ellipse and decreases tip projection and rota-
tion (the lateral crural steal performed after
the setback now increases the decreased pro-
jection and rotation).

Important
If you understand the logic of this combi-
nation, you can save your patient’s septum
cartilage from using as a graft. You may
rarely use an onlay tip graft.

5. The amount of stealing from the lateral and

the increase in the height of the infralobule are
equal. This effect is free from rotation and
projection.

Perform the steal from the lateral crus until the

nose tip comes to your desired position. Dissect
the footplates and take back as much as you need.
If the infralobule rises too much or hangs, make a
middle crural overlap as required.

Important
The key point in tip surgery is lateral crus
length.

13 Results Patient Example

1. The lateral crural steal procedure is especially
effective on rotation.
2. The domes are mostly situated in the highest
projection point due to the current nose shape.
This can easily be illustrated with the help
of this patient. You can see the photo of a
patient who has all the problems mentioned
above and her results in the first year.
186 4 Surgery

– Tension nose Nose movement decreased while smiling.

– Axis deviation to the right
– Septum deviation to the left
– Hump
– Thin skin
– Short infratip polygon
– High projection
– The patient’s domes are tight and asymmetric.
These were produced by the middle crura.
– When the patient laughs, the nose falls down,
the depressor is overly active.
– When you look from the basal view, footplates
are active.
– As the nose base stays in front, gummy smile
occurs in this patient.
– Lateral crura are both wide in cephalic and
caudal directions, long and convex. In the view below, the footplates fit into their posi-
– The lateral crus supports the cephalic malpo- tion and infralobule polygon length increases due
sition diagnosis. If you are not sure about to the lateral crural steal procedure.
cephalic malposition in the front views, as I
used paraflash, please see the top views.

Cephalic malposition appearance has disappeared.

13 Results 187

– A strut graft was fixed.

– Osteotomy low-to-low + external transverse.
– A Libra spreader graft was placed.
– Projection control suture.
– Scroll region mucosa was supported by sutur-
ing with dermocartilaginous ligament.
– Excessive mucosa in membranous septum and
internal valve region were resected.

13.2 How to Perform the Footplate

Setback

1. Make a transfixion incision.

2. Make a subperiosteal dissection from the ante-
rior maxillary spine towards the teeth and create
a space for the footplates. When the dissection
increases, the footplates go posteriorly.
3. If this is not enough, then the right and left
periosteum of the spine is dissected.
4. If this is not enough, cartilages and perios-
teum pieces in this region are resected.

Nostril base skin resection is invisible.

13.1 Surgery

– Excision was made from the septum base.

– Deviated vomer was excised.
– Cephalic excision was made from 4 mm lat-
eral crus.
– 2 mm autorim flap.
– Domes were moved upwards by 6 mm. 5. Mucosa surplus in the transfixion incision are
– 2 mm medial crus overlap. Thus infralobule removed.
extends for 4 mm.
– Dissection of depressor and orbicularis oris
muscles and footplates were taken 8 mm pos- Important
terior and nose tip projection was decreased. As most of the patients’ footplates are ante-
– Little contour grafts were put in front of the riorly placed, you may have to do a set-
medial crura. back. Rotation may cause results that are
– With the cephalic dome suture, the lateral crus not natural. Setback and steal combinations
resting angle was corrected. Dog ears that had give better results.
formed in the caudal of the dome were resected.
188 4 Surgery

spine and septum caudal and this lowered nose

projection. Patient is now ready for the steal to be
performed from the lateral crus.

Patient Example
Short infralobule
Anterior localized footplate
High tip projection
Below I am showing where the tip position was
when I started the surgery.

Nasal dorsum dissection was applied and a 4 mm

hump removed. The footplate was set back,
resection was made from the anterior maxillary
13 Results 189

Domes were delivered and markings made. A Nostrils are now smaller, as can be seen in the
steal was made from 6 mm lateral. postop photos.

Patient’s infralobule polygon extends 6 mm.

Our patient’s one-year photos.

Two millimeter medial crus was overlapped and

the infralobule polygon was shortened by 2 mm.
190 4 Surgery

Note Soft tissue edema in maxillary spine region

increases projection. This efffect is not permanent.

Patient Example
The amount of steal from the lateral changes
from patient to patient. Therefore, we are giving
different patient examples.
The following patient’s nose tip is bulbous.
Nose length is long enough to cover the lip. The
13 Results 191

patient has a little hump. The main problem is the We planned both nose shortening and rotation for
length of the lower lateral cartilage. Both lateral this patient.
crus and medial crus are long.

Our patient’s infralobule height is long. I per-

formed a 7 mm steal from lateral.
192 4 Surgery

Eight millimeter oblique medial crus was over-

lapped. The medial crus was shortened by 3 mm,
and a 5 mm overlap was applied. Thus we shorten
both the lateral crus and infralobule polygon of
the patient.

The patient’s one-year photos. For the one-year

photos, see the section of forehead lipo-filling.
13 Results 193

2. Resume folding as the peak point of the

lower lateral cartilage comes to the same
level with the lines marked on the cheek and
mark the identified point on the cartilage.

If you are at the right of the patient make a simu-

lation on the right lateral crus, and vice versa for
the left.

13.3 Lateral Crus Steal

Procedure

1. Curve the dome slowly using two forceps and

find the new dome point.

Important
This should be done after cephalic resec-
tion because there can be a 1–2 mm change
after resection.
194 4 Surgery

Markings on the cheek help to identify the new

nose tip point. Examine the cheek lines below
and tip position at the end of the surgery.

Important
Since a 1 mm steal creates approximately
6–8° rotation, even millimeters are very
Important important. Hence, we draw reference lines
If you are performing a steal only for rota- next to our patient’s cheek.
tion or nose shortening, copy the lateral
crus by stretching it anteriorly. If you are
going to reduce projection, you may have
to steal 1–2 mm more. In this case, copy the
lateral crural steal procedure by placing the
forceps that you have used for folding
1–3 mm posteriorly and steal more. In this
way you will have taken into account the
effect of the footplate setback as well.
13 Results 195

3. If the nose tip is in the midline, use reference

points for the first marking. Measure the dis-
tance between the new dome and reference
point with a beaked tipped scissors. Mark its
tip. Put a mark for the new dome on the other
lateral crus.

You can adjust symmetry in the closed technique.

The dome symmetry test removes the advantage
of open technique tip symmetry. In the dome
symmetry test you can adjust symmetry by bring-
ing the domes together without the help of an
assistant holding the nose tip flap.
4. You should test the symmetry of the new dome.

13.4 Dome Symmetry Test
Create traction on the lateral crus with two for-
ceps. Join the domes in the midline by taking the
skin inwards. The new dome marks should be next
to each other when the cartilages are at the mid-
line. In patients with tip deviation, an asymmetric
lateral stealing procedure should be used.
Otherwise tip deviation does not recover. A lateral
stealing difference of 1 mm between the right and
left dome can cause a 10° middle axis deviation. I
use this geometrical power for correcting tip devi-
ations. The nose tip bends to the more stolen side.
Important
In patients with over-projection, the total
lower lateral cartilage length is more than
normal. In this situation, you should
shorten the lower lateral cartilages from
one point. In the planning of the shadowed
photos of these patients, the new nose
stays inside the nose shadow. In this type
of patients you may predict to perform a
middle crus overlap.
196
13.4.1 From Where Is the Cartilage
Generally Cut?
1. Dome: Cutting there results in sharp edges.
The need for camouflage occurs, and its con-
trol is difficult.
2. Lateral crus: This can create depression in the
nostrils as the area beneath it is empty. You
can cut and slide. In thin-skinned patients, the
sliding point can be seen from the outside.
13.4.2 What Is the Most Reliable Lower
Lateral Cartilage Cutting Point?
This should be the middle crus. The area beneath
is not empty. When you overlap them, they do not
produce puff. Overlap in this region strengthens
the middle crus.
Important
Do not forget that, in approximately
30–40 % of your patients, you should cut
the lower lateral cartilage at one point.
Otherwise, you cannot solve all of the over-
projection problems, or you may cause a
hanging columella. Do not open your
4 Surgery
sutures, as hanging and elongation occurs in
the infralobule after making a lateral steal.
This puffiness will recover simply with
middle crural overlap. Middle crus overlap
is used if infralobule polygon is long or
hanging. In order to lower nose projection,
set back the footplates.
13.5 Cephalic Dome Suture
13.5.1 How I Developed the Cephalic
Dome Suture
I have been using this suture since 2008. When
Gruber published it based on 11 patients in
2010, I realized that I was too late to publish my
results based on 200 patients (hemitransdomal
suture). I was usually performing the lateral cru-
ral steal procedure. In order to make a new
dome, I used the transdomal suture several
times. Of course, these domes were spongy. I
was making trials between medial crus and lat-
eral crus cephalic edges in order to find the right
dome. After a while, I saw that these trial sutures
gave a better shape than the transdomal suture
and therefore never used transdomal suture
again. I asked Gruber at the Vancouver
Rhinoplasty Society meeting whether he used
only this suture, and he usually combines it with
a transdomal suture. More important than who
first used and published this suture is that this
constitutes the most practical technique for giv-
ing domes the triangular shape. In the article co-
authored with Rollin Daniel and referenced
below we have discussed this technique in detail.
The technique was described there as “cephalic
dome suture.” Ali Teoman Tellioğlu has named
it as such.
13 Results 197

Çakir B, Doğan T, Öreroğlu AR, Daniel RK.

Rhinoplasty: surface aesthetics and surgical tech-
niques. Aesthet Surg J. 2013 Mar;33(3):363–75.

“Cephalic dome suture is a simple suture”

1. 3 mm away from the new dome point, pass

2 mm next to the medial crus and lateral crus
cephalic edge and tie the knot. Thus you will
have a dome triangle. This suture has a side
effect: a dog ear at Ti point. This side effect
raises the Ti point.
198
In the place of your cephalic dome suture, carti-
lage can attach tightly to the soft tissue. In this
case, a 2–3 mm dissection of the soft tissue can
facilitate the cephalic dome suture. If you per-
form a subperichondrial dissection, you will
rarely need this procedure.
4 Surgery
Important
I do not fix the nose tip to the septum.
Hence all of the cartilage heights should be
fixed according to the new nose. We make
the rotation by shortening the lateral crus.
Indicator of the rotation is the lateral crus.
13.6 Control 1
Now we should check the nose tip rotation. Fix the
domes simply by using the soft tissue in the medial.
Put the cartilages in place and check the tip rota-
tion. The columellar polygon and the infralobule
may appear damaged, but this can be disregarded.
Now we are only adjusting the length of the lateral
crus. During this test, the medial crus folds inwards
and does not show surplus. When we put addi-
tional cephalic dome sutures and the strut graft,
they may be too long. This problem may make you
think that you have stolen too much from the lat-
eral. If the middle crus extends, the infralobule
extends, too, and becomes hanging. In order to fix
this, you should perform a middle crus overlap.
13.7 Control 2
If you are satisfied with the tip rotation, extract the
domes and open the figure-of-eight suture. Pull the
domes with two forceps anteriorly. The new dome
edges should contact each other at the midline of
the face. If it is not symmetrical, open your dome
trial sutures and take the measurement again.
2. One cephalic dome suture will usually not be
enough. As this suture corrects the lateral
crus resting angle, you need to make position
sutures into the deeper regions. When the
nurse tightly pulls the domes with a hook to
the front and lateral, the caudal edge of the
lateral crus comes into the right position. As
the skin of the nostril pushes the caudal
edges of the lateral crus to the medial, the
resting angle improves. While the nurse is
13 Results
holding the cartilage in the right position, put
the second and third dome sutures to the 5th
and 7th mm, respectively, without squeezing.
Important
Do not forget that the second and third
dome sutures are for protecting the shape in
traction. If you squeeze it, the internal
valve can be narrowed. When the nurse
releases traction, the medial and lateral
crura should be in place.
Note The second and third cephalic dome sutures
are the best technique I know to solve superior
localized lateral crus and hanging medial crus
problems.
Important
The caudal edges of the medial crus and
lateral crus will form the facet polygon.
When you are suturing cartilage, do not
concentrate on the suture, but instead con-
centrate on the shape of the cartilage. I use
suture and graft for giving the aesthetic
form that I want.
3. In approximately 70 % of patients, when you
perform a steal from the lateral, the height of
the middle crus becomes correct. Most
patient’s infralobule is short and stealing from
the lateral increases its height.
199
Note When the position of the footplates is sta-
ble, lateral stealing cannot increase tip projection
by more than 1 mm (see the ellipse model). The
infralobule increases depending on the amount of
stealing from the lateral.
4. If you are sure about the position of the domes,
cut the dog ear related with the first cephalic
dome suture. You can place another cephalic
dome suture here.
Note I have learned this procedure from Teoman
Doğan. Gruber’s article on hemitransdomal
suture does not present much detail. If you do not
correct the dog ear caused by the cephalic dome
suture, you may not resume using this suture.
Until 2009 I was increasing the projection of Ti
points with little grafts instead of removing the
dog ear and decreasing the projection of the Ts
point. Removing the dog ear is a much more
practical method. When you remove it, the load
on the cephalic dome suture decreases. This is
because the lateral crus curves easier for making
the dome.
Important
If the dog ear is obvious and you do not
remove it, the Ts point will be higher than
the Ti point. Placing the Ti and Ts points on
the vertical plane at the same height will
have more aesthetic results. See the tip
breakpoints.
200 4 Surgery

Markings were placed.

Patient Example
The left dome of the patient was shapeless and
the right dome regular.

Cephalic dome suture used on the left dome.

13 Results 201

Important
The cephalic edge of the lateral crus is very
strong in some patients, and the cephalic
dome suture will not be adequate to turn
the cephalic edge of the cartilage. In this
case, a 3–4 mm incision that does not pass
the bottom perichondrium will suffice.

The abnormal dome was made similar to the

normal dome with one suture.

This incision produces another facet which is

2 mm wide in the cephalic part of the lateral crus.
Examine this facet in the polygon model. The
medial part of the scroll ligament will sit on this
section.
202 4 Surgery

13.7.1 Advantages of the Cephalic

Dome Suture

1. Dome triangles form easily.

2. It corrects the lateral crus resting angle.
3. It is a simple technique.
4. As it supports the nostril edges, you will rarely
need a rim graft.

Important
We know that the transdomal suture should
not be tightened too much. One cannot
emphasize this enough for a suture that
gives shape to the most important part of
the nose. Less or more changes from sur-
geon to surgeon. I have seen that even very
famous surgeons squeeze domes with a
transdomal suture. The first suture at 3 mm
is the most important suture that gives
shape to domes. If especially this suture is
tightened too much, the surgeon will not
have the opportunity to adjust the tension
on the knot.

5. It is more controlled.
6. It does not disturb the facet polygon. A graft from the septum was fixed to the left
7. It forms the new dome at a point on the lateral medial crus without passing through the graft
crus easily. Its curving effect is more than the with a loop suture.
transdomal suture.
8. It stabilizes the medial crus and lateral crus by
taking support from them.
9. It solves the hanging medial crus and superior
localized lateral crus problems.

Patient Example
Absence of left lower lateral cartilage. There is
no significant problem in the examination. After
surgery we learned that the patient had suffered a
nasal infection in her childhood. We created a left
lateral crus with the cephalic dome suture.
13 Results 203

The cephalic dome suture was used on the right Note that when you squeeze the graft, a natural
dome. A 3 mm lateral stealing procedure was dome is produced.
applied at the right dome. The length of the defect
at the left medial crus was determined by measur-
ing the other medial crus and marked on the carti-
lage graft.

When the second cephalic dome suture was used,

the free tip of the graft rotated inwards and
formed the resting angle.

Cephalic dome suture was used at equal distance

from the point of the graft.
204 4 Surgery

Tip cartilage was planned because the skin of the

patient was thick and the cartilages were weak.
I usually prefer to use separate grafts for each
dome. But as the left dome was reconstructed
with one graft, a one-piece Peck graft was pre-
ferred. The Peck graft was designed for creating
the dome triangles.

A strut graft was placed.

13 Results 205

One-year photos of the patient.

13.8 Medial Crus Overlap

This is usually done in long and big noses if the

infralobule height is normal. After putting the
dome in its right place, perform this procedure if
necessary. This procedure is irreversible. It is
done in two types, total and partial.
206 4 Surgery

13.8.1 Total Medial Crus Overlap Slide the upper piece onto the lower piece.
Cut the medial crus from the most bulging point. Make sutures with 6/0 PDS to the caudal edge.
Generally this is at a distance of 5–7 mm from the This will be stabilized easily.
new dome. Cut the medial crus with the blade.
Dissect the part under the dome with a blade until
the part that you will overlap ends. Thus it can be
more stable.
13 Results 207

Since the infralobule and columellar polygons

were not repaired, the length of the middle crus is
Important
not obvious in the lateral view. If we like the rota-
Do not cut the middle crura before suturing
tion, we will now treat the middle crus length
the domes.
using the middle crus overlap technique.

Patient Example

A 6 mm steal was performed from the lateral

crus. Cartilages were inserted and the rotation
was checked.
208 4 Surgery

You can see the surplus in the medial crus.

A 4 mm middle crus overlap was performed.

When the infralobule was elongated by 6 mm
with the lateral crus and shortened by 4 mm, the
infralobule became 2 mm longer than before.
13 Results 209

13.8.2 Oblique Overlap Modification

Sometimes a transverse incision in the medial
crus can coincide with the second or third
cephalic dome sutures. In these cases you can cut
the medial crus in an oblique manner. Thus the
contact area increases, and you can perform a
more stable repair. The incision also does not
disturb the cephalic dome sutures.

Patient Example
210 4 Surgery

13.8.3 Partial Medial Crus (Anterior)

Overlap
The partial medial crus or anterior overlap can be
used after the lateral crus steal is applied, if the
infralobule is hanging but not long. If you make a
total overlap, the infralobule height decreases.
Cut the most bulging part of the medial crus until
1–2 mm cephalic is left behind. Make a 2–3 mm
overlap of the caudal edge and suture it. This
procedure repairs the middle crus bulging with-
out shortening the medial crus. After making the
overlap, return to the top of the page and resume
stabilizing the new position of the lower lateral
cartilages using second and third cephalic dome
sutures.

Patient Example
We have a performed lateral crus steal on our
patient, but the infralobule is still hanging. As the
infralobule length was still not sufficient, we
planned to make a partial medial crus overlap.
13 Results 211

13.9 Suturing the Domes

We have formed the dome triangles separately,

and now we are going to join them. Please do not
forget the polygon drawings during these proce-
dures. The nurse should also know these draw-
ings. The nurse will have to hold the domes in the
right position for you to fix them in that position.

1. Get the domes out of the nostril on your side.

2. Place the domes on hooks. Sometimes hold-
ing the dome which is farther away from you
with a hook may be enough.

Important
Do not suture the dome inside without visual-
ization. The joining angle is very important.

3. Bring the domes closer in men at an 80° and in

women at a 100° angle. This space will form
the interdomal polygon.
4. We split the tissue between the domes during
delivering. Repair these tissues with 2 or 3
loop sutures.

We have treated the bulging part without shorten-
ing the infralobule polygon.
Important
Repairing the soft tissue between the two
lower lateral cartilages prevents the move-
ment of nose tip cartilages to the septum.
Thus projection loss does not occur.
Repairing soft tissues increases stabiliza-
tion. In the example below you will see the
repair of a split Pitanguy ligament.

Repair of the tissues between the medial crura.

212 4 Surgery

In the open rhinoplasty below, you can see split

interdomal and Pitanguy ligaments. When these
tissues are sutured they will have a cushion effect
between the dome and septal angle and form a
2–3 mm projection.

The second loop suture is passed closer to the

dome.

The last loop suture is passed just under the

cephalic edges of the dome. This suture equalizes
the domes and prevents them from coming to rest
on top of each other.
13 Results
Now we can open a pocket for the strut graft.
13.10 Columellar Strut Graft
I always use a strut graft. If you use such a graft,
you can stabilize the dome better and form a bet-
ter interdomal polygon. Place the strut graft once
you have repaired the soft tissue between the two
medial crura and the dome. After placing it, we
will fix it with sutures passing from the medial
crus, dome and strut graft.
13.10.1 Where Is the Best Graft
Donor Area?
The strut graft should be thin enough not to fill
the columellar polygon, but it should also be
strong enough. The cartilage removed from the
septum base is a perfect strut graft material, but
the thickness must be reduced before use.
Caudal septal resection material is also appropri-
ate for a strut graft.
213
13.10.2 Strut Graft Placement
1. With sharp tipped little scissors, enter between
the footplates from a point near the cephalic
edge of the medial crus. In this way you will
not damage any artery, nerve or vein.
2. Move forward 3 mm with closed scissors.
3. Open the tip of the scissors for 3 mm and
expand the tunnel. If you open the tip of the
scissors too much, you may hurt the ligaments
and tear the footplate-narrowing suture.
4. Close the scissors and move 3 mm forward.
Repeat this procedure until you touch the
bone.
5. Pull your scissors backwards without com-
pletely taking them out, open the legs of the
scissors and put the strut graft between them.
Do not try to push the strut graft after pulling
out your scissors. This can be a very difficult
procedure.
214 4 Surgery

7. Fix the strut graft by adding a loop suture pass-

Important ing through the cephalic edges of the dome
If you dissect more superficially, you may triangles. Thus you can embed the strut graft
cause bleeding. between the domes. It will remain invisible,
and you do not close the interdomal polygon.

Important
The strut graft should be embedded
between the medial crura. If you do not
leave a space for the superficial SMAS
between the medial crura, your columellar
polygon will become round.

Below you can see the superficial SMAS and

medial crus perichondrium.

Examine the relation between the strut graft and

dome cartilages in the polygon model.

6. With the figure-of-eight suture connect the

caudal edges of the dome. Pass through the
place where the cephalic dome suture passes.

