Professional Documents
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Aesthetic Septorhinoplasty - Hoschander, - Ari - S
Aesthetic Septorhinoplasty - Hoschander, - Ari - S
Septorhinoplasty
Barış Çakır
123
Aesthetic Septorhinoplasty
Barış Çakır
Aesthetic
Septorhinoplasty
Barış Çakır
Private Practice Fulya Teras
Istanbul
Turkey
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
vii
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.
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
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.
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
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
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415
Preoperative
1
1 Patient Photographs
1.4 Fish-Eye
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 1.7 Paraflash Settings
can easily take photos with an ISO setting of 100.
You can show aesthetic lines better in front view
1.6.3 Shutter Rate if one of the paraflashlights is more intense, but
It shows how long the diaphragm stays open. If the then you will have problems with profile photos.
shutter rate is longer than 1/125 the photo can be Since we make evaluations based on photos taken
affected due to shaking. I generally use a setting of from all angles, it makes sense to adjust the
1/160. If you choose a shutter rate faster than 1/200 paraflashlight intensity to the same level for all.
there can be disparity between your camera and the Taking photos in sunlight coming from windows
paraflashlights. This can cause photos to have a dark can give better reflections, but you cannot take
half. the same photo at different times of day. Therefore
a paraflash system is a must.
1.6.4 F Since the light intensity of new video cameras
You can take artistic photos with low “f” valued is high, it is possible to have great details in the
focus distance. The front and back of the focus afternoon light from one angle. But it is difficult
point become blurry. We need a deep field of to archive videos and have one standard for all
depth. A value of 10 and above is adequate. recordings.
Here you can see a patient example with stan-
1.6.5 Skin Color dard settings.
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 Patient Photographs 9
10 1 Preoperative
1.8 Imaging
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.
Note
During surgery our perception makes a 90°
rotation.
1 Patient Photographs 15
Important
Aesthetic information feedback is very impor-
tant. You should avoid anything that may skew As I am left-handed, I stay on the left of the
your perception. For example, the head of the patient to make my evaluation. Therefore, I set up
patient should be parallel to the ground. If you the computer to show the left view of the patient.
change the position of patient’s head at a differ- Right-handed surgeons should change position-
ent angle in every operation, your chance of mak- ing accordingly. You can rotate shadowed photo-
ing a mistake increases. 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- In the photo below you can see the lateral view
out my computer. Front, lateral views and shad- of the patient before surgery, the computer design
owed photos should be open on your computer. 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.
4 Menstruation
5.1 Technique
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
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
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
7.3 Forceps
7.4 Needleholder
It is possible to get inside and up to the osteotomy – 2 mm: Concha SMR, for internal osteotomy.
area with a thin changeable tungsten tipped rasp. – 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
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
2
1 Exercises
Note
Drawings below by Yusuf Başoğlu.
Important
The fundemantal rule for closed surgery is to see
the topography of the cartilages by following the
highlights in the skin.
2 Analysis of Patient
Photographs
Shield grafts try to mimic the infratip triangle. results. Placing a block cartilage to prevent the
However, we see that this graft constantly changes shield graft from overturning is one of the least
over time. Using a shield graft in a Y shape is an common differences. The block graft both sup-
increasing trend, because the short arms of the Y ports the shield graft and forms a second tip break-
graft and the gap between them gives more natural point just 2–3 mm above the breakpoint formed by
5 The Mobile Tip Area 53
1 Infratip Triangle
3 What Is a Facet?
We try to create this triangle with a shield graft. I
use a shield graft only for overly deformed noses. These are multi-edged flat areas which surround a
I think that it has no place in primary rhinoplasty. three-dimensional objects. This is the easiest
We described this area with the infralobule poly- method for making a sculpture. You can imagine
gon and added more details to the nose tip. round organic forms consisting of several facets.
Their sizes, angles, and the ratios between them are
important. Analyzing organic forms with the help
2 Tip Defining Point of cubic forms is a basic drawing method.
Dome Triangles
Lateral Crus Polygons
Interdomal Polygon
Facet Polygon
54 3 Nasal Polygons
6 Tip Breakpoints
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.