Why not put a loop, but a figure-of-eight

suture? The figure-of-eight suture prevents the
overlapping of the domes on top of each other.
After fixing the strut graft and C’ point, you can
use a loop suture as well. If you first put a figure-
of-eight suture, it will be more comfortable.
Repairing the soft tissues between the domes can
also prevent the overlapping of domes on one
another.
13 Results 215

You can see the domes that have been fixed with Let’s examine another patient example display-
the figure-of-eight suture. Examine the embed- ing the placing of a strut graft.
ding of the strut graft into the top of the inter- Cartilage removed from the septum base was
domal polygon with a loop suture. shaped with a no 11 blade.

Important
Under your flap, you can see the superficial
SMAS tissue that has to enter between the
interdomal polygons. You should remem-
ber the volume of this tissue.

8. A vertical loop suture passing from the edges

of the middle crura can prevent the strut graft
from getting out. It also stabilizes the middle
crus.
216 4 Surgery

A secure pocket was opened with thin beaked While putting the second Pitanguy suture, the strut
scissors. A strut graft was placed beyond the legs graft was fixed into the loop. You can fix the tip of
of the scissors into the tunnel. the strut graft a figure-of-eight suture as well.

The split Pitanguy ligament was repaired with With the middle crural fixation suture, a strut
two different loop sutures. graft was embedded and fixed. You do not have to
pass this suture from the strut graft.

13.10.3 Why not a Loop, but a Figure-

of-Eight Horizontal Mattress
Suture
Pass the suture in the same direction from the
edges of the middle crura which form the infralob-
ule polygon, trying to approach the cephalic side
as much as possible. When you tie the knot, the
strand will form an 8 on the cartilage and fix
the strut graft. This suture prevents the strut graft
from filling the infralobule polygon. The tip of
the strut graft can escape the classical horizontal
mattress suture.
13 Results 217

13.10.4 Dome Caudal Edge Resection

If the tip is wider than you need, you can perform
1–1.5 mm of additional resection from the caudal
part of the dome. Note that the dome triangle
polygon height should not be shorter than 5 mm.
This procedure imitates the domal notch. In thin-
skinned patients dome caudal edge resection
should be performed carefully. More than 1.5 mm
resection will cause a retraction in the facet poly-
gon. A 1 mm dome caudal edge resection was
planned in this case.

Resection was made with a no. 11 blade.

218 4 Surgery

Thus, without opening the tip sutures, the tip 3. If the C’ point is at the level of the nostril, then
width was narrowed by 2 mm. the inside of the nostrils can be seen easily from
the front view. You can see an example below.

13.10.5 Columellar Breakpoint

Reconstruction
The columellar breakpoint (C’ point) is the join- 4. If you place the C point to the anterior of the
ing point of the infralobule polygon and columel- nostril peak point, you can achieve a more
lar polygon. raised nose without showing the inside of the
nostrils.
1. An artificial appearance may occur, if the
columella is smooth from the nasolabial angle
to the tip. In a beautiful nose, the C’ point 13.10.6 C’ Suture
should be clear.
2. In beautiful noses, the C’ point is at the same
level as the nostril peak point.
13 Results 219

2. Return to the beginning. Pass near the caudal

edge of the medial crus.

1. First pass through the strut graft 6 to 7 mm

inferior of the dome with 6/0 PDS, then pass
deeper close to the cephalic edge of the
medial crus and get out. Be sure not to pass 3. Without passing through the strut graft, pass
through the mucosa. from the caudal edge of the other medial crus.
220
4. Enter again towards the strut graft by passing
near the cephalic edge of the medial crus.
5. When you tie the knot, the strut graft is embed-
ded and the C’ point forms. You will have a
columellar polygon looking down and an
infralobule polygon looking 45° downwards.
Important
If you are going to perform a medial crus
overlap, you should do so before the C’
suture.
4 Surgery
If the infralobule and columellar polygons cannot
clearly split from each other despite the C’ suture
passing through the strut graft, you can make a
single interrupted suture. Sutures passing between
the caudal edges of the medial crus prevent super-
ficial SMAS tissue from getting inside. You can
turn this disadvantage into an advantage. As in the
example below, by making a superficial SMAS
tissue puffiness at the level of the primary C’
suture, you can make the C’ point more obvious.
13 Results 221

13.10.7 C’ Graft Above you can see the results of a patient 45 days
In some patients, despite the C’ suture, the C’ after a surgery in which a C’ graft was used.
point will not be obvious. At the end of the sur-
gery, the C’ point can be relieved by cartilage
grafts. A crushed round cartilage graft is appro-
priate for the C’ point. Do not forget that the C’
point is at the same level as the nostril peak point
in the lateral view.
222 4 Surgery

13.11 Infralobular Caudal

Contour Graft

The middle crura are the thinnest part of the lower

lateral cartilages. However, even weak middle
crura can, together with the soft tissue, create a
resistant structure. But dissection makes this weak
region even weaker. If you see folding or weakness
when you put the cartilages in place, you can use
infralobular caudal contour grafts. These grafts can
be used in every region that is injured in cartilage
dissection. If you repair the connections between
the domes, graft indication will be less than 5 %.

1. When you come to this stage you should have

a lot of cartilage on your graft cutting table.
Find thin cartilages that are sized 4–5 mm ×
1 mm.
2. Moisten them and put them on the caudal
edge of the weak middle crus.
3. Pass with 6/0 PDS 2 mm from the middle crus
edge. Do not pass any suture from the graft.
4. Tie the knot and compress the cartilage in
between.
5. You should use a second choking suture.
Choking graft sutures can be also used in
spreader grafts. I have learned the choking
suture from Ismail Kuran.
6. Cut the excess part on the columellar
polygon.
7. Elongate this graft until the Ti point.
13 Results 223

Important
Use thick grafts in thick-skinned noses. Be
careful while working with thin-skinned
patients. Choose grafts that are thinner and
hide them in the infralobule polygon as
much as possible.

Important
If you repair interdomal and Pitanguy tis-
sues anatomically, you will rarely use nose
tip grafts in primary rhinoplasty. I use
infralobule caudal contour graft usually in
secondary patients. If you usually use tip
grafts, I recommend you to consult the
nose ligaments section once again.
224 4 Surgery

Tip height was increased with infralobule caudal

contour grafts. Additionally tiny grafts were
freely placed in the tip.

Patient Example
This patient has had surgery before, and his nose
tip cartilages were deformed.

Photo of the patient after one year.

13 Results 225

Another primary case.

226 4 Surgery
13 Results
Important
If your Ti point is left below your Ts point,
your tip highlights will not be obvious. You
can raise Ti points to the level of the Ts
point with contour grafts.
Erhan Eryılmaz separates the middle crus from
the mucosa and places a graft beneath it. I have
been inspired by him regarding the infralobule
caudal contour graft, but I prefer to place it onto
the cartilages.
Important
In the profile, if the height of the infralob-
ule is adequate but it seems like it has made
an over-rotation, ...
227
1. You may not have removed the dog ear at the
Ts point. You can resect the dog ear.
2. Your Ti point may be far behind the Ts point.
You can raise the Ti point with a middle crural
caudal contour graft.
If you need a 2 mm tip projection, you can
extend the middle crural edge grafts to the caudal
edges of the dome. You will have to place an
additional 6/0 PDS suture. Cut the very end tip of
the cartilages oblique, as they should not be seen.
If you need more projection, you can put Peck
grafts behind the contour grafts, similar to dome
triangles.
In closed rhinoplasty, an onlay tip graft is rarely
needed, because we have protected the Pitanguy
ligament. The Pitanguy midline ligament has a
width of 2–4 mm. This width stays under the
dome and acts as a cushion. It also makes a
2–3 mm projection and protects the mobile nature
of the nose tip. In the photo below, you can see the
thickness of the Pitanguy ligament.
228 4 Surgery

Important
If you are removing the Pitanguy system
and using structural rhinoplasty techniques
such as septal extension graft or tongue-in-
groove, you are choosing the easy way.
You will be able to take the nose tip
wherever you want, but you will have an
immobile nose tip.

Please do not make it difficult for your patient to

kiss or pick his nose.

I compare structural rhinoplasty with making

a construction on the tip of the nose by removing
most of the cartilage in the septum and adding
reinforced concrete. Do not turn the soft tissue/
cartilage ratio in favor of cartilage. The revision
of these patients will be very difficult.
When you start to enjoy the tracing of carti-
lage highlights on the nose skin, you are a closed
rhinoplasty surgeon.
13 Results 229

13.12 Columellar Polygon

Stabilization

You should also stabilize the columellar polygon.

You can do this by starting with 6/0 PDS from
inside and using a continuous horizontal mattress
suture. Needle hooks are very useful while stabi-
lizing the columellar polygon.

Another Patient Example

230 4 Surgery

While using this suture, pay attention to have the

strut graft embedded. The strut graft should be at
least 2 mm cephalic to the caudal edges of the
medial crura, because during dissection we pro-
tected the superficial SMAS behind the colu-
mella skin. We should leave a space for this
tissue to fit in.

Important
For years I have been using 6/0 PDS in tip
surgery. There is no need for permanent
sutures in the tip. Even if you use a PDS,
the knots should remain between the carti-
lages. Mithat Akan who taught me open
surgery is particularly sensitive about this
point: knots should stay inside. Suture
reaction destroys the beauty of the nose
that you have created.

Important
You can use SMAS resections in order to
make the tip facets clearer. If you think that
the facets are depressed, you can fill them
with tiny grafts.
13 Results 231

13.13 Closure of Tip Incisions
When tip surgery is finished, we will close the
infracartilaginous incisions completely and move
on to closing the roof and nasal dorsum recon-
struction. This is an advantage of closed surgery.
You have finished the nose tip but you can con-
tinue the surgery. If the nasal dorsum is high
compared to the tip, you can resect somewhat
more. You can resume septum caudal resections.
If there is no intercartilaginous incision, we will
close the tip incisions at the end of the surgery.
you use an autorim flap you will make less
cephalic resection and the incision will be
stable as there is cartilage in the mucosa
wound edges. Because of this, you will rarely
cut the mucosa sutures anymore.
4. Sometimes the autorim flap is long and causes
bulging in the facet polygon. Rotate it with a
doubled hook and cut the excessive tip. The
autorim flap can sometimes be wider than
desired. In this case, you can make a cephalic
resection from the autorim flap.

1. Close both sides with at least 7 sutures using

6/0 Monocryl.
2. Put the first suture into the region of the inci-
sion next to the dome. We make a perpendicu-
lar 3 mm cut in this region. Take this as the
reference point while suturing.

Important
If you did not draw a mark while making
the incision, close the incision starting
from lateral. With 3–4 mm intervals, suture
towards the dome. In this way the possibil-
ity of sliding will be smaller.

5. Once you have created the autorim flap, pass

3. If you have done the autorim flap, the nose tip
will look better as you suture it back. All of us
have cut our patient’s mucosa stitches and left
them for secondary healing. Because of the
cephalic resection, the lateral crus changes
place, and this will cause alar retraction. If
only through the mucosa while suturing. If
you pass through cartilage, you may fix the
autorim flap to the lateral crura again. We
should allow the autorim flap to rotate freely
into the facet polygon.
232 4 Surgery

13.14 Tip Asymmetry

It is possible to treat asymmetric noses with the

closed technique. Let’s examine the surgery of a
patient who has serious asymmetry in the tip. The
left dome is in an upper and perpendicular posi-
tion while the right dome is located lower and at
an oblique position.

The left middle crus is hanging lower.

13 Results 233

Dissections were made in the subperichondrial

plane and cartilages were prepared.

There is a bulging in the middle of the left lateral

crus. Lateral crus deformities form in very wide
and long crura that cannot fit into their pockets.
After correcting the length and width, you can
correct most of the deformities with the cephalic
dome suture.

Note the curves in the left lateral crus.

234 4 Surgery

Making a wide dissection in the subperichondrial A 2 mm steal was planned from the lateral crus.
plane gives us the opportunity to improve
asymmetries.

There are asymmetries as we predicted before

surgery.

The left dome is 2 mm higher than the right dome.

Also, the right dome is curved more sharply.

The new dome point was determined on the other

lateral crus, while the lateral crura were held
tightly in the midline. We planned a 4 mm steal
from the right dome.
13 Results 235

We used cephalic dome sutures.

We tested to see whether the domes were in the

right place. Cartilages were put back into the
nose and rotation was checked.
236 4 Surgery

Bulging on the left middle crus was corrected

with a 3 mm total medial crus overlap.

If we hold the new domes tight, we have con-

trolled the middle and lateral crus lengths.
Additional cephalic dome sutures were applied.
The Pitanguy ligament was repaired.

A 3 mm total medial crus overlap was applied to

the right middle crus.
Domes were equalized with a figure-of-eight suture.
13 Results 237

A strut graft was placed. The C’ suture was fixed

with columellar and infralobule polygon sutures.
Dog ears that formed in the domes were removed.

Six-month patient photos.

238 4 Surgery

– There is no rotation problem.

– The scroll line is above the normal position.
– The region without cartilage between the
lateral crus caudal edge and alar edge is wider
than normal.

– Since the nostril crease creates a wider bow,

the ala seems wider than normal.

13.15 Cephalic Malpositioning

Ali Teoman Tellioğlu has taught me about this

deformity. Lateral crus repositioning is generally
used for its treatment. We have discussed the rea-
son for this problem in the topographic examina-
tion, under the title of lateral crus polygon. When
the width, length, convexity, caudal surplus and
resting angle of the lateral crus are corrected,
cephalic malposition is also corrected in my
opinion. There is no need to remove the lateral
crus and reinsert it by putting it in a new pocket.
Cephalic malpositioning is defined as the
position of the lateral crura being on a vertical
axis. In droopy tips, the long lateral crura also
acquire a vertical axis. Below you can see the
example of a patient who can be defined as a real
cephalic malposition case.
13 Results 239

Important
In spite of having the anatomy above,
patients with beautiful nose tips have come
to me because of the lateral crus resting
angle. Examine the beautiful nose below.
The lateral crus is on the vertical plane. In
the basal view, you can see that the region
without cartilage looks wider than normal.

Since the lateral crural resting angle is not very

disturbed, alar notching is not noticable in the
basal view.
240
On the other hand, in the example below, although
the starting and ending points of the patient’s lat-
eral crus are the same, the resting angles and
topographic anatomy are different. Since the
right lateral crus resting angle is good, it has sup-
ported the ala in the basal view. However, the left
lateral crus resting angle is disturbed and convex.
Because of this it looks like a cephalic malposi-
tion. If we repair the shape of the lateral crus,
there will be no need for repositioning.
In order to show the deformity better, the left
photo was taken with paraflash and the right one
with a single flash.
4 Surgery
In the photos taken with paraflash, the cephalic
malposition is hidden. Let’s examine the patient
with the most obvious cephalic malposition on
which I operated recently. In the front view,
because of the convexity of the lateral crus, a
shadow is formed behind the convex area, and
this increases the parenthesis look.
Patient Example
13 Results 241

The top view can give better information about

the lateral crus anatomy, independent of flash
equipment.

In the view below, you can see that especially the

left external valve is closed because of cephalic
malposition.

The infralobule polygon is short, the facet poly-

gon narrow, the lateral crus long and wide. The
lateral crus is convex.
242
A 3 mm autorim flap was left behind.
The caudal of the medial crus was cut by 5 mm
and the two incisions were joined. Tip cartilages
were dissected in the subperichondrial plane and
exposed.
4 Surgery
You can clearly see the lateral crus surface
problem. Since the long and wide lateral crus
cannot fit into the nose, it takes a convex shape in
the vertical and horizontal axes. Remember the
nose deterioration theory.
The resting angle is imitated with a forceps. Thus
we can see the caudal edge of the lateral crus
more clearly outside the nose. We will set in the
cephalic edge of the lateral crus, which causes
the appearance of a parenthesis. Thus we will
have a resistance in the horizontal axis. This
resistance will open the external valve.
13 Results 243

We performed a 2 mm caudal resection. The

autorim flap gave us confidence. On thin-
skinned patients, it is possible to cut the 1 mm
caudal excess and leave it attached to the mucosa
as a mucosa autorim flap.

We marked the caudal surplus.

244 4 Surgery

A 3 mm autorim and 2 mm additional caudal

resection caused 5 mm reduction in the lateral
crural width. Therefore only 2 mm of cephalic
resection was enough.

The resting angle was corrected with a cephalic

dome suture.

A 3 mm lateral steal was planned. The height of

the infralobule polygon increased by 3 mm. Wide
dissection of the lateral crus in the subperichon-
drial plane created a relaxation in the lateral crus
topography. The caudal part which is inverted
towards the nostril is used as autorim flap, and as
a result the straight middle part is used.
13 Results 245

The split Pitanguy ligament was repaired. The strut graft was placed.

You can see that the lateral crus polygon was The strut graft was stabilized with a figure-of-
corrected in the photo taken before the complete eight horizontal mattress suture which passes
stabilization of the cartilages. When the resting through the middle crus.
angle is corrected, the parenthesis view disap-
pears. The short infralobule was 3 mm elevated
as a result of a 3 mm steal from the lateral, but
since the infralobule rotated too much, a partial
medial crus overlap was planned. This problem
was solved without shortening the infralobule
with a partial medial crus overlap.
246 4 Surgery

The skin forms its own shape over the years. In

order to change the memory of the skin, the
lateral crus procedure will not be sufficient. Thus,
in order to control the healing process, rim grafts
were placed.

With two 3 mm incisions on the lateral crus,

cephalic pieces were allowed to curve towards
the inside.

While closing the incision note that the cartilage

piece that was curved towards the inside at the
beginning is now inside the facet polygon.

Examine the two incisions that were formed on

the lateral crus caudal side in the polygon model
(scroll facet).
13 Results 247

Examine how the external valve was corrected in

the surgery.

The external valve was opened since the lateral

crus turned to the horizontal axis in the basal
view.
248 4 Surgery

The scroll ligament was sutured to the septum Note the enlargement in the facet polygon with
perichondrium. The skin was convex because of the autorim flap.
the convex cartilages. The skin was fixed onto the
cartilage skeleton when the scroll ligaments were
repaired. This procedure also stabilized the new
position of the lateral crus. The lateral supratip
bulging on the skin was corrected with the scroll
ligament.

The supratip break is controlled by the Pitanguy

ligament.

Scroll lines can be seen clearly in the views from

the top.
13 Results 249

Tenth-day photos.

First-month photos.
250 4 Surgery

The patient was operated again after one year due

to an overprojected tip. The columellar strut was
shortened and the posterior strut released (depro-
jected). Nostril reduction was performed and fat
transfer applied to the upper lids.
Two-month photos after revision.
13 Results 251

13.16 Interdomal Graft

If you resect too much from the cephalic parts of

the domes, the tip can become narrower than
desired. The tip can be widened by means of
interdomal grafts.
Cut the figure-of-eight suture and stabilize the
strut graft with a loop suture between the domes.
If this procedure is not adequate for widening the
tip, you can place additional interdomal grafts
into the loop suture. Grafts that are 1–2 mm wide
and 5 mm long are appropriate for this purpose.
252 4 Surgery

14 Nasal Dorsum

14.1 Setting the Dorsum Height

We performed a nasal dorsum resection before the

tip surgery. After finishing the tip surgery, you
should check the nasal dorsum height. Adjust the
position of the tip with your finger. If the nasal
dorsum is still high, lower it as much as desired.

14.2 Osteotomy

We perform wide dissections until the osteotomy

lines. We work on the bone after the tip surgery
in order to reduce swelling.

1. At the cephalic top of the open roof, remove

the bone triangles and ensure that the roof is
opened until the nose radix, especially in wide
noses. Otherwise the roof will not close easily.
You can use a 4 mm chisel for this purpose. If
you prefer a saw, you have to use it with
caution.

Initially, the mucosa should be completely

dissected.
14 Nasal Dorsum 253
254
2. Considering the lateral aesthetic line, protect
the Webster triangle.
If the base of the nose radix is wide, select
a high-low-low, otherwise a high-low-high.
osteotomy
3. If you have made a wide dissection, NEVER
use a guided lateral chisel: you will lose the
bones.
4. You can perform an osteotomy while visual-
izing the procedure from the intercartilagi-
nous incision with a 2 mm chisel.
5. Perform the osteotomy at the nose radix which
is perpendicular to the bone. In this way the
nasal dorsum can be closed more easily. You
can perform an osteotomy with a 1 mm chisel
also. An internal oblique osteotomy creates
less of a step deformity, but we have to mobi-
lize the bone flaps sufficiently.
4 Surgery
Important
Your chisel should always be sharp. An
Arkansas stone sharpens tools without pro-
ducing dust. Chisels should be cleaned
after this procedure, otherwise permanent
color changes may be formed on the skin
after external osteotomy.
Gryskiewicz JM. Visible scars from percuta-
neous osteotomies. Plast Reconstr Surg. 2005
Nov;116(6):1771–5.
Important
If you perform an inadequate lateral oste-
otomy at the medial canthus level and can-
not do a nose radix osteotomy, then the roof
closes too much at the keystone and the
nose radix remains open. If you do not use
a Spreader graft, you may possibly cause
inverted-V deformity. If we damage the
soft tissues during dissection, we will not
be able to look at the faces of the patients
after two to three years.
14.3 Osteoectomy
I have not performed a lateral osteotomy since
2012. I prefer thinning the osteotomy lines with
the Çakir 90 chisel. Following my explanation,
you should be able to choose your preferred
method.
Important
Osteoectomy feels more controlled in my
hands when compared with osteotomy. Yet,
it takes more time (5–10 min). I am design-
ing tools to simplify this procedure.
Currently I am using a 90°, 5 mm chisel
and a replaceable tipped rasp.
14 Nasal Dorsum 255

An 8 mm chisel is placed.

The bone was inscribed with the tow edges of an

8 mm chisel, by pushing gently five times. You
can see scratches and bone particles on the bone.
I did not perform this procedure for a surgery. I
did it for demonstrating the effect of an osteoec-
tomy on the most visible part of the bone.

You can see the surface of the right nasal bone.

Can we use a rasp?

Using a rasp takes more time, and it is very diffi-
cult to perform nose radix and medial canthus
thinning. I use a rasp for irregularities.
256 4 Surgery

14.4 Osteoectomy Technique 3. Align the edge of the chisel to the osteotomy
line.
1. Dissect the periosteum until the osteotomy
line. This is three to four times more than the
dissection to which we are used. Never insert
a chisel into a non-dissected region. Below
you can see the dissection region and the area
where the osteoectomy will be performed.

2. First, correct the superficial bone asymmetries

with the rasp.

4. Use force on your chisel at the chin-forehead

line level. With your other finger check the
direction of the chisel while protecting the
eye. By pressing gently on it chisel with your
finger, you can control the chisel.
14 Nasal Dorsum 257

6. Bone saw dust will start to accumulate next to

the nose radix and on the tip of the chisel.
Remove it with a Bayonet forceps and collect
it externally. These grafts can be used to fill
the anterior part of the maxilla and to camou-
flage irregularities of the dorsum.

5. Using the edge of your chisel, reduce the bone

thickness by making scratching movements at
the lateral osteotomy line. You cannot do this
procedure with a blind chisel. Straight chisels
are not appropriate for osteoectomy.
258 4 Surgery

Below you can see the endoscopic photos of a Below you can see the bone saw dust that was
patient who had an osteoectomy. The right nasal removed by means of a 90° angled 5 mm chisel.
bone can be seen at the base. Lateral osteoectomy
can be seen at the left, and the transverse osteoec-
tomy area at the right. The bone was mobilized
after approximately 4 mm of osteoectomy. If we
had made an osteotomy, we would have to make
a 4 mm infracture in order to achieve the same
base width.
The left lateral osteoectomy and left trans-
verse osteoectomy regions can be seen below.
Note the bone width (aspirator tip is 4 mm)

14.4.1 Instruments Suitable

for Osteoectomy
I have used a 120° angled 8 mm chisel in 200
patients. None of my colleagues have even tried
this tool because they found it unreliable. Curved
8 mm chisels cut while pulling, and one has to
use force. Hence, it is not a controlled tool. As a
result, I started using a 90° angled 5 mm chisel. I
performed osteoectomy on sheep scapula with a
20° chisel, 90° chisel and piezoelectric tools. As
piezoelectric produces heat, it has to be cooled
with water. Procedures with a 90° angled chisel
seemed like scratching the bone. It scrapes dur-
ing both forward and backward movements and
produces thinner bone saw dust.
The bone saw dust obtained in this way can be
a used as more appropriate graft material. Below
you can see 90° and 120° angled chisels.
14 Nasal Dorsum 259

Patient Example
This patient had left axis deviation. Therefore,
the right nasal base was wider. As a result, more
osteoectomy was applied to the right side. Since
the left nasal base was not very wide, more rota-
tion was given to the 8 mm chisel and less osteo-
ectomy was applied for mobilization.

Right lateral and transverse osteoectomy line.

Let’s examine left lateral and transverse osteoec-

tomy step by step.
260 4 Surgery

A lateral osteoectomy was made for 2 mm. The groove was deepened to have less bone
removal with lateral osteoectomy. Thus bone was
mobilized with less infracture.

Bone saw dust particles.

14 Nasal Dorsum 261

In the model below you can see where the osteo-

ectomy was made.

Nasal passage after the roof has been closed.

7. Move to the nasal dorsum. Press the entire

surface of the 90° chisel to the bone, not only
the edge. With 1 cm back and forward move-
ments, perform a thinning of the lateral walls
of the nose radix (transverse osteoectomy).
This procedure decreases step problems that
occur due to bone mobilization. Examine the osteoectomy areas in the polygon
model.
262
8. Continue the transverse osteoectomy proce-
dure with gentle finger movements until the
roof is closed. We frequently add medial
oblique or transfer osteotomy.
Important
Do not use a finger compress near the open
roof. You may break the naso-maxillary
junction. Instead, do the compression on
the maxillary bone.
4 Surgery
Important
Thin rasps decrease thickness of the base
with 10–15° rotation movement to the lat-
eral. Doğan has been making osteoectomy
with a rasp, and I began to do so after
observing him. I prefer the chisel to the
rasp. Motorized systems or special saws
can be designed for this region. The aim is
to reduce the thickness of the bone, not to
cut it. In this way we can close the roof
without making an infracture.
Important
In patients where less of the dorsum is
removed, the roof will not open until the
nose radix. In these patients, you should
open the roof until the top cephalic region
with a 4 mm osteotome or saw. If we do not
remove bones between these regions, we
cannot narrow the nose radix.
14.4.2 Why Osteoectomy?
Improved Control
In my opinion, osteotomy is the most uncon-
trolled step of nose surgeries. One of my best nose
surgeries started going bad during osteotomy and
the operation was therefore prolonged. I used to
perform osteotomy with great anxiety, because it
was a procedure which I could not see while per-
forming. I was looking for a more controlled pro-
cedure. Bone thickness can change in most
patients. Neither is bone thickness similar along
the osteotomy line. With osteotomy, it is not easy
to perform a greenstick fracture. We can reduce
the bone wherever we want by means of an osteo-
ectomy. Bones are especially thick at the medial
canthus level and because of the bleeding in this
region we may be hesitant. Hence, bones may not
be mobilized sufficiently at the radix and medial
canthus, whereas they are mobilized too much at
the keystone and the caudal margin. This can
cause an open roof and inverted-V deformity.
14 Nasal Dorsum 263

Function Below, you can see the open internal valve of a

I was very much disturbed by osteotomy-related patient whose roof was closed with osteoectomy.
breathing problems. Although I had been protect-
ing the Webster triangle for years, I still had cases
of breathing problems because of infracture.
Bone width at maxillary base can change between
2 and 5 mm. In order to narrow the base by 4 mm,
we should make a 4 mm infracture during the
osteotomy technique. In the osteoectomy tech-
nique, on the other hand, we can achieve the
same result with a 3 mm osteoectomy and a 1 mm
infracture. Bone constitutes the lateral wall of the
internal valve. In my opinion, there is nothing
that disturbs breathing as much as infracture.

Step
As the region in which bone steps occur is thinned
by osteoectomy, a step rarely occurs.

Unsuccessful Osteotomy
In patients with thick bone bases, osteotomy can
be unsuccessful. In some patients the bone is too
long and convex. Especially in the region
described by Webster, the caudal part of the bone
turns towards the septum. Osteotomy has a nega-
tive effect on breathing in these patients and may
even be unsuccessful. As a result, you can use
osteoectomy in these patients.

Bone Surface Problems

It is very difficult to correct bone surface prob-
lems with osteotomy. Osteotomy moves the bone
as a whole, similar to a flap. It is possible to give
shape to the bone by thinning the convex parts
with thin rasps. I do not have full control in
double-leveled osteotomies.

Bruising
Since osteotomy mobilizes the bone too much,
we cannot dissect all of the periosteum. Injury to
the angular artery passing over the osteotomy
line is a common problem and can cause extreme
bruising and edema. As we protect vessels with
dissection to the osteoectomy line, bruising sel-
dom occurs. There will be no need to use ice and
apply cold.
264 4 Surgery

Redrape Problems
With limited dissection, redrape problems occur
less often. Redrape problems can cause wrinkles
on the nose skin in the long term. Nose size can
be reduced more with a wide dissection.

Patient Example
This patient had two surgeries by talented nose
surgeons, yet the open roof problem continues.
The bone base width was 5 mm. You can see
the osteoectomy material. It is not logical to con-
strict the airway by making an infracture to this
much bone. Standard osteotomy did not work on
a patient with such a thick bone.
14 Nasal Dorsum 265

Outfracturing the Nose with Osteoectomy

It may be necessary to widen the nose base due to
breathing problems. If the nose base widens
when we take out the bone with osteotomy, then
osteoectomy is indicated.

The patient below had surgery after two years

because of nose tip deviation. Our patient said
that her breathing was getting worse after the sur-
gery. Therefore, the osteotomy lines were thinned
with a 90° curved chisel and the bone bases were
opened to the lateral. In this way, the airway was
opened without the widening of lateral aesthetic
lines.
266 4 Surgery

Note the amount of bone saw dust removed from In the endoscopic photo below, you can see the
the patient. left lateral osteoectomy line.

Patient Example Bone width in this lateral osteoectomy line was

Our patient had undergone surgery before. I per- measured at 4 mm.
formed the surgery because of the axis deviation
to the left. I used the osteotomy technique in this
patient. In her check-up after 1.5 years, she said
that she was not happy with her nose base and
could not breathe easily. Hence, I performed both
and lateral osteoectomy on her. I applied an out-
fracture in the Webster region.

Bone Massage
In patients who have an infracture with osteot-
omy, bones cannot be opened easily. As the
infracture procedure is not used in osteoectomy
technique, bones can be opened because of
mucosa edema. I ask my patients to press on their
nose bones for 10 minutes every day. I ask them
to start this procedure on the tenth day and to
continue for one month.
14 Nasal Dorsum 267

Reconstruction of the Nasal Dorsum

We will form the fusiform shape of the nasal dor-
sum again. By using the cartilage that we take out
of the nasal dorsum, it is possible to reconstruct it
similar to the original anatomy. There is no need
to take any cartilage graft from the septum.

The splitting and use of nasal dorsum cartilage

as spreader graft was first published by Gürsel
Turgut (Turgut G, Soydan AT, Baş L. A new tech-
nique for creating spreader and septal extension
grafts. Plast Reconstr Surg. 2010 Nov;126(5):
252e–254e).

1. We previously mentioned that, in normal key-

stones, the two sides of the bone shelves have
notches. Nasal dorsum aesthetic lines until
3–4 mm above the keystone region are made
of cartilage. We will imitate the same
anatomy.
268 4 Surgery

Important
During dissection, the perichondrium
which is in the notch region of the keystone
area should be left in the skin. Thus this
region can be well camouflaged. We dis-
sected this region with a blunt elevator in
order to get under the bone. This procedure
protects the soft tissues very well.

2. After removing the hump, the bone edges

will be formed at the anterocaudal parts of
the bone. Bone edges can even be curved to
the medial as a result of bone topography. In
patients where the curvature is extreme, it can
prevent closing of the roof. In normal anatomy,
these bone edges do not exist. There are bone
notches at the two sides of the keystone region,
and these notches are filled with cartilage.
3. Cut the edges of the bone with bone scissors.
The bone triangle to be removed will measure
approximately 3 × 3 × 5 mm. If you do not
remove the corners, the bone becomes more
dominant on the dorsal aesthetic lines.
Handling the bone is more difficult. It is more
logical to imitate the original anatomy. We
will insert the wings of the Libra grafts into
these notches that we formed by removing the
Important
bone corners. In the drawing below, examine
the keystone anatomy. There is a bone shelf in If you are going to make spreader flaps,
the middle and bone notches on the sides. there is no need to remove this bone trian-
Nasal dorsum fusiform cartilage enters into gle. However, if you are going to make
the bone notches. Libra spreader graft, you should remove
the edges of the bones.
14 Nasal Dorsum 269

The Libra Graft

3. Split the cartilage in half with the blade.

1. Place the cartilage you removed en bloc from

the nasal dorsum onto the table, with the nasal
dorsum side facing the table.
2. Apply thinning to the septum with a no. 15
blade, just like the side view of a plane wing.
4. Compress the upper lateral cartilages with for-
ceps and hold them together.
5. You can make additional resections in order to
arrive at a symmetric fusiform shape. As the
septum cartilage will enter the middle of these
two grafts, you should also take into account
the width of the septum.
270 4 Surgery

6. The upper lateral cartilage pieces of the Libra

graft that will be embedded into the two sides 8. Put the tip of the spreader graft into the space
of the septum should be shortened if they are that is formed by the resection of the bone
wide. Do not narrow more than 4 mm. edges.
7. At the cephalic tips of the Libra grafts, resect
the two edges that you are going to embed into
the two sides of septum. If the caudal tip of the
grafts are too wide, you can trim them slightly.
14 Nasal Dorsum
Important
The wings of the Libra grafts, which are 2
mm thick near the keystone region, create an
angle towards the anterior, as a result raising
the nasal dorsum by 1–2 mm. Because of
this, you should remove 1–2 mm more from
the septum in the keystone region. Hence,
you will form a nasal dorsum groove in which
the nasal dorsum perichondrium will fit.
Important
If you do not remove the bone edges, Libra
grafts cannot fit due to the bones, and this
may form protrusions at the nasal dorsum.
The same is valid for Sheen spreader grafts.
271
Nasal Dorsum Control
At this point sit on your stool and scrutinize
whether the Libra grafts fit into their places.
Examine your nasal dorsum profile. Libra grafts
should be fitted in the lateral view without creat-
ing a hump. Raise yourself until you align the
nose tip with the cheek. In the oblique view, be
sure that the small hump formed by the Libra
graft on one side is in the same position and has
the same size on the other side. This angle gives
us information regarding the nasal dorsum aes-
thetics. You have to see a parabola that falls in the
nose radix, elevates at the keystone and falls
again at the supratip region.
272
8. If you are happy with the nasal dorsum width
and position of the grafts, stabilize them.
9. Generally two fixing points are enough. First
execute a loop suture near the anterior angle.
Second is a horizontal mattress suture at the
caudal. This suture allows you to make addi-
tional resections if necessary. If you are
removing cartilage from the Libra graft or
septum, you will not be cutting any sutures.
10. Check again the heights of the upper lateral
Important
Do not pass the first loop suture through the
11. Suture the upper lateral cartilages to the
Libra graft. It should only pass through the
septum cartilage. When you tie the suture,
the cartilages are being squeezed and stabi-
lized. This is a very good method for stabi-
lizing small grafts.
4 Surgery
Important
If you do not suture the edges of the Libra
graft to the upper lateral cartilages, the
internal valve mucosa can swell and widen
the roof. For suturing Libra grafts to the
upper lateral cartilages, 6/0 PDS is appro-
priate. Moreover, this can facilitate dissec-
tion in secondary surgeries.
Important
There are many layers between mucosa
and skin. If mucosa has approached the
skin due to surgery, sympathetic system
effects such as abnormal sweating can be
seen as a result of innervation disturbances.
Be sure that the mucosa is embedded in
your surgery. Mucosa should be dissected
at least 1–2 mm inwards from the open roof
bone border.
cartilages.
Libra grafts from caudal to cephalic with 6/0
PDS. Go back and tie the suture. If you
suture the stitch continuously by taking from
right and left, respectively, your suture will
be more stable. Because of the continuous
suture, you do not need to tie a knot deep in
the tunnel.
14 Nasal Dorsum 273

Examine the harmony between the Libra

grafts and the upper lateral cartilages in the poly-
gon model.
274 4 Surgery

If you are used to spreader grafts, try the Libra

Important
In the first article on splitting and using of
this cartilage, the cartilage was split in the
original position before use. The upper lat-
eral section of cartilage fits the nasal dor-
sum. In Libra grafts, the septum side of the
cartilage fits the nasal dorsum.
graft. It is an easy technique.
Sheen spreader grafts can be shaped similar to
Libra grafts. Alan Landecker has also discussed
this shaping. But keep in mind that the cartilage
hump is the best donor region for this graft.
Shaping the hump cartilage as below is much
easier.

Why do we rotate it by 90° instead of insert-

ing it in the original position?
Nasal dorsum cartilage is generally not
straight in the lateral view in patients with a
hump. If we split it in the original position, it may
not fit completely into the two sides of a straight
septum. Moreover, upper lateral cartilages
become very thin as a result of splitting.
When the septum side of nasal dorsum car-
tilage is used…

1. We obtain straight spreader grafts in the lat-

eral view.
2. As septum is a thicker cartilage, we receive a
more stable nasal dorsum. The upper lateral Patient Example
cartilage parts of the Libra graft that are Below is the one-year photo of a patient who had
embedded into the two sides of the septum a Libra graft. Note the parabolic nasal dorsum
hold the grafts stable. Since they are not thick aesthetic line in the oblique view. Nasal dorsum
like the embedded parts of Sheen spreader aesthetic lines have been formed in a natural way.
flaps, they do not pop out when we stroke the
edema of the nose. Furthermore, they never
cause extra thickness at the internal valve area,
as the Sheen spreader graft does. Below you
can see the upper lateral cartilage of the left
Libra grafts embedded next to the septum.
14 Nasal Dorsum 275
276 4 Surgery

14.5 Bone Dust and Cartilage Paste

In the long term I have seen collapse and irregu-

larities in the dorsal bone polygon in some of my
patients. Nasal dorsum irregularities can be seen
more frequently if the periosteum is damaged
during the nasal dorsum bone dissection.

1. Protect the periosteum during dissection. Do

not think that you are already protecting it
anyway. It is very difficult to protect the peri-
osteum with a blind dissection and the wrong
tools (round tipped elevators do not fit the
bone). You can protect the periosteum better
by visualizing, getting into the planes laterally
and joining them in the middle, as well as
using curved straight tipped elevators. The
Daniel-Çakır elevator is particularly useful.
2. There can be a 1–2 mm bone distance even if
we close the roof. These spaces cannot be
seen during surgery because of skin edema,
but become visible after 1–2 years.

Grind bone dust from the bone which was taken

out of the nasal dorsum by scratching it with a no.
11 blade. You can mix it with blood. If you com-
press the bone dust with gauze to take out the
water, you can see the real amount of bone dust
which does not expand (Volkan Tayfur, reported).
I have satisfactorily used bone dust since I learned
about its usage from Fethi Orak.
14 Nasal Dorsum 277

Important
Work wet while scratching with the knife,
so that you can keep bone dust together.

3. Place the bone paste at the end of the surgery.

Otherwise it may disperse on both sides of the
bone.
4. If the amount is not enough, you can increase
the volume by dicing cartilage.

From another patient, you can see bone dust which

was taken out by means of lateral osteoectomy.
278
5. If you want a more stable graft, you can use
coagulated blood. You can place it in the
nasal dorsum retractor and insert it thus.
Mithat Akan obtains a single-piece graft by
mixing it with blood.
Öreroğlu AR, Çakır B, Akan M. Bone dust
and diced cartilage combined with blood glue: a
practical technique for dorsum enhancement.
Aesthetic Plast Surg. 2014 Feb;38(1):90–4.
Below you can see bone dust particles that
have been gathered by an osteoectomy performed
with a 90° angled chisel. As the bone pieces in
this saw dust are very small, they can be used in
the nasal dorsum. If you are using the osteoec-
tomy technique instead of osteotomy, bone dust
collected from the two sides will be enough for
dorsal camouflage.
4 Surgery
Important
If the perichondrium is not dissected cor-
rectly, at some point it can take on the form
of a flap and cause irregularity in the nasal
dorsum. If you have not been able to obtain
a flat nasal dorsum line, even though sep-
tum cartilage and bone are in good shape,
then check the bottom of the flap.
Important
If we allow the bones to shape the nasal
dorsum in patients with significant axis
deviation, achieving a proper nasal dorsum
will be very difficult. If the bones are too
deformed, taking 1–2 mm and raising this
area by 1–2 mm with cartilage and bone
graft will make things easier.
14.6 Short Nasal Bones
In patients with short nasal bones, most of the
nasal dorsum consists of cartilage. In these
patients, the resected nasal dorsum cartilage is
longer. Because of this, Libra grafts prepared
from this cartilage will be longer. With the Libra
graft technique, the responsibility of the surgeon
for determining the patient’s need of a spreader
graft length is reduced. In short-boned patients,
most of the keystone consists of Libra graft. There
is no need for making a transition from bone to
cartilage. As the bone has less contribution to the
roof, it becomes possible to finish surgery with-
out performing either osteotomy or osteoectomy.
Patient Example
In nasal dorsum resection, it has been noted that
most of it consists of cartilage. The hump was
corrected despite the removal of very small
amounts of bone.
14 Nasal Dorsum 279

Below you can see the cartilaginous hump. Note

that it is longer than normal. As the bone roof did
not open, osteoectomy was not performed.

First-month photos of the patient.

Libra grafts prepared from long cartilage were

also long. A nasal dorsum bone polygon formed
by bones was formed, just like the original anat-
omy using cartilage.
280 4 Surgery

14.7 Dorsal Reconstruction in Men

In men, the keystone is much wider and closer to

the nose radix when compared with women. This
issue has already been discussed in the chapter on
aesthetics. In male patients, longer nasal dorsum
cartilages are obtained, similar to patients who
have short bones. In these patients, longer Libra
grafts are prepared. The widest part of the Libra
graft which will constitute the keystone region
must be made wider than that of women.

Patient Example
Examine the location and shape of the keystone
region.
14 Nasal Dorsum 281

The cartilage hump of the patient. 14.8 Stabilization of the Nasal Tip

We have adjusted the lateral crus height accord-

ing to the tip position. By protecting the dynamic
structure of the nose tip, we will fix it to septum.

1. We have left 1 mm cartilage from the septum

attached to the Pitanguy midline ligament
(posterior strut).

When cartilages are split, the part of the Libra

graft that constitutes the nasal dorsum cartilage
polygon is longer than normal.

Important
The Pitanguy system gives shape to the nose
skin. In patients whose supratip region is
high, I shorten the Pitanguy ligament to give
tip definition. On the other hand, in the open
technique, I repair it with overlap. Shortening
the Pitanguy ligament is an effective tech-
nique, but managing it is very difficult. It is
difficult to talk about the long-term effect of
plication which was performed in soft tissue.
Moreover, a shortened Pitanguy ligament
can fall to the right and left of the septum.
Although it is very effective, it is not so easy
as to become a popular procedure.
282 4 Surgery

I have not made any Pitanguy ligament plica-

tion ever since I started using the posterior strut
technique. When I make the transfixion incision
through the septum, the integrity of the Pitanguy
system is protected better. My need for plication
might have disappeared for this reason.
1 mm. While performing the loop suture,
put it at a distance of just 1 mm from the
septum cartilage. A posterior strut of
1–2 mm width will not find any space for
moving to the right or left of the septum.

2. Stabilize the posterior strut to the caudal sep-

tum with 5/0 or 6/0 PDS.
3. Sit down and check from lateral.
4. You can perform an additional resection from
the caudal septum if necessary.
5. According to your projection, you can stabi-
lize the posterior strut graft more posterior or
anterior. Generally, the peak of the posterior
strut is at the same level as the new septal
angle. Thus, the dorsal resection amount at the
septal angle is the same as the deprojection
amount. Note that the posterior strut has a
connection with the supratip SMAS. Hence,
we also deproject the supratip area.