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.
58 3 Nasal Polygons
8 Interdomal Triangle
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.
For the purposes of aesthetics, you should not
only see mass, but also the spaces in between. Important
The superior angle of the interdomal triangle is As the rotation of the nose tip increases, the cau-
80° in men and 100° in women. dal edges of the domes drift apart. The angle dif-
ference between women’s and men’s noses is due
to the rotation differences.
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.
Important
Do not resect too much because you may damage
the artery, vein and nerve.
10 Columellar Polygon 61
11 Footplate Polygons
These are the planes formed by the footplates. It can be plumper in women. In men, it is not
They look at sideway and downwards. 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 63
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?
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.
14 Resting Angle
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 67
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.
Important
The length of the lateral crus should fit the nose
planned.
The caudal excess of the lateral crus was left on The following image demonstrates a puff
the skin as autorim flap. 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.
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
Patient Example
In the case of this patient who underwent surgery
ten years ago, the lateral crus has herniated
inwards into the nose.
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
lateral crus becomes more significant than the skin, chondrial dissection. Subperichondrial dissection
so it shows the medial canthus. As the caudal edge of was applied to the mucosal side of the left lateral
the convex cartilage is folded into the nose, it cannot crus, without any repositioning.
be seen through the skin, and this creates the illusion
of insufficient cartilage in the alae.
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).
15 Scroll Facet
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
Note
This maneuver prevents the lateral crus from
overlapping and slightly narrowing the tip.
17 Dorsal Cartilage Polygon 83
Note
The Pitanguy ligament was described by Pitanguy
in 1960. It was initially named the dermocarti-
16 Scroll Line laginous ligament. Pitanguy stated that this liga-
ment begins from the supra-tip dermis, passes
The scroll line is the area where the upper lateral through the area between the dome and the septal
cartilage and the lateral crus meet, forming a angle and is finally attached to the medial crura.
groove that is visible through the skin. If we do In terms of surgical importance, he has stated:
not form this line, the nose becomes round. If the “Cut this ligament for nose rotation, if the liga-
lateral supra-tip skin does not fit completely onto ment is too much then resect.”
the cartilage skeleton after the rhinoplasty opera-
tion, the dead space fills with fibrosis and the If you are making a subperichondrial dissec-
scroll line becomes indistinct. For a beautiful tion, forming this groove wherein the tissues
scroll line, a correct resting angle is essential, above fit will strengthen the dorsum highlights.
since the scroll line is formed by the pit where the The drawing below illustrates a man’s nose
upper lateral cartilage and lateral crus connect. expressed with cubic forms. Therefore, the dor-
In order to form the scroll line, we should sum cartilage polygon is longer. As the dorsum
reconstruct the scroll area. This is also function- cartilage approaches the nose tip, the Pitanguy
ally important. 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.
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.
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
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.
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.
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
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
1 Patient Position
and Tracheal Intubation
– A small gauze pad can prevent blood coming – You should have a foot-controlled adjustable
from the mouth. chair. Profile assessment is required fre-
– Systolic blood pressure should not go beyond quently. In addition nose tip sutures are per-
80 mmHg. A stable blood pressure is impor- formed more easily while seated.
tant: If the blood pressure decreases and then
increases, the vasoconstriction effect of the
local solution could decrease.
Important
– After the patient becomes unconscious, spray
Check the position of the tube from time to
pseudoephedrine onto the nasal mucosa; two
time since the tube can pull at the upper lip
puffs for each nostril is enough. I have not yet
and the nose. Connecting the intubation
tried cocaine for mucosal vasoconstriction.
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-
– Raise the patient 20–30° from the waist and rine-soaked gauze for mucosa vasocon-
by laying down the head position the face par- striction. I use gauze if there is an active
allel to the floor. Be very careful about the par- bleeding in the posterior.
allel position of the face to the floor. The head
position will affect your decisions about nasal
tip rotation.
2 Local Anesthesia 97
– 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.
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.