Note The bisector of the septal angle shows the

nose tip. You can follow the septum caudal resec-
tion from the line drawn from cheek.

6. When the posterior strut is in the correct posi-

Important
tion, apply 3–4 additional stitches.
When passing the needle through the pos-
terior strut graft, if you pass underneath the
perichondrium that lies on the other side of
Important
the cartilage, you will decrease the rotation
If the posterior strut is wider than 1 mm, it
possibility of the cartilage on both sides of
will be difficult to fix it to the septum. It
the septum. You may try a double loop, a
can fall to the right or left. After the trans-
figure-of-eight, or a mattress suture. I could
fixion incision we performed a thinning to
not yet find a perfect way to fix this.
14 Nasal Dorsum 283

7. Identify the excess mucosa in the membrane-
ous septum. By stretching the mucosa with
5/0 Monocryl, stabilize the septum mucosa to
the septum cartilage with one loop suture.
8. Remove excess mucosa.
Important
If you have made the subperichondrial dis-
section in the septum caudal, the membra-
nous septum mucosa will be very thick. If
you do not remove this mucosa, you can
encounter breathing problems or hanging
columella problems. In nose shortening
and reduction procedures, you will have
difficulty, if you do not remove the mucosa.
If you are not using the procedures for fix-
ing the nose tip to the septum as I do, your
mucosa length should be appropriate to the
new nose. The patient in the photo had
undergone a surgery before and said that he
was breathing less from his left nostril. You
can see the excess mucosa in the membra-
nous septum, the internal valve and the
long upper lateral cartilage.

14.9 Reconstruction of the Scroll

Line

Suture the peak point of the septum perichon-

drium with 5/0 Monocryl. Try to see the junction
point of the scroll ligament and the Pitanguy mid-
line ligament with a small retractor. Just there
you will see a 1.5 × 3 mm sized sesamoid carti-
lage. Stich this cartilage with 6/0 PDS and tie the
knot. Suturing the scroll sesamoid creates little
pits at both sides of the supratip break point,
which are created by the intact Pitanguy liga-
ment. Thus you can stabilize the peak point of the
mucosa to the site above and the lateral supratip
skin to the base.
284 4 Surgery

Right scroll ligament repair Left scroll ligament repair

Remember the endoscopic view below. We suture

the short sesamoid piece at 11 o’clock to the sep-
tum perichondrium and use the long piece in the
middle for repair of the scroll region.

14.9.1 Scroll Sesamoid Cartilage

In most patients, at the point where the scroll liga-
ment and the Pitanguy ligaments join, there is a
1.5 × 3 mm-sized cartilage. Anatomical studies
should be conducted on this cartilage. There are
two of these cartilages, and their mass is high
enough to be taken into serious consideration.
These cartilages are part of the Pitanguy system.
By suturing these cartilages to the septum mucosa
and embedding them into the space between the
dome and septal angle, we can have an additional
1 mm projection advantage.
In another patient, you can see how the suture
passing through the peak point of the scroll liga-
ment controls the skin. You can see that the suture
passing through the scroll ligament can make the
supratip skin hollow. If you protect the scroll
ligament it is impossible to pass this suture asym-
metrically. Simply pass through the sesamoid
cartilage that is attached to the scroll ligament.
14 Nasal Dorsum 285

Sometimes sesamoid cartilages break into pieces Scroll ligament can be repaired through an infra-
during dissection. In this case, you can pass the cartilaginous approach.
suture through the upper lateral cartilages and
lateral crus perichondrium.

Important
If the supratip breakpoint formed by the
Pitanguy ligament is prominent enough,
you may think of cutting the Pitanguy liga-
ment. If you cut in the way that Pitanguy
himself suggested, you will lose the advan-
tages. Instead of cutting, increase your dis-
section between the Pitanguy ligament and
the SMAS by 0.5 cm. In this way you can
decrease the effect of the Pitanguy liga-
ment without disturbing its function.
286 4 Surgery

Important
If you pass the stitch from the dermis or
SMAS without performing a subperichon-
drial dissection, you may cause an ugly
dimple or even skin necrosis. Sesamoid
cartilages that are attached to the scroll
ligament and perichondrium are the most
appropriate tissues for passing sutures.

9. Close your transfixion incision using contin-

uous 5/0 Monocryl sutures by putting one
edge suture to the top of the transfixion inci-
sion. Before closing the intercartilaginous
incision, place the bone paste into the nasal Upper lateral cartilage surplus is removed with
dorsum bone polygon. the mucosa.

10. At this point, we have already stabilized the

nose tip to the nose body. Shortening or
rotating the nose generally requires resec-
tions from the caudal part of the upper lateral
cartilages. It is easy to determine the amount.
The surplus part is the one that runs over the
scroll region. If you remove excess parts,
you can make the scroll region reconstruc-
tion more functional. Below you can see the
upper lateral cartilage surplus during removal
of the membranous mucosa surplus.
Note
I have examined many patients who had open
surgery before. In most of them I could see excess
cartilage and mucosa at the caudal of the internal
valve region. Whether more incision is used in
the closed technique or less incision is performed
in the open technique needs to be discussed.
14 Nasal Dorsum
Patient Example
The patient below had two open rhinoplasty sur-
geries. Due to deteriorated muscle functions and
a lateral crus that was left longer than necessary
and had a wrong resting angle, the external valve
had narrowed. Moreover, as there is no primary
repair in the scroll region and as the caudal edges
of the upper lateral cartilages are in excess, the
internal valve had narrowed as well. Deterioration
of the nose muscles could have increased the
closing of valves.
11. Resect the upper lateral and lateral crus
excess mucosa surplus.
12. While closing the intercartilaginous incisions
with 2–3 5/0 Monocryl sutures, take the scroll
ligament in between as well. In this way you
can also control the lateral supratip skin.
287
Important
In the dissected nose, the nose tip skin is
prone to swelling and the internal valves
are prone to collapsing. If you suture the
intercartilaginous incision by taking the
scroll ligament in between, the internal
valves will also open in the middle point.
The middle part of the internal valve is
formed by the caudal edge of the upper
lateral cartilages and the cephalic edge of
the lateral crus. The most important factor
that holds the caudal edge of the upper lat-
eral cartilage in the air is the cephalic edge
of the lateral crus. If you form a cartilage
defect between the cephalic edge of the lat-
eral crus and the caudal edge of the upper
lateral cartilage, you cannot reconstruct the
scroll region anatomically. Thick spreader
grafts are effective only when used near the
septal angle, up to the peak of the internal
valve. The septal angle is the thinnest point
of the nasal dorsum. Thickening this region
with spreader grafts is not appropriate in
light of aesthetic rules. Spreader grafts can
open the upper lateral cartilages only in the
nasal dorsum region. The effect of spreader
grafts on the middle of the internal valve is
less. In my opinion the effects of a spreader
graft on breathing is exaggerated. The most
important part of the internal valve is the
caudal edge of the upper lateral cartilages.
Forming a cartilage defect in the scroll
anatomy and narrowing the lateral edge
of the internal valve by lateral osteotomy
are the main reasons that damage internal
valve function.
288 4 Surgery

15 Internal Splints
When you have finished the rhinoplasty, find the
splints that you have put after the septoplasty and
fix them to the septum with 5/0 Prolene or 5/0
PDS. Close to the transfixion incision with the
splint to ensure a better alignment of the wound
edges. Do not tighten the knots too much. This
can cause pain. Do not use silk for fixation; as it
is not slippery enough, it can cause pain while
removing the stiches.
part at tip, the plastic will bend while inserting
the intracath in the nose, and it will remain out-
side. Insert the drains from the most lateral point
of the intercartilaginous incision towards the
medial canthus. Turn the open side of the drain to
the bone in order to avoid clogging. Remove its
needle and cut it so that 2 cm remains of the
mucosa. After two days remove them together
with the internal splints.

16 Internal Valve Functions

1. Use the subperichondrial dissection for pro-

tecting the muscles.
2. Do not make an infracture with lateral osteot-
omy. The airway is minimally contracted with
osteoectomy.
3. Do not cause a cartilage defect in the scroll
region with extreme cephalic resection.
4. If the caudal edge of the upper lateral cartilage
is left long, it obstructs the internal valve,
hence excess cartilages must be removed.
5. Excess mucosa in this region may cause thick-
ness at the internal valve region. If you have
resected too much of the cartilage, you should
also resect the excess mucosa.
6. After the surgery, repair the scroll region such
that the upper lateral cartilage and lateral crus
are in contact.
7. Nose muscles are attached to the scroll region
with the scroll ligament. When you are clos-
ing the intercartilaginous incision, take the
scroll ligament formed as a result of the SMAS
thickening in between during the repair.
8. Avoid osteotomy that restricts the caudal Cut the body of the intracath.
edges of the nasal bones where the upper lat-
eral cartilages start.
Important
You should keep drains long so as to not
forget them inside.
17 Drains

Using a no. 11 blade, split the green intracath

with its needle inside, such that 3 mm at the tip
remains unsplit. If you do not keep a 3 mm intact
18 The Pitanguy Ligament 289

18 The Pitanguy Ligament In the patient below, subperichondrial dissection

was performed. The Pitanguy ligament was
We mark the Pitanguy ligament before cutting in marked and cut.
the open technique. After surgery, repair the
marked Pitanguy ligament such that it enters
between the dome and septal angle.

This suture decreases supratip bulging. You can

treat supratip bulging with increasing projection.

The suture is passed through the marked Pitanguy

ligament under the supratip skin.
290 4 Surgery

The suture is passed through the Pitanguy liga-

ment under the dome.

19 The Superficial SMAS

In order not to form pits in the infralobular and

The supratip skin is stabilized after repairing the columellar polygons, the superficial SMAS that
Pitanguy ligament. fills these regions should be repaired.

In the open technique, repairing the scroll liga- Since this maneuver decreases the tension on the
ments on the two sides of the Pitanguy ligament wound, it increases scar quality.
holds it in the middle axis. Hence you should per-
form internal taping with 3 sutures in the open
technique.
The scroll ligament on two sides of the repaired
Pitanguy ligament was repaired.
20 Internal Taping 291

In order to avoid deviation of the tip ...
1. repair the Pitanguy midline ligament without
shortening.
2. use the posterior strut technique also in open
surgery. The posterior strut fixes the Pitanguy
system in the midline.
3. use 2–3 sutures or horizontal loop sutures, and
not only one.
4. if you also repair the scroll sesamoid carti-
lage, you will reach the original width of the
Pitanguy midline ligament and prevent it from
falling right or left of the septal angle.
The nose does not only consist of cartilage,
bone and skin, but also of ligaments. If you perform
surgery under the perichondrium, soft tissues not
only act like a cover, but also help to give shape to
the nose with their special form. We have men-
tioned that the SMAS forms ligaments by thicken-
ing at the supratip and lateral supratip regions and
that these ligaments enter between the cartilages.
This system forms a compartment for cartilages.
In the model below you can see the spaces
between the cartilages and thickening in the soft
tissues.

20 Internal Taping

Since the Pitanguy and scroll ligament recon-

structions are new notions, these will be dis-
cussed in greater detail.

20.1 The New SMAS Anatomy

With Daniel and Saban’s new studies on anat-

omy, we have gained more knowledge about the
Pitanguy and scroll ligaments. Pitanguy has
defined this ligament as the dermocartilaginous
ligament, stating that this ligament starts from the
dermis. To surgeons he advises: “Cut this liga-
ment for nose rotation or resect if it is in excess.”
The SMAS thickens in the supratip region; it
can be divided into deep and superficial. Deep
SMAS passes between the septal angle and dome
and moves to the medial crus and maxillary crest.
This ligament is named the Pitanguy midline liga-
ment. The thickness between the dome and septal
angle measures about 2–3 mm. The Pitanguy mid-
line ligament both fixes the tip position and makes
it semi-mobile. Moreover, it also increases tip pro-
jection because of its 2–4 mm thickness. In open Important
surgery we have to cut this ligament from the sep- We have to know the anatomy of ligaments
tal angle. In this situation, the Pitanguy midline that fill the space between skin and carti-
ligament moves under the supratip skin. With the lage and manage these ligaments during
dissection of soft tissue, tip projection decreases surgery. If we do not deal with them prop-
by 2–4 mm. The main reason is the destruction of erly, there will be projection loss and
the integrity of the Pitanguy ligament. abnormal ligament accumulation. If con-
Superficial SMAS moves over the domes and trolled, however, we can better control pro-
passes through the space between the dome and jection and redrape.
medial crus and joins the orbicularis oris muscle.
292 4 Surgery

Relation between Pitanguy and scroll ligament 20.2 Importance of the Pitanguy
and cartilages. Ligament in the Supratip
Region

The Pitanguy ligament makes a dynamic increase

in projection by getting under the dome and
behaving like a cushion. Also, it passes between
the lateral crura and separates them like septa.

In the open technique, we often see that the

lateral crura contact each other in the middle
axis. But the anatomy does not conform to this
observation. The Pitanguy ligament enters
between the lateral crura and continues under the
domes. The Pitanguy ligament prevents lateral
crura from moving medial. If the lateral crura
move to medial, they will appear as a cephalic
malposition. In the model below, there is a space
under the domes. This space is the trace of the
Pitanguy ligament. If the Pitanguy ligament is
not repaired, this space will close due to a col-
lapse of the domes on the septal angle and a
2–4 mm projection loss occurs.
20 Internal Taping 293

You can resect the Pitanguy system and insert a

septal extension graft. You will use the most non-
anatomical graft in rhinoplasty surgeries and
obtain a stiffness that is not natural. In closed
rhinoplasty, if you perform surgery without cut-
ting the Pitanguy ligament, you may not need a
septal extension graft or tongue-in-groove.
294 4 Surgery

Examine my drawing that shows the effect of the

Pitanguy ligament on nose tip projection.

Note We can have dynamic nose tip stabiliza-

tion with a reconstruction of nose ligaments. The
stiffness caused by structural rhinoplasty can dis-
turb patients. Below you can see the nose tip elas-
ticity of a patient after dynamic stabilization.
21 Redrape 295

21 Redrape

The adaptation of the skin to the reconfigured

nose skeleton can be described best with the term
“redrape.” The only intervention we perform to
control redrape is bandaging the nose. Even if we
have given a magnificent shape to the cartilage
and bone anatomy, if we cannot properly manage
the skin, surgery will not be successful. Redrape
problems can occur in moderately thick and thick
skins and humped noses or extreme reductions.
Redrape occurs in the region where the skin has
been dissected.

In both dissection types, the supratip and lateral

21.1 Dissection Borders
1. Traditional dissection methods are limited to
sub-SMAS dissection and wide sub-SMAS
dissection. Redrape is limited to the dissected
area. If you are using subperichondrial dissec-
tion, you should perform a wider dissection
for the same redrape effect. This is because
the thickness of the flap increases.
supratip regions are at risk. If excess skin accu-
mulates in these regions, the nose tip may become
round and loss in tip definition occurs. You will
face problems especially in the first type, in which
dissection width is smaller. You cannot make big
changes in the nose shape. You can increase
redrape by elevating the thin flap, but you may
lose all the advantages of subperichondrial
dissection. If there is too much skin, supratip
deformity can occur. You can control redrape
with the scroll and Pitanguy ligaments. The
Pitanguy ligament controls the supratip region,
and the scroll ligament controls the lateral supra-
tip region. Thus we can redrape excess skin in the
supratip breakpoint and the area on the scroll line.

2. You can widen your dissection until the oste-

otomy lines. In this case you should change
your osteotomy technique. You may have a
wide redrape area.
296
Below, I will give an example of redrape control.
We planned a massive reduction on the patient’s
nose size. If we do not keep the excess skin under
control, it will easily accumulate at the supratip
area. You can see the Pitanguy ligament’s effect in
the tenth-day photograph. The supratip breakpoint
was still constituted by the Pitanguy ligament, even
though there is much excess skin and edema pres-
ent. In the first-month and first-year pictures, the
effect of the Pitanguy ligament is seen on the
patient. On the tenth-day pictures, the extra skin of
the nose is present. The extra skin is accumulated
on the supratip and lateral supratip areas. At the
first-year mark, the tip definition clearly exists.
21.2 How to Use the Ligaments
for Redraping
Up to 1.5 cm of excess skin can occur when we do
a rotation in a patient with a droopy tip. If you do
not manage this skin, it will accumulate on the
supratip and lateral supratip areas. If you cut but do
not fix the Pitanguy ligament, the system that fills
the space between the septal angle and the domes
can slide under the supratip skin. The Pitanguy
ligament is 2–4 mm thick, 4–5 mm wide and
approximately 1 cm long.
4 Surgery
Important
You have 1.5 cm extra skin, if not repaired,
and a Pitanguy ligament 2–4 mm thick,
4–5 mm wide and 1 cm long. If you do not
control skin and ligament, they will accu-
mulate in the supratip area.
Supratip deformations lead us to the diagnosis
of fibrosis. Why does no other place present
fibrosis but this one?
We try to make tissues thinner by injecting
steroids, not dissolving fibrosis.
I do not even remember the last time I have
performed a steroid injection. If you control the
skin, no supratip deformation occurs. Control of
a steroid injection is even harder than managing
the redrape of the skin. In one of my cases, the
steroid caused an atrophy of the fat I had injected.
Telangiectasia and white steroid cysts are other
potential problems.
21.3 Why Internal Taping?
Tapes for the nose are used to control edema and
to adhere to skin cartilages such that there will be
no dead spaces. But external tapes will not help to
put ligaments in their place, and one can keep
them on for a maximum of two weeks (in Iran,
tapes are kept on for three months). When the
Pitanguy and scroll ligaments are used, you will
stabilize the supratip and lateral supratip skin
parts so that no dead space remains inside. In this
way you will also push the extra skin above the
supratip breakpoint and scroll line. The present
22 Additional Grafts 297

book includes many patients who were candidates

for supratip deformation, and their redrape was
controlled by scroll and Pitanguy internal taping.

Important
In my opinion, patients with thick skin
should be treated with internal taping rather
than removing their muscles, a procedure
called “defatting.” A wide dissection on top
of the lateral cartilage and bone will make
redrape easier. If you ever see a patient who
underwent a defatting procedure one year
ago, have her take a deep breath in and you
will understand what I mean.
22 Additional Grafts

There is no obligation to give shape to the 22.1 Extra Columellar Strut

nose skin by massaging when subperichondrial
wide dissection and internal taping are done. If you press your finger on the tip and do not feel
tip support, you may insert additional strut grafts.

21.4 Camouflage

At the end of the surgery, if small asymmetric

spaces are present, small crushed or thin sliced
cartilages can be placed on those surfaces. It is
inadvisable to expect too much from these grafts.
Use them for small asymmetries or depressions.
These grafts are needed for 2–3 % of our primary
patients. I use a maximum of 2–3 pieces. Do not
forget that they can be become visible in thin-
skinned patients.
298 4 Surgery

I use an additional strut on 10–20 % of my 22.2 Rim Graft

patients. I prefer thin grafts, and if these are not
sufficient, I generally use one, rarely three addi-
tional strut grafts.
If you have closed all incisions and there is still
alar asymmetry or weakness, you can use addi-
tional rim grafts without removing the stitches.
You can place a graft by opening a pocket with
the help of a green needle and 1 mm chisel.

Important
In those patients on which we plan a dramatic
rotation, an additional strut graft angled
towards the lip can control the rotation.
23 Nostril Surgery 299

23 Nostril Surgery

23.1 Problems and Solutions

1. The base of the ala might be thick.

Treatment: Simple elliptic resection.
2. Nostrils might be big.
Treatment: Avulsion advancement flap.

Important
If the nostril sill is hanging, internal rota-
tion is added while advancing.

3. Nostrils might be big, and the alar base thick.

Treatment: Avulsion advancement flap and
elliptic resection can be combined.
4. Ala can be hanging.
Treatment: Alar margin resection.
5. Nostril sill can be hanging.
Treatment: Skin resection inside the nostril.

Important
Do not perform a resection without
markings.

23.2 Thick Alar Base: Simple

Elliptic Resection

This is done when the nostril is normal but the ala

thick. It is a simple elliptic tissue resection.

1. Draw an ellipse on the area where you want to

make it thinner. The incision must be placed
on the alar crease. Do not leave a 1 mm stitch
margin. From my personal experience, a scar
on the alar crease is less visible.
300 4 Surgery

4. Apply 1–2 6/0 Monocryl subcutaneous

sutures. Try to go through the deep dermis.
This area might cause small pockets to form,
because of the presence of many sebaceous
glands. If you do not bury the sutures under
the skin well, it will cause a reaction and you
will have pockets where dirt accumulates.
5. Skin should be closed by loose and continu-
ous stitching using 6/0 round needle Prolene.
If you tighten the stitches, it will cause scar-
ring and be buried deeper. This area will expe-
rience edema, and even normal stitching can
turn into tight stitching and leave scars.

Important
Cutting and stitching is the simple part.
The most important step is to apply the
marking in the right area.

2. The base should be cut parallel to the cheek.

3. Take out just enough tissue to make it close
comfortably. Try to protect the muscles.

Important
If the nostril sill is thick, elliptic excision
may include the nostril sill, but incision
should not turn into the nostril. In this case
the nostril will also get smaller.
23 Nostril Surgery 301

6. Take the stitches out on the tenth day. Patient having undergone elliptic surgery after
nine-month mark.
Tenth-day photos of the patient above.
302 4 Surgery

practicing anatomic resection. I have learned

this technique from Nuri Çelik. Jack Sheen per-
forms the incision 1 mm above the alar crease.
Millard noted that his disagreement with Sheen
and argued the incision should be in the alar
crease. Because alar surgery is next to the lips, I
have to agree with Millard since he is an author-
ity on cleft lip.

Note Do not decrease your indications because

of bad scarring experiences. You should perform
alar treatment if needed.

1. Drawing: In cases where the nostrils are big,

23.3 Big Nostrils: Avulsion the distance between the nostril sill and foot-
Advancement Flap plate is generally large. The aim is to narrow
this region.
You cannot perform this procedure without
knowing the nostril sill anatomy. Take a close
look once more at the nose drawings. The outline
used while drawing the nostril base and the place
where the blade will cut are the same.