4 Cleaning
5 Lighting
in the Operating Room
course in Istanbul in 2009. As Esson said: the cheek. These lines guide me while adjusting
“Operating room lights prevent you to see the the tip position. I determine the amount of steal-
form.” 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.
6 Drawings
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
Important
In patients with outfracture, the bone
should be supported for at least 4–8 days.
Benlier E, Top H, Aygit AC. Management of With your scissors, advance 2 mm under the
the long nose: review of techniques for nasal tip perichondrium. Get under the perichondrium
supporting structures. Aesthetic Plast Surg. 2006 with the Çakır perichondrium elevator and
Mar-Apr;30(2):159–68. advance along the midline for 1 cm.
9 Nasal Dorsum Surgery 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.
By moving the elevator sideways, dissect the In the scroll area, detach the upper lateral carti-
perichondrium of the upper lateral cartilages. lage and lateral crus from each other completely.
Extend the dissection and combine this plane You can see that the upper lateral cartilage peri-
with the intercartilaginous incision, hence chondrium stays on the skin side without
dissecting the upper laterals completely. tearing.
110 4 Surgery
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.
Dissect the upper lateral cartilages perichon- When you reach the bone, cut the periosteum and
drium by making right and left swiping move- perichondrium with a blade. There is a sharp
ments similar to the closed approach. 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
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.
I try to dissect the periosteum very delicately. 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.
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.
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 4 Surgery
Important
Cartilages are surrounded with perichon- 9.6.5 Effect of Subperichondrial
drium. When you make a sub-SMAS dis- Dissection on Ligaments
section you resect the cartilage with the The Pitanguy and scroll ligaments are in fact
perichondrium on it. Especially at the nasal thickenings of the SMAS. These ligaments can
dorsum, the cartilages left over will be in tear if you pass the suture through them. The
direct contact with the overlying soft tissue perichondrium and sesamoid cartilages on the
without the perichondrium barrier. 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.
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.
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.
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.
10 Septum
10.1 Dissection
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.
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
Leave a 2 mm space between the septum base Correct deviations of the ethmoid bone.
and the anterior maxillary spine. Periosteum and
perichondrial tissue left on the mucosa will fill
Attention
the space.
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
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.
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.
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
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 143
12 Tip Surgery
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.
However, some patients may need this effect.
Suturing the footplates in the patient below will
result in blunting of the nasolabial angle and a 1. Sit on your chair. Lower it to the level that can
better-looking nostril shape. 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
12.2.1 My Experience
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 4 Surgery
The incision is placed on the cartilage in order to The case below is a case of my own with caudal
keep this part of the cartilage on the skin flap. 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.
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.
The domes are relocated 5 mm superiorly. 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.
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
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 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
Important
If your suture is passed through the carti-
lage, the autorim flap cannot rotate into the
facet polygon.
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.
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.
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.
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.
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
9. While stretching the perichondrium with one 11. Place the hook closer to the dome and, while
hand, move forward with the elevator in the protecting the perichondrium, approach the
subperichondrial plane. The perichondrium dome using subperichondrial dissection.
can be dissected easily through the dome. Be 12. Attach the hook to the dome’s mucosa, cre-
careful about lateral dissection. The peri- ate traction and move forward by cutting the
chondrium can tear easily in this region. You tight junctions of the perichondrium to the
can perform lateral dissection after deliver- caudal side of the lower lateral cartilage.
ing the domes.
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.
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
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.
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.
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.
6. Check whether the remaining parts of the lat- 12.6 How Did the Nose
eral crus are equal. Break Down?
Examine the determination of the cephalic resec- I often investigate my patient’s families.
tion amount of another patient. 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?
12.7.1 Observations
5. These patients have weak dome cartilages. The patient’s nose tip cartilages have been
dissected.