Important
Ala will attach to the upper part of the lips
by embryological twisting and thinning.

Remember how the nostril sill is drawn. The

nostril sill finishes 2 mm from the footplates by
thinning and narrowing. The incision should
extend from the alar crease to the footplate. Mark
the tissue that you are going to resect.

2. Incision: You should cut from your mark par-

Our scar should stay on this line. Do not for-
get that there are not many doctors who are
allel to the surface of the lips, without cutting
too deep. The nostril sill has an anatomy that
rests on the lips. In this incision the tip of the
flaps will look as if they have been avulsed.
The tip of the flaps should be thin and become
thicker as they get lateral.
23 Nostril Surgery 303

4. Hold the tip of the flap using the forceps and

stretch it. Next, lay it onto the base and fix it.
Using your surgical blade, cut the flap such
that it is avulsed and then remove the excess
parts.

3. Elevate your flap and decide where to put it

by pulling with the forceps. You can mark the
right point by grasping and squeezing it with
the forceps.

5. Stabilize the flap’s tip with a key suture.

Finish the procedure on the other nasal ala.
304 4 Surgery

6. Apply subcutaneous sutures using two 6/0

Monocryl sutures. Close it from medial towards
lateral by means of a 6/0 round needle Prolene
using the continuous suture technique.

One-year photo of a patient who had nostril reduc-

tion by means of an avulsion advancement flap.
23 Nostril Surgery 305

Another Patient Example One-year photo of a patient who had nostril reduc-
tion by means of avulsion advancement flap.

Scars remain in the natural lines; therefore, they

are not visible in the close-up picture of the
patient after one year.
306 4 Surgery

Important
Your incision in alar base surgery should not
extend beyond 8 to 4 o’clock. The problem is
under the 8 to 4 o’clock line, and with a sur-
gery in this region you can solve most of the
problems. Remember from the drawings that
the alar crease becomes smooth above 9 and
3 o’clock. By going around the nostril circles,
it ends beside a small triangular cavity located
5–6 mm above the RL point of the lateral
crus. An incision that extends beyond the 3 to
9 o’clock line would ruin the anatomy and
result in an ugly appearance. It will be very
difficult to hide a scar over 9 to 3 o’clock.

23.3.1 Superior Repositioning

of the Nostril Sill
This is performed if the patient’s nostril sill is
hanging on front view. The avulsion flap will lift
the nostril sill. Make an internal rotation towards
the inside of the nostril and set the resection level.
This is a combination of advancing and internal
rotation.

This is the one-year postop result of the above

patient.
23 Nostril Surgery 307

Important
Cut appropriate to nostril sill anatomy.
Consider how we settle the nostril sill flap
to the lips in cleft lip surgery.

23.4 Big Nostril and Thick Alar

Base: Combination of
Avulsion Advancement Flap
and Elliptic Resection

In the patient below, nose projection was reduced.

Nasal alae were thick.
308 4 Surgery

When projection was reduced, the nostrils

became bigger as well. Avulsion advancement
flap and elliptic resection were combined.
Perform elliptic resection first, then do an
advancement flap for easy planning.
23 Nostril Surgery 309
310 4 Surgery

Tenth-day photograph of the patient. Patient Example

After two years.

23.4.1 Common Mistakes

1. Incisions that disrupt the continuity of the

nostril sill.
23 Nostril Surgery 311

2. Resections that are done on the body of the

nostril sill.

23.5 Hanging Alae: Alar Rim Excision
Note Do not perform this procedure on your first
100 patients.
Some patients have more skin, not cartilage.
This generates a flabbiness of the alae. Our
patients also want to get rid of this fleshy appear-
ance. It is not possible to satisfy these patients
with cartilage shaping only. Alar rim resection is
a radical technique.
23.5.2 Incision
Cut the ala through the marking so that it splits
right from the middle using a no. 15 blade. Your
incision should be deep in the middle, but super-
ficial at the top and bottom. For the first 2-3 mm,
cut obliquely towards the lateral in order to keep
the lateral skin flip thin. Moreover, you can turn
the lateral flap easily while suturing.

23.5.1 Marking
Put a point 1–2 mm lateral to the lowest edge of
the hanging ala. Draw it throughout the excess
skin. While you are finishing your line at the
upper and lower side, slightly turn to the nostril.
If not, little dog ears that appear at the end points
of the scar will be visible from the outside.
312 4 Surgery

23.5.3 Resection
Stretch the tissue with the forceps and shorten the
flaps with your tissue scissors. I still hold my
breath at this point. Please act very carefully. You
can do additional resection if necessary. Your
nasal alae will rise as you resect.

23.5.4 Suture
Without any subcutaneous suture, suture very
loosely by inverting the wound edges with a con-
tinuous 6/0 round needle Prolene. While suturing,
your needle axis should always be towards the cen-
ter of the nostril. In this way your incision’s end
points will not be visible from outside. If you wash
the wound with a 1/5 diluted corticosteroid solu-
tion when the suture is finished, the wound will
heal better. Remove the sutures on the tenth day.
After closing the wound, the ala will seem erect
and the nostrils bigger. This is a transient effect.
Do not perform a nasal base resection for this
appearance, and do not forget wound contracture.
23 Nostril Surgery 313
314 4 Surgery

Irrigating the suture lines with triamcinolone.

Tenth-day photos of the patient. For the same

patient’s one-year results, see page 26.
23 Nostril Surgery 315

Patient Example

Another Patient Example

The first-year picture of a patient who has had
skin resection due to hanging facet polygon skin.
316
Patient example: Cleft lip nose case
Skin resection was performed directly from right
nostril apex to improve nostril asymmetry.
4 Surgery
Patient Example: Composite Graft
The patient’s right nostril was contracted due to
trauma. The tissue removed from the left alar
base was adapted to the contracted region as a
composite graft. These are photographs seven
months after surgery.
24 Taping 317

splinting for preventing your surgery from

becoming unsuccessful due to swelling. Apply
taping according to the contours of the nose tip.
You can protect your facets by affixing little
tapes. Also use the splint for closing the roof.
Excessively tight taping can cause necrosis and
destroy the shape of the cartilages. I place the
tapes on the nose without squeezing.

24 Taping

In order to avoid a pinched nose, do not squeeze

the nose tip with tapes. To prevent a tube-shaped
nose from the front, do not squeeze the base of
the splint to prevent infracture. Apply taping and
318 4 Surgery

25 Postoperative Care

Keeping the patient’s head positioned at an angle

of 30° is usually sufficient. It is not necessary to
apply cold. If you pay attention to the surgery
details, you should rarely see any bruising. With
the right techniques, it is virtually impossible to
cut the large vessels. It is very difficult not to
injure a vessel with 4–5 mm lateral osteotomy
chisels. For controlling the edema, we tape the
lower eye lid when the surgery is finished. If the
periosteum did not tear at the dissection border,
bruising and edema rarely happens at the top
eyelids. When removing the internal splint, you
can also shorten the tapes that placed on the
lower eyelids. You can remove the external splint
on the tenth day and tape for five more days.
25 Postoperative Care 319

Patient Example
Below you can see the two-day postop photo of a
patient who had osteoectomy and whose hump
was removed.

Patient’s photographs before and after the tenth

day.

The internal splints inside the patient’s nose were

removed and the tapes on the eye lid shortened.

Patient’s tenth day, with the external splint removed.

320 4 Surgery

First-month photos of the same patient.

26 How to Correct
the Deviated Nose

Sixty-five percent of my patients have axis devia-

tion. Left axis deviation is more common. Nose
axis deviation is a very common problem, and it
is very difficult to correct.

26.1 How Did the Nose Deviate?

The main reason for axis deviation is septum devi-

ation. A septum that does not fit inside the nose
can bend the nose to one side. As trauma prior to
adolescence can affect the growth of the nose, size
differences in nose cartilages can occur as well.

Problems with left axis noses

1. Right lateral crus is longer.
2. Right lateral crus is wider.
3. Right upper lateral cartilage is higher.
4. Right upper lateral cartilage is longer.
5. Right bone is higher.
6. Right bone base (lateral aesthetic line) is wider.
7. Bone surface problems usually accompany
the deviation. We generally see concave and
convex bones on patients with axis deviation.
26 How to Correct the Deviated Nose
8. Septum is deviated to the right at the back,
and to the left at the front.
9. Anterior maxillary spine is deviated to the
left at the front, and to the right at the back.
10. Left concha is hypertrophic.
11. Soft tissues are also deviated. In noses that
have deviated since development, the mus-
cles that are attached to the nose have asym-
metric lengths as well. Ali Teoman Tellioğlu
reported that a part of the levator labii supe-
rior aleque nasi muscle is connected to the
lateral crus, stating in an article that this
connection should be surgically cut. For
very deviated noses I think this has a similar
effect as performing a very wide dissection
on the lateral crus at the subperichondrial
plane until the piriformis aperture.
If the soft tissue deviations try to pull the nose
to the same side after surgery, I ask patients to
massage their nose. The patient pushes the nose
with his/her palm such that the deviation is fixed.
I ask for this to be performed 10–15 minutes per
day. The patient tries to lengthen the levator
muscle through smiling mimics. A regular
massage in the first two months provides a
1–2 mm correction.
In order to correct the nose deviation, we should
solve all of the above problems step by step.
321
26.2 Reference Points
The surgery of patients who have axis deviation
should be done asymmetrically. We need refer-
ence points during the operation. We cannot fix
the nose based on rule of thumb. Thus, we should
mark the middle line of the patient’s face before
surgery. Put medial line marks on the glabella
and vertex. Even the patient’s nose radix may not
be at the middle line. For this reason the nose
radix must not be taken as reference.
What can we take as reference in asymmetri-
cal faces?
Asymmetries are commonly seen at the man-
dibula. The medial line of the chin and the medial
line of the forehead may not be in alignment. I
usually take the eyes as reference. People usually
look at each other’s eyes while talking.
Let’s investigate the correction of a deviated
nose on a patient example.
A very thin-skinned patient with left axis devi-
ation has a septum deviation to the right.
Local infiltration was made before preparation.
As the patient was prepared, the nose had already
turned white.
322 4 Surgery

Left concha SMR was performed. The subperi-

chondrial plane was entered from the septal angle.
It was dissected laterally.

The bone was reached over the upper lateral

cartilage.
26 How to Correct the Deviated Nose
The bone was incised with a blade and we entered
under the periosteum. (We could have also found
the periostal plane by scratching the corner of the
bone with the elevator.) A wide dissection was
made until the osteotomy line. In this way, it was
possible to reach all the deviated regions.
323
26.3 Nasal Dorsum Resection
The nasal dorsum was exposed by mucosa dis-
sections. Resections were made while pushing
the nose cartilages to the midline with our fin-
gers. In this way, we could perform more resec-
tion from the long right upper lateral cartilage. If
a patient has weak dorsal cartilage, use the
spreader flap technique.
324 4 Surgery

26.4 Septoplasty

The septum base was exposed by subperichon-

drial dissection. Excess cartilage was removed
starting at 2 mm in front of the septum base. A
2 mm space was left between the septum and
maxillary spine. This space will be filled with the
perichondrium and periosteum thickenings.

Important
Additional 1–2 mm resections are gener-
ally needed for symmetry after osteotomy.
It is reasonable to perform the resections
conservatively. The bones were also
resected asymmetrically at the level of the
upper lateral cartilages. The right nasal
bone was further reduced.

Important
The nasal roof of patients with axis devia-
tion should be opened asymmetrically. If
you open it symmetrically, it will be asym-
metrical after osteotomy. Therefore, if you
open it asymmetrically, then the roof will be
symmetrical, as desired, after osteotomy.
Important
1. If you do not separate the septum from
the maxillary spine, you cannot correct
the deviation easily. You will usually
need camouflage techniques.
2. The excess in patients with axis devia-
tion is at the septum base. Emptying the
posterior septum with L septoplasty
does not have any effect on correcting
the deviation. Scoring techniques are
not effective enough on a septum on
which an L septoplasty was performed.
3. If you perform an L septoplasty for the
cartilage graft and separate the septum
from the maxillary spine, then the sep-
tum becomes excessively mobilized.
4. If you use the libra graft or spreader flap
technique, you do not need to take an
additional graft from the septum. The
cartilage that has been removed from
the base is more than enough.
26 How to Correct the Deviated Nose
The anterior maxillary spina was dissected after
cartilage removal. According to the midline mark-
ings, the anterior maxillary spine is made sym-
metrical by thinning it from the right and left sides.
Important
The maxillary spine is one of the basic
points of the nose. The base must be sym-
metrical for fitting the septum symmetri-
cally. The midline at the forehead should be
taken as reference while thinning the maxil-
lary spine. The maxillary spine is quite
hard. You cannot perform a greenstick frac-
ture. If you break the spine to move it to the
midline, it may be mobilized too much. It is
safer to make a bone segment in the middle
by trimming the deviations.
You can control the alignment with the help of a
Bayonet forceps.
325
The septum was stabilized to the periosteum
above the maxillary spine by making two loop
sutures with 5/0 PDS. The knot was placed inside
the cavity.
Important
The septum must be stabilized at this level.
The septum can be mobilized during nose
radix osteotomies. It is very difficult to sta-
bilize the mobilized septum in the correct
position.
26.5 Tip Surgery
The nose tip cartilages were exposed by dissec-
tion in the subperichondrial plane with autorim
flap technique. The domes were taken into trac-
tion and brought to the midline. Reference points
were determined by holding and stretching the
medial crura.
A 2 mm lateral crural steal was performed from
the left dome, and 4 mm from the right dome.
326 4 Surgery

Cephalic dome sutures were placed.

Important
Performing asymmetrical steals from the
lateral crura is a very effective maneuver.
In this patient, a 7° midline deviation was
corrected by performing a 2 mm asym-
metric steal.

1. In tip surgery even a 2 mm asymmetry can

destroy the tip axis.
2. Acquiring a symmetric tip without correcting
the lengths of the asymmetric lateral crura is
too difficult.
3. The dome symmetry test is very important to
obtain a symmetrical result in tip surgery.

The split Pitanguy ligament was repaired. The

right autorim flap was longer because of stealing
from the right lateral crus 2 mm more than from
the left crus and caused a bulging on the right
facet polygon. Therefore, the right autorim flap’s
tip was shortened by 2 mm.
26 How to Correct the Deviated Nose 327

When you steal more than 2 mm from the right

lateral crus, the right medial crus is extended by
2 mm. A 2 mm overlap was made on the right
medial crus and a strut graft was placed. Then a
C’ suture was placed. The columellar polygon
was stabilized. The tip cartilages were placed
under the skin and the mucosa was repaired.

A transverse osteoectomy was performed.

Important
Performing transverse osteoectomy is
important. The bone at the medial cantus
level is very thick. If it is not thinned enough,
the nasal bone can separate from the maxil-
lary bone while opening osteotomies.
A right lateral osteoectomy was performed. Since
the right maxillary base was wider, more osteoec-
tomy occurred to the right than the left side.

The lateral chisel was inserted between the right

nasal bone and septum. The nose radix was
inserted to a depth of 4 mm with the aid of a ham-
mer. The chisel was turned outwards so that its
body stood posterior to the maxillonasal junction.
328 4 Surgery

Important
If lateral osteoectomy is not applied ade-
quately, especially at the medial canthus
level, the opening osteotomy will be unsuc-
cessful. The opening osteotomy increases
the height of the bone that is opened. When
we opened the roof, we took more of this
bone. If it is longer than desired, we can
perform additional resections up to 1–2 mm
with bone scissors. Do not use a rasp at this
level because the bone can be mobilized
too much. Bone scissors are one of the saf-
est tools for performing a resection on a
bone that has been osteotomized.
Important
During this movement you should hear a
cracking sound from the bone.
In order to lay down the open left nasal bone onto the
corrected septum and right nasal bone, lateral and
transverse osteoectomy were performed. Since the
left nasal base is narrower, the base is thinned with a
Çakır 90 chisel. Less bone was removed when com-
pared to the right. Thinning was continued until the
bone was fractured with finger pressure.

A lateral chisel was put between the left nasal

bone and septum and inserted about 4 mm deep.
It was laid to the right with the ethmoid bone to
which septum was affıxed.
26 How to Correct the Deviated Nose 329

Scoring was performed until the septum aligned

Important with the midline.
Although we perform resections according to
opening and closing osteotomies, additional
1–2 mm upper lateral cartilage, septum and
bone resections may be needed.

Important
Perform scoring on the same side of the
deviation. If you want to bend the septum to
the right side, do the scoring on the left side.

The radix was corrected with opening and

closing osteotomies. In order to take the caudal
septum to the midline, a 45° scoring was per-
formed starting from the attachment point of the
septum to the ethmoid bone.

Important
In septum base surgery, most of the axis
problems are fixed with the nose radix
opening and closing osteotomies and scor-
ing. Spreader grafts are used for stabilizing
the current situation. If we do not perform
asymmetric resections while taking the
nasal dorsum into the midline, we will have
a deviated axis again when we repair the
upper lateral cartilages. If we perform the
correct resections, we can achieve a cor-
rected axis stabilization when we fix the
upper lateral cartilages with a Libra graft.
330 4 Surgery

The excess mucosa was resected.

Important
You can control the placement of the
septum in the midline with the help of a
Bayonet forceps.

Important
You should perform mucosa resections
with correct measurements. More mucosa
is accumulated on the right membranous
side and right internal valve area of a
patient who has left axis deviation.

After the septum was placed in the midline, the

Libra graft was stabilized to the septum and upper
lateral cartilages were sutured to the Libra graft.
26 How to Correct the Deviated Nose 331

Three millimeters of cartilage and mucosa were

removed from the caudal edge of the right upper
lateral cartilage.

The final view after surgery.

Here you see the nasal dorsum which has been

stabilized by means of the Libra graft technique.
332 4 Surgery

Deviated Nose Patient Example

Tenth-month photos.
26 How to Correct the Deviated Nose 333

Deviated Nose Patient Example

Two years after surgery, a minimal right devia-
tion has occurred although the patient had left
deviation.
334 4 Surgery

When cartilage is needed for secondary sur-

gery, the graft is removed with correct planning,
and markings are made according to the respec-
tive needs. The graft is cut with a no. 11 blade.

27 Cartilage Grafts

27.1 Septal Cartilage

I do not remove too much cartilage from the sep-

tum except in secondary surgeries. In primary
rhinoplasty, a cartilage graft taken from the
septum base is enough for the rhinoplasty.
27 Cartilage Grafts 335

27.2 Rib Cartilage

If the patient had previous surgery and there is no

graft in the septum, we will have to harvest from
the rib or ear. Ear cartilage is mostly used as fill-
ing, and rib is appropriate for straight and strong
cartilage grafts. If you need rib, take it before the
rhinoplasty. Since taking a rib segment causes
serious pain and risk of complications, we prefer
to take split cartilage. I learned this technique
from Sacit Karademir.

27.2.1 Cartilage Chips

This serves as excellent filling material. Rib car-
tilage chips for grafts are best prepared by
scratching with a Çakır 90 chisel which we use
for osteoectomy.

Patient Example
Closed technique rhinoplasty was performed on
the patient.

– 5 × 4 cm perforation is present in the septum

– Pinched nose
– Hanging columella
– Alar retraction
– Left axis deviation
– Skin was thinned due to previous surgery

27.2.2 Surgery
A closed approach, dome delivering technique
was used. The pinched nose was corrected with
lateral crural strut grafts. Strut grafts were
inserted. The septum was taken to the midline by
scoring and stabilized with spreader grafts. Since
336 4 Surgery

the skin was very thin, block cartilage was not

inserted in the nasal dorsum. The nasal dorsum
was augmented with cartilage chips that were
taken from the rib.
Patient photos one year after the surgery.

27.2.3 Block Cartilage

I use block cartilage in major defects and defi-
nitely combine it with cartilage chips. Coagulated
blood is an excellent adhesive for holding grafts
27 Cartilage Grafts 337

together. When block cartilage is shaped accord-

ing to nasal dorsum fusiform shape, a grafted
nose appearance can be avoided. The edges
should be sharp and the base concave.

Block cartilage was combined with cartilage

chips as depicted below.
338 4 Surgery

27.2.4 Strip Cartilage Grafts

It is possible to get strip grafts from the rib, keeping
the base intact. Half of these cartilages curved when
they were submersed in water. I use the curved ones
for filling. I make strut and spreader grafts from
straight ones. This is not an easy technique.
The major problem with rib cartilages is bend-
ing. I have even used K-wires for this problem;
however, one of my patients had the K-wire exposed
from the nasal tip two years after surgery. Eren
Taştan has developed a very practical method, as
described in the following article:
Taştan E, Yücel ÖT, Aydin E, Aydoğan F, Beriat
K, Ulusoy MG. The oblique split method: a novel
technique for carving costal cartilage grafts. JAMA
Facial Plast Surg. 2013 May;15(3):198–203.
He cuts the rib cartilage in an oblique direc-
tion instead of horizontal or vertical. In this way,
the cartilages do not bend. The cartilage is har-
vested in block form and the oblique incisions are
done on the table. I harvest the cartilage struts
directly from the rib without disturbing the costal
cartilage integrity. Since the rib base is intact, the
patient will have very little pain.

Surgery
Make a 1.5–2 cm incision in the medial part of the
right inframammary fold. Dissect the muscles in
the vertical direction and expose the cartilage.
Dissect the perichondrium if you need a perichon-
drial graft. I usually do not dissect it. Mark oblique
incisions on the cartilage. Cut the incisions with
the blade 4 mm deep. Sacrifice one strut in order
to remove the other struts easier. Use a thin Cottle
to get under the other struts and mobilize them
28 Columellar Show
28 Columellar Show
Hanging columella will be discussed in three cate-
gories: retracted nasal alae, hanging columella, and
a combination of the two. I often see a combination
of these in patients who come for a revision.
Increased columellar show can be seen more
frequently in open surgery. This is because sur-
geons who use the closed technique manage the
excess in the membranous mucosa and scroll
regions in a better way.
Important
Increased columellar show occurs as a
result of a difference in the raising of the
nasal alae and columella during the short-
ening of nose length and rotation.
Proportional rotation must be made on
columella and nasal alae. A common prob-
lem is the insufficient rotation of columella
while making nasal alae rotation with lat-
eral crus cephalic excision. Medial crura
that have been left too long can also cause
increased columellar appearance.
1. Remove cartilage and mucosa from the caudal
septum for elevating the columella. Usually
removing cartilage is not enough. Excess
mucosa can push down the columella or dis-
turb breathing by forming a thickness at the
membranous septum in the long term. We
339
cannot take from the nose skin; there has to be
a redrape, but this should not allow the mucosa
redrape to affect this surgery.
2. In order to elevate the nasal alae, we perform
resection from the cephalic part of the lateral
crus, but this is not the only way. Using only
lateral crus resection is not correct. Generally
we perform too much cephalic resection from
the lateral crus. It is more logical to resect just
enough for the lateral crus to turn inside with
a cephalic dome suture. When we use an auto-
rim flap, generally 2–4 mm cephalic resection
will be enough. If we only perform cephalic
excision from the lateral crus for elevating the
nasal alae, the possibility of a pinched nose
can increase. Primary cartilage contact is very
important in the scroll region. If we try to
achieve alar rotation solely by lateral crus
cephalic excision, a cartilage defect will occur
in the scroll region. Although this defect may
seem normal during surgery, it will pull the
nasal alae in the long term.
Important
Do not treat the lateral crus wideness with
cephalic excision only. In a very wide lat-
eral crus you may have to perform about
8 mm resections. It is not possible to repair
the primary scroll region in a patient on
whom you have performed 8 mm cephalic
excision. You will generate a big space
between the upper lateral cartilage and lat-
eral crus. If they do not contact each other,
the lateral crus shows cephalic migration
and its resting angle deteriorates. Its silhou-
ette under the skin disappears, and it may
appear as a cephalic malposition; a pinched
nose may even result.
Example
For decreasing the width of the lateral crus from
15 to 8 mm, you should make a 7 mm cephalic
excision. In the autorim flap technique, with a
3 mm autorim flap and 1 mm additional caudal
excision you can narrow 4 mm from the caudal
side of the lateral crus. When we make a 3 mm
340 4 Surgery

cephalic excision, we have 7 mm narrowing in rotation in the open technique, you can see the
total. Thus we have 8 mm lateral crus width. excess while examining the patient’s internal
Three millimeters of cartilage stay inside the valves.
facet polygon so that it supports the alar edge. Below you can see the removal of the excess in
Another important disadvantage of large cephalic the membranous and internal valve in a greatly
resection (7 mm in this example) lies in the fact reduced nose.
that the caudal half of the lateral crus, which is
convex and weak, stays in the nose. The pieces
curving to the facet polygon do not allow for a
nice highlight on the skin. A great space between
the upper lateral cartilage and lateral crus occurs.
In the autorim flap technique, we use the mid-
dle section which is the straight and strongest part
of the lateral crus. With the autorim flap we sup-
port the nasal alae. We can repair the scroll region
again in such a way as to allow the contact of the
upper lateral cartilage and lateral crus cartilages.

Note In a patient who has a wide lateral crus it is

not appropriate to attempt a retraction on the
nasal ala or on a pinched nose. We may ruin the
material at hand with the incorrect strategy. If we
use more skillfully what we have at hand, such as
rim graft, then we will need much fewer correc-
tive maneuvers.

Important
In order to support alae and generate a lat-
eral crus caudal edge highlight, the lateral
crus should have support from the other lat-
eral crus and the upper lateral cartilage.

3. Our main weapon for elevating the nasal alae

is upper lateral cartilage caudal resection. This
must be done in the right amount. One of the
advantages of the closed technique is that it
gives lots of feedback regarding resection
amounts. In closed technique, caudal resec-
tion of upper lateral cartilages is performed at
the end of surgery. The intercartilaginous inci-
sion is closed at the end in closed technique.
When we reach this step, the excess of the
upper lateral crus comes out of the incision. It
is very important to remove excess cartilage
and mucosa. Otherwise this will close the
internal valve. When you perform the nose
28 Columellar Show 341

28.1 Hanging Columella

Let’s examine a patient who has hanging colu-

mella. Closed technique and extreme cephalic
resection were applied on the patient. The colu-
mella was not elevated enough. Nasal dorsum
and bone/cartilage transition are disturbed, and
there is a left axis deviation. Nose tip bulbosity is
still there. The lateral crura are convex.
342 4 Surgery

Excess resection has been made especially from

the right lateral crus. The lateral crura have there-
fore been cephalically migrated.

28.1.1 Surgery
Excess cartilage and mucosa at the septum cau-
dal side were resected and the nose tip cartilages
exposed.

The fibrosis between the lateral crus and upper

lateral cartilage was released. The new position of
the domes was determined. Generally the lateral
crus is left long in these patients. Hence, a lateral
crural steal was made as needed. The amount of
steal has been discussed above in detail.
28 Columellar Show 343

A 6 mm lateral crural steal was performed in this

patient.

A. This procedure will strengthen the alar rim

B. Since the cephalic dome suture is used
The domes were shaped with cephalic dome
sutures. The lateral and medial crus were hooked
to each other. Thus, the medial crus moved
upward and the lateral crus moved downward.
and take the lateral crus slightly downwards.
between the medial and lateral crus, it
stretches the lateral crus downwards and the
medial crus upwards. In other words, this is a
good solution for patients with both hanging
columella and supratip thickness. But if the
lateral crus is weakened because of extreme
cephalic excision, the cephalic dome suture
cannot show the desired effect. Therefore, we
have to strengthen the lateral crus.

28.1.2 Lateral Crural Cephalic

Strut Graft
One may think of the lateral crural cephalic strut
graft as a step in front of the lateral crural strut
graft. It is similar to a middle crural contour graft,
based on strengthening the weak edge. It serves
the stabilization of the strut cartilage to the
cephalic resection region with a loop suture. If
extreme cephalic resection has been performed,
you can use a thicker graft.
344 4 Surgery

A C’ suture was used.

A strut graft was inserted.

The columellar polygon was shaped.
28 Columellar Show
The stabilized tip aesthetics.
28.1.3 Scroll Graft
When the subperichondrial dissection is per-
formed, you will see the sesamoid cartilages
attached to the scroll ligament. This cartilage deter-
mines the upper edge of the lateral crus. In other
345
words, it blocks the cephalic migration of the lateral
crus as a stopper. This is the logic behind the scroll
graft. When we perform surgery on a patient who
has had previous surgery in the sub-SMAS plane,
we will only see fibrosis in the scroll region. This is
because the ligament and cartilage in this region
were resected and a cartilage defect was created.
Scroll graft is used for the same reason as the
intercartilaginous graft in open rhinoplasty. The
intercartilaginous incision passes exactly below
the area where we insert this graft in closed tech-
nique. Because of this we stabilize our graft to
the SMAS which is equivalent to the scroll liga-
ment. Similar to repairing the scroll ligament
while closing the intercartilaginous ligament, we
also include the scroll ligament graft in the repair
process. Thus, the scroll graft enters between the
lateral crus and upper lateral cartilage and also
prevents the cephalic migration of the lateral crus
as it is fixed to the SMAS.
346 4 Surgery

Spreader grafts were placed for dorsal aesthetic

lines.

28.1.4 Medial Crus Caudal Resection

If the medial crus is wide enough, we can perform
resections until 3 mm. This procedure directly Internal taping was made by using the scroll
elevates the columella. I sometimes use this pro- grafts that were sutured under the SMAS.
cedure in primary rhinoplasty. Non-extreme
hanging medial crura can be treated in this way. If
the hanging cannot be corrected by the cephalic
dome suture, medial crus overlap can be used.
28 Columellar Show 347

The patient’s tenth-day photographs.

348 4 Surgery

Patient Example
Our patient had two surgeries with the open tech-
nique. After the first surgery retraction in the
nasal alae had occurred, and during the second
surgery lateral crural strut grafts were placed. But
neither axis nor tip were corrected. The patient
had a hanging columella. The columella was ele-
vated by means of mucosa and cartilage resec-
tions. The nasal alae were lowered with lateral
crus strut graft and scroll grafts.
Patient one year after surgery.
29 Prescription
29 Prescription
1. Paracetamol with codein in the first 5 days
2. Sea water irrigation ten times a day for 10
days
3. Decongestant tablet 1 × 1
4. Pseudoephedrine spray (use only if bleeding
occurs)
5. Diclofenac sodium SR. Start on the fifth day,
use for 5 days
Internal Splint: If you have performed a sim-
ple septum procedure, remove the internal splint
after 2–3 days. If the septum is deviated too much
or mucosa is torn, this time can be extended up to
5 days.
External Splint: If you are using a plastic splint
you can allow a shower for 2 minutes each day.
Below you can see a sample of the medical
report that I give to my patients:
Complaint: Nasal deformity.
Physical Exam: No breathing problems,
hump, bulbous tip, mid-thickness skin, big nose.
Systemic Examination: Normal.
Surgery: closed technique; septum caudal was
exposed with transfixion incision, septum caudal
was left for 1 mm in the columella, wide dissec-
tion was made until maxilla, nasal dorsum was
dissected in the subperichondrial and subperios-
teal planes, hump was resected extramucosally,
septoplasty was performed, domes were delivered
through the infracartilaginous incisions, autorim
flap 3 mm, lateral crus caudal excision 1 mm,
349
cephalic excision was made from lateral crus
3 mm, a 5 mm steal was made from the left dome
and a 4 mm one from the right, Ti graft, lateral
crus resting angle was corrected with a cephalic
dome suture, lateral crus caudal excision 2 mm, 1
strut graft was inserted and infracartilaginous
incisions were repaired. Bone osteotomy lines
were thinned with Çakır 90 chisel, Libra grafts
were inserted, columellar cartilage was sutured to
septum, dermocartilaginous ligament was kept
intact, scroll ligament was sutured to septum peri-
chondrium, bone dust was placed on nasal dor-
sum and nose radix was elevated, internal valve
region mucosa was sutured together with scroll
ligament and therefore supported, footplates were
sutured to each other with 5/0 Prolene.
Follow-Up: Since no complication occurred
on the first day, the patient was discharged.
Recommendations after Rhinoplasty:
1. Geralgine -K tb 3 × 1. Use if there is pain. It
may make you sleepy. You can take it before
bedtime.
2. Sterimar nose spray 10 × 1. Use for 10 days.
Take a slight breath while spraying it into your
nose and after 2–3 s slightly blow your nose.
Thus you can prevent plugging of the internal
splints.
3. Xylo-Comod (otrivin, iliadin) nasal spray.
This is for precaution. Use only if bleeding
occurs. Spray 2 puffs into each nostril twice
and come to the hospital.
4. Cirrus. We give this to decrease blood circula-
tion in nasal mucosa. Use once a day.
– Sleep with 3 pillows for 5 days.
– Do not stay in hot places.
– Avoid movements that can elevate your
blood pressure. Do not bend your head.
– Try to stay in vertical position when not
sleeping.
– Water does not affect the plastic splint. You
can take a shower for 2–3 min. The splint
can get wet.
– You do not have to apply ice or cold on
your face, as it was applied in surgery and
the surgery was done carefully.
– From the tenth day on, you can use green
tea or parsley to remove edema.
 Patient Analyses
5

1 Case Analysis: A Common

Patient

The patient does not have a facet polygon. The

lateral crus is wide. The nose should be short-
ened, but the ala is floppy. The infralobule is too
short and the upper lateral cartilage too long.

© Springer International Publishing Switzerland 2016 351

B. Çakır, Aesthetic Septorhinoplasty,
DOI 10.1007/978-3-319-16127-3_5
352 5 Patient Analyses

A three-stage incision has been performed

safely. A 3 mm autorim flap has been made. An
additional 2 mm resection will be made from the
lateral crus.

Lateral crus cephalic excision was not planned

for the patient. The lateral crus will only be nar-
rowed caudally. Rotation will be achieved with
upper lateral cartilage caudal resection.

A subperichondrial dissection has been

performed.
1 Case Analysis: A Common Patient 353

Nose tip cartilages were dissected. Another A resection was made with scissors after
cartilage fold was seen on the lateral crus. The cutting with the blade.
domes have been developed on the medial crura.

A resection (1–2 mm) was performed from the

lateral crus caudal edge until rotation was
achieved.

A 2 mm resection from the lateral crus caudal

edge was planned.
354 5 Patient Analyses

The second fold on the lateral crus was

planned to constitute the dome. Tip surgery has
been finished.

One-year photos of the patient.

Alar edge resection has been performed for

the floppy alae. The nostril was reduced using an
avulsion flap.
2 Case Analysis: Thick Skin 355

2 Case Analysis: Thick Skin

In thick-skinned patients, the closed technique

is more advantageous because of less nose tip
edema. With the open technique, patients would
be unhappy in the first months. While the patients
were expecting a smaller nose, their nose would
seem bigger due to edema. In these types of
patients, in spite of diminishing soft tissue, we
are trying to increase the highlights that are
formed on the skin by repairing the Pitanguy and
scroll ligaments.
356 5 Patient Analyses

– Axis deviation to the left

– Septum deviation to the right
– Hump
– Thick skin
– Bulbous tip

Closed technique was applied. The septum’s

caudal was dissected with a transfixion incision.
The nasal dorsum was dissected in the subperi-
chondrial and subperiosteal plane. The hump was
resected. Excision was made from the septum
base.
The domes were delivered through infracarti-
laginous incisions. A 3 mm cephalic incision was
made, followed by a 1 mm caudal excision. A strut
graft was then placed. A 4 mm steal was per-
formed from the lateral crus. The lateral crus rest-
ing angle was fixed using the cephalic dome
suture. The dog ears which formed at the caudal of
the domes were resected.
A 3 mm medial crus overlap was performed.
Low-to-low + external transverse osteotomies
3 Case Analysis: Thick and Oily Skin 357

were performed. Libra grafts were utilized.

Projection control suture.
Surplus mucosa was excised at the membra-
nous septum and internal valve region. The sep-
tum was placed in the midline with scoring. In
the end the depressor was excised.

3 Case Analysis: Thick

and Oily Skin

The nose skin of patients who have a lot of oily

pores will hardly adapt to the new anatomy. It is
difficult to make oily noses smaller, and some-
times one surgery may not be enough. In thick-
skinned noses, when the nose is reduced, the skin
compresses like a bow and tries to return the nose
to its previous shape during the healing period. In
the first surgery that we performed on the patient
below, the nose could not be reduced adequately.
Axis deviation was corrected, but tip projection
was not decreased enough. Surgery in this kind of
patients can cause a long inflammatory period on
the skin. Note the color change on the patient’s
skin.

The second operation was performed one year

later. These are the photographs one year after
the second surgery. A fat injection was made to
the patient’s forehead in order to make the nose
appear smaller.
The columella can react better to nose reduc-
tion, but the alae cannot elevate the same amount.
Projection was decreased. A resection was made
from the alar bases. Alar edge resection was
planned. In order to decrease the skin pores, oral
vitamin A treatment was suggested.
358 5 Patient Analyses

The patient did not use vitamin A. In the third

surgery, the nostril edge resection was performed.
The nasal base was narrowed with external lat-
eral osteotomy without dissection of the nose
skin.
These are the patient’s photographs on the
fourteenth day.
4 Case Analysis: Revision of My Own Case
4 Case Analysis: Revision
of My Own Case
The patient wanted a smaller nose. The tip was
narrow and there existed a depression on the
infralobule. A cartilage hump is still seen. I made
the first surgery using the open technique. Below
there is a view of the cartilages at the beginning
and after surgery. I did not shorten the lateral crus
enough to decrease the rotation and projection.
The resting angle was not corrected adequately.
Before changing to the cephalic dome suture
technique in 2008, my technique was creating
dome triangles with two separate dome sutures.
But this technique is not sufficient for correcting
359
the resting angle. I used this doubled dome suture
only for a short time, since its planning and execu-
tion are difficult.
The closed technique was used. The septum’s
caudal was dissected with a transfixion incision.
A wide dissection was made until the maxilla.
The nasal dorsum was dissected in the subperi-
chondrial and subperiosteal plane. The cartilage
hump was resected extramucosally.
A 2 mm autorim flap and a 1 mm lateral crus
caudal excision were performed. A 3 mm cephalic
excision was made from the lateral crura. Both on
the right and left did I perform a 4 mm lateral
crus steal. Then a 5 mm medial crus overlap was
performed. The lateral crus resting angle was
corrected by the cephalic dome suture.
Three strut grafts were inserted. The Ti point
was supported by the medial crural strut grafts.
The infracartilaginous incision was repaired.
The bone osteotomy line was reduced by
means of a Çakir 90 chisel, and Sheen spreader
grafts were used.
By means of cartilage and mucosa resec-
tions from the caudal septum, the nose was
shortened. The dermocartilaginous ligament
was repaired in the first surgery. The integrity
of the repaired dermocartilaginous ligament
did not deteriorate.
360 5 Patient Analyses

The new placement of the domes was deter-

mined. A 4 mm steal was performed, causing
increase in rotation and decrease in tip projection
while the nose was shortened.

After four years we could perform a subperi-

chondrial dissection on our patient. The revision of
the subperichondrial dissection was much easier.

You can see the Pitanguy ligament below

repaired with a 6/0 Prolene suture. A 5 mm medial crus overlap was made. As a
result the infralobule was shortened by 1 mm.
The footplates were set back posteriorly with the
transfixion incision, and columella projection
was decreased.
4 Case Analysis: Revision of My Own Case 361

Photographs of the patient six months after

revision.
362 5 Patient Analyses

5 Case Analysis: Thick Skin

and Large Hump

In this kind of patients, the skin is too loose

for the new nose. Excess skin can accumulate
in the supra-tip region. In addition, alar resec-
tion was applied to the patient. Alar resection
is also important for the smaller appearance
of the patient’s nose. The patient’s infralobule
polygon is short; therefore, with the lateral steal
procedure, used for rotation, the infralobule will
extend. Left axis and tip deviation exists. Below
are the first-year photographs.
The effect of footplate setback can be seen
clearly in the basal view.

Because of the autorim flap, the caudal edge

highlight of the lateral crus has become more
obvious.
5 Case Analysis: Thick Skin and Large Hump 363

Septum deviation to the left, axis deviation to

the left.
Wide nasal base, wide nose alae.
Thick skin.
Bulbous tip.
Closed technique.
Hump was resected.
The excision was made from the septum base.
The domes were delivered through an infra-
cartilaginous incision.
A 2 mm cephalic excision was made from the
lateral crus.
Left lateral crus steal of 2 mm.
Right lateral crus steal of 3 mm.
A 2 mm lateral crus caudal excision was
performed.
A strut graft was inserted.
The lateral crus resting angle was fixed using
the cephalic dome suture.
Internal high-to-low osteotomy + external
transvers osteotomy.
Spreader flaps.
Projection control suture.
The footplates were sutured to each other with
5/0 Prolene.
Left levator was dissected.
Rim grafts were placed.
The nostrils and alae were reduced using the
avulsion flap and elliptic resection.
364 5 Patient Analyses

6 Case Analysis: Closed

Approach Healing Rate

The patient has a 2–3 mm hump. Her skin is thin

and her tip low. The patient needs a good rotation.
It is necessary to do more steal from the lateral
crus. The left dome is lower, and tip asymmetry is
observable. Hence it will be necessary to steal
more from the left than the right one. The patient’s
infralobule polygon is not very short. As stealing
from the lateral crus increases the infralobule, a
medial crus overlap will be needed. As the
patient’s depressor is active, strut grafts can be
used more than once. Moreover, caudal resection
of the upper lateral cartilage was planned for nose
shortening and rotation. We determine the amount
of resection at the end of surgery. Before closing
the intercartilaginous incision, we resect the pre-
viously protruding upper lateral cartilage. The
patient’s footplate polygon is wide. It might not
be enough to resect the septum inside. Soft
tissue resection between the footplates will be
required. Below you can see the patient’s one-
year photographs.
6 Case Analysis: Closed Approach Healing Rate 365

Left lateral crus steal of 6 mm.

Right lateral crus steal of 5 mm.
Medial crus 3 mm overlap.

The lateral crus resting angle was fixed with a

cephalic dome suture.

Closed technique was used.

One millimeter of the caudal septum was left
on the columellar side.
Wide dissection was made until the maxilla.
Hump was resected extramucosally.
A 1 mm autorim flap and a 2 mm lateral crus
caudal excision were performed.
A 3 mm cephalic excision was made from the
lateral crus.
366 5 Patient Analyses

By making two cuts on the lateral crus, the
scroll facets were created. You can see the
Pitanguy midline ligament in between. A poste-
rior strut graft was sutured to the septum.
noticeable if edema in the lip region pushes the
nose tip further than its position in surgery. This
is generally a temporary effect and requires some
waiting. Protecting the Pitanguy ligament in thin-
skinned patients can cause a depression that will
require revision. During surgery, if the supra-
tip breakpoint is obvious, I dissect between the
superficial SMAS and the Pitanguy wider than
normal. If this is not enough, then I use cartilage
chips grafts.

The patient’s six-month photographs.

Three strut grafts were placed.

Upper lateral cartilage caudal excision 4 mm.
The bone osteotomy line was reduced with a
Çakır 90 chisel and bone rasp.
Libra grafts were placed.
The footplates were sutured to each other with
5/0 PDS.

7 Case Analysis: Supratip

Healing Period

Leaving the Pitanguy ligament intact and repair-

ing the scroll ligament can create an obvious
depression in the supratip region. The effect of
an intact Pitanguy midline ligament can become
7 Case Analysis: Supratip Healing Period 367

Appearance of the cartilages before tip

surgery.
368 5 Patient Analyses

Appearance of the cartilages after tip surgery. 8 Case Analysis: Wide Dorsum,
Wide Radix, Bulbous
Overprojected Tip

Below are the patient’s second-year photographs

after surgery. A revision was planned for our
patient. I have decreased the patient’s tip projec-
tion by moving the footplates posteriorly, but I
did not shorten the lateral crus enough. As the
infralobule polygon length is adequate, I am
planning to make a 3 mm lateral crural steal and
3 mm medial crus overlap. Thus, without chang-
ing the infralobule length, rotation will be
possible.
Hump.
Low tip.
Thin skin.
Closed technique.
One millimeter of the caudal septum was left
on the columellar side.
Nasal dorsum was dissected in the subperi-
chondrial and subperiosteal plane.
Three millimeter lateral crus cephalic
excision.
Two millimeter lateral crus caudal excision
Left lateral crus steal of 3 mm.
Right lateral crus steal of 3 mm.
Medial crus 2 mm caudal excision.
Partial medial crus overlap.
Three strut grafts were put.
Diced grafts for the tip.
The lateral crus resting angle was corrected
using a cephalic dome suture.
Lateral osteoectomy.
Libra grafts were placed.
Columellar cartilage was sutured to the
septum.
Dermocartilaginous ligament was kept intact.
Scroll ligament was sutured to the septum
perichondrium.
Cartilage chips were placed on the nasal dor-
sum, and the nose radix was elevated.
The footplates were sutured to each other with
5/0 PDS.
8 Case Analysis: Wide Dorsum, Wide Radix, Bulbous Overprojected Tip 369

8.1 First Surgery

Closed technique.
Nasal dorsum was dissected in the subperi-
chondrial and subperiosteal planes.
Hump was resected.
Excision was made on septum base.
The domes were delivered through an infra-
cartilaginous incision.
Cephalic excision was made from the lateral
crus.
A 3 mm lateral crural caudal excision was
performed.
A strut graft was inserted.
A 2 mm dome cephalic excision was made.
The lateral crus resting angle was corrected
using the cephalic dome suture.
Osteotomy low-to-low + external transverse.
Libra grafts were inserted.
Projection control suture.
Dermocartilaginous ligament was repaired.
Cartilage chips were placed on nasal dorsum.
Mucosa of the scroll region was sutured with
dermocartilaginous ligament and supported.
Excess mucosa in membranous septum and
internal valve region were excised.
Z-plasty was applied to the nostril base.
370 5 Patient Analyses

8.2 Second-Year Revision Let’s examine the second surgery

photographs.
Closed technique In the previous surgery an infracartilaginous
Middle of the septum caudal was put forward incision had been made. Now a 2 mm autorim
with transfixation incision. flap was performed.
One millimeter of caudal septum was left in
the columella.
A wide dissection was made until the maxilla.
Nasal dorsum was dissected at subperichon-
drial and subperiosteal plane.
A graft was taken from the septum.

Note
As I had not performed an L septoplasty in the first
surgery, there was enough graft in the septum.

Domes were delivered with rim incision.

Autorim flap: 2 mm.
Lateral crus caudal excision: 1 mm.

Note
It is possible to perform an autorim flap in
patients who have a revision.

Another lateral steal was planned, but not per-

formed due to fibrosis. A 3 mm overlap was
applied to the lateral crus near the dome.
A 4 mm incision was made for the scroll
section.
The domes’ positions were fixed by means of
a cephalic dome suture.
One strut graft was inserted.
Bone osteotomy lines were reduced with a
Çakır 90 chisel. Bone rasp. Osteotomy was
applied in the first surgery.
Sheen spreader graft to the right.
Columellar cartilage was sutured to the septum.
The dermocartilaginous ligament is intact.
The scroll ligament was sutured to the septum
perichondrium.
Cartilage chips and rasped bone were placed
for dorsal camouflage.
Internal valve region mucosa was sutured with
the scroll ligament and supported.
Nostrils were reduced.
8 Case Analysis: Wide Dorsum, Wide Radix, Bulbous Overprojected Tip 371

You can see the shapes of the domes after two

years, if a cephalic dome suture was used.
Because of the fibrosis it was impossible to per-
form a lateral steal. As a result a 3 mm overlap
was made to the lateral crus near the dome.

The subperichondrial dissection was easier

than in the first surgery. The previous surgery had
also been performed in this plane.
372
The current domes were fixed with a cephalic
dome suture, and the tip was shaped.
Important
PDS will be sufficient for the shaping of the
nose tip. There is no need for permanent sutures.
Below you can see the two-year postoperative
5 Patient Analyses
photos of a tip surgery in which PDS was used.
If PDS was used in the first surgery of a patient,
then you do not need to clean the permanent
sutures. A round needle will be less damaging to
the cartilages.
One year after the secondary rhinoplasty.
9 Case Analysis: Fractured
Nose, Operated Twice
The patient had a trauma history. He had previ-
ously had two surgeries. In the first one, only
resections had been performed. In the second sur-
gery, a bone graft had been used. The projection
is very low and the nasolabial angle very narrow.
The tip is very bulky and asymmetrical. The bone
graft for nasal dorsum in not adequate, as it has
enlarged the nasal dorsum.
9 Case Analysis: Fractured Nose, Operated Twice 373

We choose a fusiform nasal dorsum graft in

patients who have serious nasal dorsum defi-
ciency. The rib graft is carved to give it fusiform
shape. If the graft is not high enough, cartilage
chips can be placed underneath. Bending does
not occur in rib block cartilage. Since the base
is carved concavely, it fits into the nasal defect.
Cartilage chip grafts also fill spaces and stabilize
the graft. In the one-year photos of the patient,
you can see that the fusiform form has taken
its shape in the nasal dorsum. From the lateral
view, a smooth nasal dorsum is created, but in
the oblique view a little hump can be seen. In the
first months, the patient’s nose tip skin was red.
This redness was due to multiple surgeries. In the
first year, redness was much less. In this patient,
a shield graft, block cartilage behind the shield
graft, and lateral crural strut grafts were used.
Since we inserted so many grafts, the patient’s
nose had a rigorous structure. We do not prefer
structural rhinoplasty in primary cases.

First-year photos of the patient.

Note
The graft that I prepared from the rib was similar
to the silicon graft that Gunter uses for saddle
nose. I gave the base of the graft a concave shape.
Thus, the graft stabilizes. I have never seen
bending in grafts prepared in this way. The graft
can bend if it is thick. Therefore, Gunter inserts a
K-wire into the graft. Since I reduce the thickness
of the graft, I have to use additional grafts under
the block cartilage to compensate for the thick-
ness loss.
374 5 Patient Analyses

9.1 Surgery

Open technique.
Nose anatomy was totally deteriorated.
Bone graft was removed from the nasal dorsum.
The right eighth rib was harvested, shaped, and a
fusiform shape was obtained. Diced and block carti-
lages were used for dorsum reconstruction. Cartilage
chips were placed under and around the graft.
Strut graft.
Lateral crural strut.
Long shield graft.
Behind the shield a block graft.
Diced and block cartilages in front of the
maxilla.
The tip grafts were covered with
perichondrium.

10 Case Analysis: Long Nose

In these patients you have to perform upper lat-

eral cartilage and septum caudal cartilage and
mucosa resections. Otherwise it is very difficult
to shorten the nose length. In this patient 1.5 cm
mucosa was resected. Note the apparent appear-
ance of the lips in the front view. Resection was
only made from the cephalic edge of the lateral
crus. If an autorim flap had been chosen, the nose
tip could have been narrower. In the basal view,
minimal alar retraction has occurred.
10 Case Analysis: Long Nose 375
376 5 Patient Analyses

11 Case Analysis: Cephalic

Malpositioning

First-year photos of the patient.

11.1 Surgery Photos

In the single-flash photos cephalic malposition is

more distinct.
11 Case Analysis: Cephalic Malpositioning 377

Lateral crural steal.

Autorim flap.

Determination of the new domes’ position.

Since the patient’s lateral crus is long and con-

vex and the resting angle distorted, there appears to
be a cephalic malposition appearance. The domes
Equalization of domes and strut graft.
have been formed on the weak medial crura.
378 5 Patient Analyses

Stabilization of the columellar polygon.

The infralobule polygon was made distinct

with medial crural contour grafts. The height of
the Ti points was increased.

12 Case Analysis: Closed

Approach Revision

First-year photos.
12 Case Analysis: Closed Approach Revision 379
380 5 Patient Analyses

Before, closed rhinoplasty had been performed. 12.2 Surgery Photographs

Long nose.
High projection.
Insufficiently removed hump.
Thick nasal alae and big nostrils.
Normal infralobule height.

12.1 Operation

Closed technique.
Septum caudal was exposed with transfixion
incision.
Nasal dorsum was dissected in the subperi-
chondrial and subperiosteal planes.
Hump was resected.
The excision was made from the septum base. Marking and symmetry test.
Deviated vomer was excised.
The domes were delivered through infracarti-
laginous incisions.
A 3 mm cephalic excision was made from
each lateral crus.
Left lateral crus steal of 6 mm.
Right lateral crus steal of 4 mm.
Medial crura 4 mm overlap.
Two millimeter upper lateral cartilage caudal
excision.
A strut graft was placed.
The lateral crus resting angle was corrected
using the cephalic dome suture.
Sheen spreader grafts.
Projection control suture.
Excess mucosa was excised from the membra- Lateral steal simulation.
nous septum and internal valve region.
Depressor was resected.
Transfixion incision was repaired.
Lateral crural strut.
Nostril was reduced.
13 Case Analysis: Overrotated Saddle Nose 381

The final view after tip surgery.

13 Case Analysis: Overrotated

Saddle Nose

First-year photographs.
382 5 Patient Analyses

Closed surgery had been performed twice

before. Ear cartilage and hip bone have been
harvested.
Saddle nose.
Septum is completely removed.
Tip overrotated.
Tip is very bulky.
The incision has been made to the alar edges
and cartilage grafts have been inserted.
13.1 First Operation

Open technique.
Right eighth rib was harvested and shaped.
All of the cartilage grafts in the nose were
removed.
The fusiform block graft prepared from the rib
was placed into the nose dorsum.
Cartilage chip grafts were placed around the
rib graft.
In order to decrease tip rotation, cartilage sup-
ports were put between the rib graft and the tip
graft.
Lateral crural struts were placed.
You can see the graft prepared from the rib.
In the previous surgeries, both composite and
cartilage grafts were taken from the ear.

Note
I prefer an incision from the back of the ear for
cartilage harvesting. One of the most appropriate
locations for the composite graft (skin-cartilage)
is the cymba conchae. For defects in this region,
a full thickness skin graft from the back of the ear
can be used.
13 Case Analysis: Overrotated Saddle Nose 383

13.2 Second Operation

I operated on the patient one year later for minor

revisions.
Retraction at the facet polygon.
Nasal dorsum irregularities.
Wide nasal base.
Bulbous tip.

13.3 Surgery

Closed technique.
Nose radix was reduced by 2 mm.
Composite and cartilage grafts were taken
from the right ear.
Nose base was narrowed with lateral
osteoectomy.
In order to make the left dorsal aesthetic lines
distinct, cartilage grafts were placed inside.
Crushed grafts were inserted into the tip.
Composite grafts were places after making an
incision from 2 mm inside of the alar free edges
for the notches on the facet polygon.
See the six-month photos after the second
operation.
384 5 Patient Analyses
13 Case Analysis: Overrotated Saddle Nose 385

Adaptation of composite grafts. You can see the shape of the patient’s nose
after the open technique reconstruction and addi-
tional procedures in closed technique. The sur-
geon should know both open and closed
techniques in rhinoplasty for managing these
patients. Performing the open approach on a nose
that received a lot of grafts will disturb the previ-
ous interventions. As the region feeding the com-
posite graft was dissected, the success of the graft
take could diminish. Necessary procedures were
made by opening tunnels only.
386 5 Patient Analyses

14 Case Analysis: Thin Skin

The patient’s before and after photos illustrate

that the skin was so thin that the nose cartilages
could be seen clearly. In these patients, the soft
tissue can best be protected by subperichon-
drial dissection, and surgery for the cartilage
will cover the perichondrium of the cartilage.
You can see the patient’s photographs after one
year.
14 Case Analysis: Thin Skin 387
388 5 Patient Analyses

15 Case Analysis: Thin Skin,

Deviated Nose, Tip
Asymmetry

First-year photos.

Bulging in the right lateral crus was treated

with lateral crus overlap, but even the overlap
caused bulging in the skin.
16 Case Analysis: Tip Asymmetry 389

16 Case Analysis: Tip

Asymmetry

The patient’s septum deviation caused asymme-

try in the right lateral crus, domes and nose axis.
The photographs show the patient one year after
surgery.
390 5 Patient Analyses

17 Case Analysis: Thick Skin,

Low Radix and Cephalic
Malpositioning
18 Case Analysis: Saddle Nose, Notched Nostril 391

17.1 Surgery

Closed technique
The septum’s caudal was exposed with trans-
fixion incision.
Nasal dorsum was dissected in the subperi-
chondrial and subperiosteal planes.
Hump was resected.
The excision was made from the septum base.
The deviated vomer was excised.
Domes were delivered with infracartilaginous
incision.
Lateral crus cephalic excision was made: 3 mm.
Lateral crus caudal excision was made: 2 mm.
Lateral crus steal of 3 mm.
A strut graft was inserted.
Lateral crus resting angle was corrected with
cephalic dome suture (6/0 PDS).
Dog ears that formed at the caudal of dome
were resected.
The infracartilaginous incision was repaired.
Osteotomy was high-high-to-low + external
transverse.
Libra grafts were placed.
Projection control suture.
The dermocartilaginous ligament was plicated
without cutting.
Study the patient’s nose tip polygons at the room
light.
Note
I use Pitanguy plication in patients who have
thick skin and a non-distinct nose tip. But I use
that technique very rarely, as it is a difficult con-
trolled technique.

Radix was augmented.

Cartilage chips were placed in the nasal dorsum.
Mucosa of the scroll region was sutured with
dermocartilaginous ligament and thus
supported.
Excess mucosa in membranous septum and
internal valve were excised.

Hump 18 Case Analysis: Saddle Nose,

Thick skin Notched Nostril
Cephalic malpositioning
Short columella Below see the photos of the patient in the first
Wide footplate year.
392 5 Patient Analyses
18 Case Analysis: Saddle Nose, Notched Nostril 393

18.1 Surgery Photographs

394 5 Patient Analyses

19 Case Analysis: Very Short

Infralobule, Very Narrow
Facet Polygon

The patient’s first-year photos.

20 Case Analysis: Saddle Nose, Hanging Nostril 395

19.1 Surgery Photographs A strut graft was inserted.

Lateral crus steal of 5 mm.
Lateral crus resting angle was corrected with
cephalic dome suture. Dog ears that had formed
in the caudal of the dome were resected.
Osteotomy low-to-low + external transverse
Sheen spreader grafts
Projection control suture
Dermocartilaginous ligament was plicated
without cutting.
Cartilage chips were placed in nasal dorsum.
Excess mucosa in membranous septum and
internal valve region was excised.

No facet polygon
Left axis deviation 20 Case Analysis: Saddle Nose,
Septum deviation to left Hanging Nostril
Nose hump
Thick skin The patient had a serious trauma to the nose and
Droopy tip the entire septum had been removed by the
surgeon.
A rib graft was taken, and fusiform hump car-
19.2 Surgery tilages were prepared and supported with a strong
strut graft. By placing block cartilages behind the
Bilateral inferior concha SMR. columella, the latter received support. When this
Septum caudal was exposed by means of a proved insufficient, the nasal ala was elevated
transfixion incision. with free edge skin resection.
Nasal dorsum was dissected in the subperi- Below are the photos of the patient in his
chondrial and subperiosteal planes. second year.
Hump was resected.
Excision was made in septum base.
Deviated vomer was excised.
Domes were delivered with infracartilaginous
incision.
Only caudal excision was made from the lat-
eral crus. Cephalic excision was not performed.

Note
Performing a direct resection from the lateral
crus caudal part in thick-skinned patients does
not cause nostril asymmetry. When I compared
my direct resection results with the autorim flap
technique, I found the autorim flap technique
much safer.
396 5 Patient Analyses

21 Patient Example:
Bulbous Tip
22 Patient Example: Thin Skin, Big Nose 397

22 Patient Example: Thin Skin,

Big Nose
398 5 Patient Analyses

23 Patient Example: Thin Skin,

Pseudocephalic
Malpositioning and Tip
Asymmetry
24 Case Analysis: Tension Nose 399

24 Case Analysis: Tension Nose

400 5 Patient Analyses

24.1 Surgery

Hump was resected.

Excision was made from septum base.
Deviated vomer was excised.
Domes were delivered with infracartilaginous
incision.
Cephalic excision was made from the lateral
crus.
Left lateral crus steal of 3 mm.
Right lateral crus steal of 3 mm.
With a cephalic dome suture, the lateral crus
resting angle was corrected.
Two strut grafts were placed.
Osteotomy internal high-to-low + external
transverse
Libra grafts were placed.
Projection control suture.
Dermocartilaginous ligament is intact.
Cartilage chips were placed in nasal dorsum
and nose radix was elevated.
Excess mucosa in membranous septum and
interval valve region was excised.
Right lateral crural strut was placed.

25 Case Analysis: Thin Skin,

Tension Nose

Tension nose
Short infralobule polygon
Thick skin
Anterior maxillary spine is hypertrophic.
Because of this, the footplates are anteriorly
placed.
26 Case Analysis: Ideal Patient for the Closed Approach 401

26 Case Analysis: Ideal Patient

for the Closed Approach

Patient’s photos in her first year.

402 5 Patient Analyses

26.1 Surgery

Unilateral transfixion and intercartilaginous inci-

sions were used. The septum was corrected and a
graft taken from it.
The nasal dorsum was filled with cartilage
grafts. Surgery was finished in 1.5 hours, and we
did not risk its shape as we did not touch the nose
tip. The healing period was short. There was no
need to take any more cartilage graft from any
other site.

27 Case Analysis: Learning

from a Patient

The patient’s nose tip facets are beautiful, but she

has a hump and a wide nose base. I had planned
to increase the nose tip rotation. The nostrils
were very big, and therefore a narrowing proce-
dure was planned. The hump was removed with
the closed technique. The base and skeleton were
narrowed with osteotomy. A minimal cephalic
resection was made from the lateral crus. The
photographs show the patient three years after the
operation. If one has to find fault, the lateral view
is beautiful, but while smiling her nose tip seems
to be droopy. Shortening the lateral crus length
for about 2–3 mm will yield better results. I no
longer perform surgery without seeing the dome.

The patient had fallen on her nose. She had

been happy with her nose before the fall and
wanted its shape back. The septum was broken
due to trauma and had folded inwards. Her nose
tip is beautiful.
28 Case Analysis: Bulbous Tip 403

28 Case Analysis: Bulbous Tip

The patient’s skin is thin. Supratip skin is abun-

dant and a possibility of supratip deformity is
present.
Skin redrape was controlled with the Pitanguy
ligament and scroll ligaments. Below are the
patients’ first-year photographs. It was shaped
without using tip grafts. Dorsal aesthetic lines
were created by using Libra grafts.
404 5 Patient Analyses

A 3 mm lateral crus cephalic resection was

performed.
A 2 mm lateral crus caudal resection was
done.
Lateral crus steal of 3 mm.
Depressor nasi muscle was resected.
Libra graft technique was used.

29 Case Analysis: Thin Skin,

Axis Deviation
and Breathing Problems

– Closed rhinoplasty
– Mentum hyaluronic acid filling
– Ramus of mandible hyaluronic acid filling
– Orthognathic treatment

The photographs show the results three years

after surgery.
29 Case Analysis: Thin Skin, Axis Deviation and Breathing Problems 405
406 5 Patient Analyses

30 Case Analysis: Thick Skin,

Bulbous Tip
and Deviated Nose

– A 6 mm steal was performed on the lateral

crus.
– A 2 mm medial crus overlap was made.
– Libra graft
– Alar elliptic resection

Below are the photographs of the patient in

her first year.
31 Case Analysis: Medium-Thick Skin 407

Cephalic excision was made from lateral crus

3 mm.
Left lateral crus steal of 5 mm.
Right lateral crus steal of 5 mm.
With a cephalic dome suture, the lateral crus
resting angle was corrected.
Two strut grafts were placed.
Upper lateral caudal trim 2 mm.
Osteoectomy.
Libra grafts were placed.
Projection control suture.
Dermocartilaginous ligament is intact.
Cartilage chips were placed in the nasal dor-
sum and the nose radix was elevated.
Footplates were sutured together.
Nostril reduction was performed.

31 Case Analysis: Medium-Thick

Skin

Hump
Bulbous tip
Thick skin
Droopy tip
Low radix

31.1 Surgery

The hump was resected.

Excision was made from the septum base.
Domes were delivered with infracartilaginous
incision.
Autorim flap 3 mm, lateral crus caudal trim
1 mm.
408 5 Patient Analyses

31.2 Surgery Photographs

31 Case Analysis: Medium-Thick Skin 409
410 5 Patient Analyses
32 Case Analysis: Revision for Droopy Tip 411

32 Case Analysis: Revision for

Droopy Tip

Previous open surgery

Droopy tip
Forehead and cheeks are retruded.
412 5 Patient Analyses

32.1 Surgery

A rib graft was harvested

Domes were delivered with infracartilaginous
incision.
Cephalic excision was made from the lateral
crus 3 mm.
Left lateral crus steal of 3 mm.
Right lateral crus steal of 3 mm.
With a cephalic dome suture, the lateral crus
resting angle was corrected.
A strut graft was placed.
Upper lateral caudal trim 3 mm.
Osteoectomy.
Projection control suture.
Radix was reduced.
Fat injection to forehead and cheeks.
33 What Not to Eat Before Surgery 413

33 What Not to Eat Before

Surgery

Sulphur-containing garlic is known to increase

the risk of bleeding, and therefore it must be dis-
continued before surgery. Flatulent foods like
mixed herbal tea, beans, broccoli, and milk
should not be consumed excessively. It is neces-
sary to avoid mineral water which has a high
sodium content and pickles which have a high
salt content to prevent edema. Foods and spices
that cause acquired platelet function disorders,
such as are onion, cumin and Chinese food,
should not be consumed.
Fruits: Apricot, Pineapple.
Vegetables: Lettuce, green peppers, tomatoes.
Spices: Red pepper, thyme, rosemary,
anise, sage.
Phenol-containing foods: Raisins, blueberries,
raspberries, strawberries, peanuts, green tea,
plum, pear, cherry, pomegranate, grape, oranges,
broccoli, cabbage, chervil, onions, cocoa.
Mainly anthocyanidins: Cyanidin (peaches,
cherries, figs, plums, raspberries, currants, red
cabbage), Malvidin (at some grapes), Pelargonidin
414
(strawberries, red radish, mulberry), Peonidin
(bogs cranberry), Petunidin (American grapes).
Containing catechins: cocoa and green tea.
Containing Omega 3: Walnut, almond, soy,
flax seeds, legumes.
34 After Surgery: A Few Notes
– For the next five nights, sleep with three
pillows.
– Do not stay in very warm places.
– Keep away from bleeding-enhancing food for
the first ten days.
– Do not use vitamin pills or other nutritional
supplements.
– Avoid activity that can increase your blood
pressure. Do not bend your head.
– Try to remain in a vertical position except
when sleeping.
– You can go outside after the second day.
– Plastic splints are not affected by water. You
can shower every day for 2–3 minutes. You
5 Patient Analyses
can wet the splint. However, do not expose it
to vapor.
– It is not necessary to apply cold or ice to your
face.
– Internal splints placed in the nose create a
flu-like feeling and cause a sneezing reflex.
Do not panic. Sneeze with your mouth open.
Sneezing will not disturb the nose.
– Do not exercise for one month.
– Do not swim in the sea for one month and in
the pool for two months.
– Do not wear glasses for two months.
– You can use lenses after nose surgery.
– It is not necessary to avoid the sun if you do
not have bruising. Do not sweat because of
heat.
– You can use anti-edema foods like green tea,
chervil, and pineapple starting from the tenth
days.
THANK YOU FOR YOUR ATTENTION.
Barış Çakır, MD. For inquiries and comments,
please e-mail drbariscakir@gmail.com.
 Index

A Blunt perichondrium elevator, 164

Alar rim edge excision Bone paste, 85
incision, 311 Bone scissors, 35–36, 128, 328
marking, 311
resection, 312
suture, 312–317 C
Arkansas stone, 254 Cakir perichondrium elevator, 36
Autorim flap technique Cakir periosteum elevator, 36, 113, 115
ala retractions, 145 Camouflage techniques, 85, 183, 324
alar support, 158 Cartilage anatomy, 47, 48, 55, 69
bulbous cartilage, 150 Cartilage hump, 126, 274, 281, 359
cartilage surface, 154 Cavity polygon, 61
caudal excess, 148, 160 Cephalic malpositioning
cephalic dome sutures, 156 patient analyses
cephalic migration, 150 autorim flap, 377
cephalic resection, 155 columellar polygon, 378
cephalic trimming, 147 domes and strut graft, 377
columellar strut graft, 156 infralobule polygon, 378
convex lateral crura, 149 lateral crural steal, 377
C suture, 157 single flash photo, 376
desired facet polygon, 152 resting angle
dissection, 154 autorim flap technique, 79
dome lights, 159 insufficient cartilage in nose wings, 79
facet polygon, 145 lateral crus repositioning surgery, 78
lateral crus caudal resections, 145 medial canthus, 78
medial crus, 153 repositioning technique, 80
mucosa, 153 subperichondrial dissection, 79
narrow facet polygon, 152 Choking graft sutures, 222
nostril, 162 Closed approach
preoperative photograph, 158 healing rate
in situ cartilages, 151 closed technique, 365
structural grafts, 159 depressor, 364
subperichondrial plane, 154 infralobule polygon, 364
thin skinned patient, 146 scroll facets, 366
Awareness, 40 soft tissue resection, 364
ideal patient for, 401–402
revision
B lateral steal simulation, 380
Bayonet forceps, 257, 325, 330 marking and symmetry test, 380
Black dots, 18 operation, 380
Block cartilage, 52, 53, 336–337, 374, 395 tip surgery, 381

© Springer International Publishing Switzerland 2016 415

B. Çakır, Aesthetic Septorhinoplasty,
DOI 10.1007/978-3-319-16127-3
416 Index

Columellar show nose radix, 19

autorim flap technique, 340 technique
closed technique, 340 alae rim resection, 25
hanging columella blunt radix, 25
closed technique and extreme cephalic dorsal aesthetic lines, 24
resection, 341 fat injection, 21, 25
lateral crural cephalic strut graft, 343–345 forehead nose transition, 21
medial crus caudal resection, 346–349 nose surgery, 20
scroll graft, 345–346 postoperative results, 21
surgery, 342–343 rhinoplasty, 21
retracted nasal alae, 339 sagging alae, 25
upper lateral cartilage caudal resection, 340 surgical plan, 26
Computer imaging designs, 10, 16 tip shadows, 24
Concha “F” value, 8
hypertrophic concha, 101
radiofrequency cauterization, 101
SMR G
bone pieces, 103 Glabellar polygon, 53
cavernous tissue, 102 Gummy smile deformity, 138, 139
concha bone, 105, 106
conchal mucosa, 104
electro cautery, 104 H
elliptic resections, 102 Hanging columella
inward collapsed maxillary base, 106 closed technique and extreme cephalic resection, 341
local anesthesia, 101 lateral crural cephalic strut graft, 343–345
normal anatomy, 106 medial crus caudal resection, 346–349
saline solution, 101 scroll graft, 345–346
segmental outfracture, 106–107 surgery, 342–343
septum base, 105 Hematoma, 123
silicon splint, 104 Hemitransdomal suture, 196, 199
Webster triangle out fracture, 106

I
D Intracath, 19, 28, 288
Daniel perichondrium elevator, 36, 37, 124, 125, 166 ISO, 8
Defatting, 297
Degussit (Al2O3), 38
Dome anatomy, 57 J
Dome spanning, 57, 63 Jaw and cheek
Dome symmetry test, 195–196, 326 arkansas stone, 38
Dome triangles, 54–57, 204, 217 bone scissors, 35–36
Dorsal bone polygon, 53, 84–85 under chin approach, 28
Dorsal cartilage polygon, 53, 83–84 chin augmentation, 28
elevator, 36–37
eyelash and nose relation, 33
E forehead fat injection, 30
Esthetician, 18 gray intracath, 28
Extreme grafting, 61 hook, 37
illusion effect, 32
lateral osteotomes, 37
F medpor implants, 28
Fish-eyed photo, 7 monocryl stitch, 28
Focus settings, 8 needleholde, 35
Forehead fat grafting osteotomes, 36
cannula, 19 osteotomy chisels, 37
chin prostheses, 19 rasp and saw, 36
fat injection, 19 scissors, 35
lipofilling, 19 subperichondrial dissection, 34
nose aesthetics, 19 sutures, 38
Index 417

L redrape problems, 264

Lateral crus subperichondrial dissection scratching movements, 257
autospreader flap technique, 162 superficial bone asymmetries, 256
blunt perichondrium elevator, 164 unsuccessful osteotomy, 263
cephalic malposition, 177 osteotomy, 252–254
Daniel elevator, 166 periosteum dissection, 114–122
domes, delivering, 168–175 scroll groove, reconstruction of
ellipse model, 184–185 5/0 Monocryl, 283
internal bandaging, 165 scroll sesamoid cartilage, 284–286
marking and resections, 175–177 septum mucosa, 283
observations, 177–181 septal angle, 108–110
scroll ligament, 165 short nasal bones, 278–280
secondary rhinoplasty, 167–168 subperichondrial dissection
sesamoid cartilages, 165 bleeding, 123
thoery, 181–183 camouflage effect, 123
tools, 163 ligaments, 123–124
Learning, nose drawing muscle function, 122–123
polygons, 39 nose healing, 122
sculpture classes, 39 open approach, 110–114
sketch from front, 40–41 transfixion incision, 107
Little Cottle elevator, 36, 37 upper lateral cartilage mucosa dissection,
124–126
Nasal polygons
M Cakir polygons vs. Sheen’s
Mass polygons, 53, 65 aesthetics, 51–53
Maxillary spine, 325 columellar polygon, 61–62
Menstrual delaying medicine, 19 dome triangles
Millimeter autorim flap, 242 cartilage anatomy, 55
Mucosa surplus, 330 cephalic dome suture, 56, 57
Mucosa vasoconstriction, 96 cubic forms, 57
Muscle function impairment, 122 facet polygon, 56, 57
horizontal mattress suture, 57
lateral and medial crura, 55
N organic models, 57
Nasal dorsum surgery tip sutures, 55
bone dust and cartilage paste, 276–278 Ti, Ts and Rm points, 54
dorsal bone resection, 128–130 dorsal aesthetic lines
dorsal cartilage resection, 126–127 fusiform anatomy, 87
dorsal reconstruction, males, 280–281 Libra graft technique, 87
dorsum height, 252 nasal dorsum, 87
intercartilaginous incision, 108 nose aesthetic design, 87
nasal radix, 130–131 oblique view, 87
nasal tip, stabilization of, 281–283 review, 90
osteoectomy technique rib graft, 88, 89
aspirator tip, 258 dorsal bone polygon, 84–85
blind chisel, 257 dorsal cartilage polygon, 83–84
bone massage, 266–267 facet polygons
bone saw dusts, 257 destruction, 64
bone surface problems, 263 dome polygon, 63, 65
breathing problems, 265 infralobular polygon, 63
bruising, 263 lateral crus, caudal edge of, 63
control, 262 middle crus, 63
function, 263 non-anatomical sutures, 63
instruments, 258–262 open surgery technique, 64
Libra graft, 269–271 pinched nose deformity, 64
nasal dorsum cartilage, 274 footplate polygon, 62–63
nasal dorsum control, 271–274 infralobular polygon, 60
rasp, 255 infratip triangle, 53
reconstruction, nasal dorsum, 267–268 interdomal triangle
418 Index

Nasal polygons (cont.) suturing of, 143

dome divergence, 59–60 transfixion incision, 141
facet polygon, 58 head lamp, 99
photoshop, 58 internal splints, 288
rim graft, 58 internal taping
rotation differences, 58 new SMAS anatomy, 291–292
lateral aesthetic lines, 92 Pitanguy ligament, 292–294
lateral bone polygons, 86 internal valve functions, 288
lateral crus polygons, 65 lights, operating room, 99–100
mobile tip area local anesthesia
space polygons, 53–54 Bupivacaine, 98
mass polygons, 53 infiltration, 97
non-mobile nose, 53 infraalveolar and supratrochlear blocks, 98
polygon model, 93–94 Lidocaine, 98
resting angle nasal dorsum dissection, 99
cephalic dome suture, 66 nasal dorsum surgery, 107–131, 252–287
cephalic malpositioning, 78–80 nostril surgery
convex lateral crura, 78 avulsion advancement flap, 302–307
incorrect resting angle, 70–71 avulsion advancement flap and elliptic resection
long lateral crura, 71–77 combination, 307–311
surgical techniques, 66 composite graft, 316–317
vertical compression test, 67–70 hanging alae, 311–316
wide lateral crura, 71 problems and solutions, 299
scroll facet thick alar base, 299–302
cephalic dome suture, 80 patient position and tracheal intubation,
dome cartilages, 81 95–96
open technique, 82 Pitanguy ligament, 289–290
transdomal sutures, 82 postoperative care, 318–320
scroll line, 83 prescription, 349
tip breakpoints, 54 redrape
tip defining point, 53 camouflage, 297
upper lateral cartilage polygons, 85–86 dissection borders, 295–296
Nasal surgery internal taping, 296–297
additional grafts ligaments, 296
extra columellar strut, 297–298 results
rim graft, 298 cephalic dome suture, 196–198
basic surgical steps, 101 cephalic malpositioning, 238–251
cartilage grafts cephalic malposition view, 186
rib cartilage, 334–339 C’ graft, 221–222
septal cartilage, 334 closure of tip incisions, 231–232
cleaning, 99 columellar breakpoint (C’ point), 218
columellar show columellar polygon stabilization, 229–230
autorim flap technique, 340 columellar strut graft, 213–218
closed technique, 340 Control 1, 198
hanging columella, 339, 341–349 Control 2, 198–205
retracted nasal alae, 339 C’ suture, 218–221
upper lateral cartilage caudal resection, 340 domes, suturing, 211–213
concha, 101–107 dome symmetry test, 195–196
deviated nose footplate setback, 187–193
left axis noses, 320–321 infralobular caudal contour graft,
nasal dorsum resection, 323–324 222–228
reference points, 321–323 interdomal graft, 251–252
septoplasty, 324–325 lateral crus steal procedure, 193–195
septum deviation, 320 medial crus overlap, 205–211
tip surgery, 325–334 nose movement, 186
drains, 288 surgery, 187
drawings, 100–101 tip asymmetry, 232–238
footplates septum, 131–140
anterior maxillary spine resections, 142 superficial SMAS, 290–291
contralateral footplate, 141 taping, 317–318
septum cartilage, 140 tip surgery, 143–185
Index
Nasolabial angle, 42, 184
Needle hooks, 229
Nose drawing
design, 39
learning
polygons, 39
sculpture classes, 39
sketch from above and below, 44–47
sketch from front, 40–41
sketch from side, 42–44
patient photographs, analysis of, 48–49
Nose sculpture, 45, 51
Nostril sill anatomy, 40, 302, 307
O long nose, 374–375
Open roof, 36, 85, 262, 264
Oral Vitamin A, 18, 119
Organic models, 53, 57
Osteoectomy technique
aspirator tip, 258
blind chisel, 257
bone massage, 266–267
bone saw dusts, 257
bone surface problems, 263
breathing problems, 265
bruising, 263
control, 262
function, 263
instruments, 258–262
Libra graft, 269–271
nasal dorsum cartilage, 274
nasal dorsum control, 271–274
rasp, 255
reconstruction, nasal dorsum, 267–268
redrape problems, 264
scratching movements, 257
superficial bone asymmetries, 256
unsuccessful osteotomy, 263
P bulbous tip and deviated nose, 406–407
Paraflash system, 5, 7, 8
Patient analyses
after surgery, 414
bulbous tip, 396–397, 403–404
cephalic malpositioning
autorim flap, 377
columellar polygon, 378
domes and strut graft, 377
infralobule polygon, 378
lateral crural steal, 377
single flash photo, 376
closed approach
healing rate, 364–366
ideal patient for, 401–402
revision, 378–381
common patient
alar edge resection, 354
lateral crus caudal edge, 353
nose tip cartilages, 353
419
nose tip rotation, 402
resection, 353
rotation, 352
subperichondrial dissection, 352
dermocartilaginous ligament, 359
dome triangles, 359
droopy tip, 411–413
footplate setback effect, 362
fractured nose, operated twice
calvarium bone graft, 372
cartilage chip grafts, 373
fusiform nasal dorsum graft, 373
resection, 372
silicon graft, 373
surgery, 374
mid-thick skin
surgery, 407–408
surgery photographs, 408–411
open technique, 359
overrotated saddle nose
cymba conchae, 382
first operation, 382–383
second operation, 383
surgery, 383–386
Pitanguy ligament, 360
6/0 Prolene suture, 360
saddle nose
and hanging nostril, 395–396
and notched nostril, 391–393
subperichondrial dissection, 360
supratip healing period
depression, 366
nasal dorsum, 368
Pitanguy ligament, 366
scroll ligament, 366
tip surgery, 367
before surgery, 413–414
tension nose, 399–400
tension nose and thin skin, 400–401
thick skin
and huge hump, 362–363
low radix and cephalic malpositioning, 390–391
and oily skin, 357–358
patients, 355–357
thin skin
axis deviation and breathing problems, 404–405
big nose, 397–398
deviated nose and tip asymmetry, 388–389
patients, 386–387
pseudocephalic malpositioning and tip
asymmetry, 398–399
tip asymmetry, 389–390
very short infralobule and very narrow facet polygon,
394–395
wide dorsum, wide radix and bulbous overprojected
tip
first surgery, 369
infralobule polygon length, 368
two year revision, 370–372
420 Index

Patient photographs autorim flap technique, 79

camera settings, 7–8 ‘insufficient cartilage in nose wings, 79
fish-eye, 7 lateral crus repositioning surgery, 78
image workout, 10–12 medial canthus, 78
light tricks, 6–7 repositioning technique, 80
paraflash settings, 8 subperichondrial dissection, 79
peroperative photographs, 6 convex lateral crura, 78
photography system, 5–6 incorrect resting angle, 70–71
shadpowing, workout long lateral crura
JPG, 13 airway, 73
layer adjustment menu, 13 caudal excess, 72
Macintosh: cmd-A (Windows: CTRL-A), 12 closed technique rhinoplasty, 71
Macintosh: cmd-C (Windows: CTRL-C), 12 depression, 74
photograph work, 14–17 height of, 71
PSD format, 13 herniation, 71, 73, 75
shaded picture, 14 nose length, reduction, 71
surgery drawings, 14 perichondrium, 72
smartphone, 7 skin pit, 75
Peck graft, 204, 227 subperichondrial dissection, 72
Perpendicular (portrait) photos, 5 surgical techniques, 66
Photograph work vertical compression test, 67–70
aesthetic information feedbacks, 15 breathing, 67
beauty perception, 15 cartilage anatomy, 69
brain perception, 14 cartilage thickness, 67
computer design, 16 cephalic malposition deformity, 69, 70
design, 14 corrupted resting angle, 69
front, lateral views and shadowed deep inspiration, 67
photos, 16 lateral crus, 67
integrated photo, 16 nares, 67
nose ridge, 14 resistance, 68
operation room, 16 septum deviation, 67
Photography techniques, 10 tip shaping techniques, 70
Photoshop, 10–12, 58, 100, 184 wide lateral crura, 71
Polygon drawings, 54, 211 Reverse-V deformity, 87, 254, 262
Portrait photographs, 8 Rhinoplasty
Poviodine, 99 closed technique, 71
Preoperative photographs instrument set
forehead fat grafting, 19–27 closed surgery, 34
jaw and cheek, 28–33 dorsum retractor, 34
menstruation, 19 little retractor, 34–35
patient photographs Medicon company, 34
camera settings, 7–8 speculums, 34
fish-eye, 7 surgical tools, 34
image workout, 10–12 polygon model, 93–94
light tricks, 6–7 skin care and, 18–19
paraflash settings, 8–10 Rib cartilage
peroperative photographs, 6 block cartilage, 336–337
photography system, 5–6 cartilage chips, 335
shadowing, 12–17 ear cartilage, 335
smartphone shooting, 7 strip cartilage grafts, 338–339
rhinoplasty instrument set, 34–38 surgery, 335–336
skin care and rhinoplasty, 18–19 Roaccutane treatment, 18
surgery notes and archiving, 17–18
Pseudoephedrine spray, 96, 349
S
Saddle nose
R and hanging nostril, 395–396
Resting angle and notched nostril, 391–393
cephalic dome suture, 66 Self-sticky prints, 6
cephalic malpositioning Septal extension graft, 228, 267, 293
Index 421

Septum pitanguy and scroll ligaments, 355

dissection strut graft, 356
blunt dissectors, 136 Thin skin
ethmoid bone, 135 axis deviation and breathing problems, 404–405
excised vomer bone, 135 big nose, 397–398
L-strut septoplasty, 132 deviated nose and tip asymmetry, 388–389
maxillary spine deviations, 134 patients, 386–387
mucosa tears, 133 pseudocephalic malpositioning and tip asymmetry,
nasal passage, 137 398–399
open approach, 132 Time Machine, 18
perichondrium, 131 Tip surgery
revision rhinoplasty, 132 autorim flap
rib cartilage, 132 ala retractions, 145
septoplasty, 137 alar support, 158
thin Cottle elevator, 132 bulbous cartilage, 150
transfixion incision, 136 cartilage surface, 154
extreme gummy smile, 138–140 caudal excess, 148, 160
gummy smile, 138 cephalic dome sutures, 156
septum out, 137–138 cephalic migration, 150
Septum base surgery, 329 cephalic resection, 155
Shadowed photos, 100 cephalic trimming, 147
Shield graft, 52, 53 columellar strut graft, 156
Shutter rate, 8 convex lateral crura, 149
Skin color, 8 C suture, 157
Skin ecchymosis, 119 desired facet polygon, 152
SLR camera, 5–7 dissection, 154
Surgery notes and archiving dome lights, 159
autorim flap technique, 18 facet polygon, 145
backups, 18 lateral crus caudal resections, 145
drawings, 17 medial crus, 153
epicrisis report, 17 mucosa, 153
patient archiving programs, 17 narrow facet polygon, 152
photography archive, 18 nostril, 162
pre-written surgery note, 17 preoperative photograph, 158
recordings, 17 in situ cartilages, 151
structural grafts, 159
subperichondrial plane, 154
T thin skinned patient, 146
Tebbett’s technique, 105 infracartilaginous incision, 144–145
Telangiectasia, 296 lateral crural length, 143
Thick skin lateral crus subperichondrial dissection
bulbous tip and deviated nose, 406–407 autospreader flap technique, 162
and huge hump blunt perichondrium elevator, 164
ala resection, 362 cephalic malposition, 177
avulsion flap and elliptic resection, 363 Daniel elevator, 166
patient’s infralobule polygon, 362 domes, delivering, 168–175
low radix and cephalic malpositioning, Ellipse model, 184–185
390–391 internal bandaging, 165
and oily skin marking and resections, 175–177
alar edge resection, 357 observations, 177–181
columella, 357 scroll ligament, 165
fat injection, 357 secondary rhinoplasty, 167–168
long inflammatory period, 357 sesamoid cartilages, 165
nostril edge resection, 358 thoery, 181–183
vitamin A, 358 tools, 163
patients nasal dorsum and septal surgery, 143
closed technique, 355 Tongue-in-groove, 228
Libra grafts, 357 Topographic anatomy, 53, 92
osteotomies, 357 Transdomal suture, 64, 82, 196, 202
422 Index

Triamcinolone, 314
Turkish Aesthetic Surgery Society, 161
U
Upper lateral cartilage polygons, 53, 85–86
W
Webster’s bone triangle, 92
Webster triangle, 92, 106, 254, 263
White steroid cysts, 296