Patient Example
12 Tip Surgery 179
12.7.2 Theory
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- Important
lescence. The nose tip seems like a cephalic mal- In nose tips moving downwards when
position, but the nostrils of the two sisters were the laughing, if we diagnose the problem as
same. The nostril crease produces the lower edge strong or short depressor, we have to per-
of the lateral crus. As a result their lateral crura end form a muscle resections. I think that the
at the same point. Parenthesis view occurs as a problem is the forward movement of the
result of lateral crus surface problems and is not footplates because of the overgrowth of the
related to the lateral crus long axis. Thus, repairing septum. If we dissect the footplates and
surface problems will be more logical than reposi- move them towards the anterior maxillary
tioning the lateral crus. 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.
12.7.4 The Ellipse Model He said that this technique can be explained
We first investigated the geometry of the lateral cru- with an ellipse model.
ral steal technique with my father, who was a math- The Ellipse is a curve on a plane surrounding two
ematics teacher, on millimetric paper in 2010. 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.
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.
Important
The key point in tip surgery is lateral crus
length.
13.1 Surgery
Patient Example
Short infralobule
Anterior localized footplate
High tip projection
Below I am showing where the tip position was
when I started the surgery.
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 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.
Important
This should be done after cephalic resec-
tion because there can be a 1–2 mm change
after resection.
194 4 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
Important
13.4 Dome Symmetry Test In patients with over-projection, the total
lower lateral cartilage length is more than
Create traction on the lateral crus with two for- normal. In this situation, you should
ceps. Join the domes in the midline by taking the shorten the lower lateral cartilages from
skin inwards. The new dome marks should be next one point. In the planning of the shadowed
to each other when the cartilages are at the mid- photos of these patients, the new nose
line. In patients with tip deviation, an asymmetric stays inside the nose shadow. In this type
lateral stealing procedure should be used. of patients you may predict to perform a
Otherwise tip deviation does not recover. A lateral middle crus overlap.
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.
196 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
holding the cartilage in the right position, put Note When the position of the footplates is sta-
the second and third dome sutures to the 5th ble, lateral stealing cannot increase tip projection
and 7th mm, respectively, without squeezing. by more than 1 mm (see the ellipse model). The
infralobule increases depending on the amount of
stealing from the lateral.
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 I have learned this procedure from Teoman
Doğan. Gruber’s article on hemitransdomal
suture does not present much detail. If you do not
Note The second and third cephalic dome sutures correct the dog ear caused by the cephalic dome
are the best technique I know to solve superior suture, you may not resume using this suture.
localized lateral crus and hanging medial crus Until 2009 I was increasing the projection of Ti
problems. 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
Important practical method. When you remove it, the load
The caudal edges of the medial crus and on the cephalic dome suture decreases. This is
lateral crus will form the facet polygon. because the lateral crus curves easier for making
When you are suturing cartilage, do not the dome.
concentrate on the suture, but instead con-
centrate on the shape of the cartilage. I use
suture and graft for giving the aesthetic
Important
form that I want.
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
3. In approximately 70 % of patients, when you the vertical plane at the same height will
perform a steal from the lateral, the height of have more aesthetic results. See the tip
the middle crus becomes correct. Most breakpoints.
patient’s infralobule is short and stealing from
the lateral increases its height.
200 4 Surgery
Patient Example
The left dome of the patient was shapeless and
the right dome regular.
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.
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.
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
Patient Example
Patient Example
210 4 Surgery
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
Important
Do not suture the dome inside without visual-
ization. The joining angle is very important.
Important
We have treated the bulging part without shorten- Repairing the soft tissue between the two
ing the infralobule polygon. 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.
Now we can open a pocket for the strut graft. 13.10.2 Strut Graft Placement
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.
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.
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.
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.
Important
If you are going to perform a medial crus
overlap, you should do so before the C’
suture.
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
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
Patient Example
This patient has had surgery before, and his nose
tip cartilages were deformed.
Important
In the profile, if the height of the infralob-
ule is adequate but it seems like it has made
an over-rotation, ...
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.
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 you use an autorim flap you will make less
cephalic resection and the incision will be
When tip surgery is finished, we will close the stable as there is cartilage in the mucosa
infracartilaginous incisions completely and move wound edges. Because of this, you will rarely
on to closing the roof and nasal dorsum recon- cut the mucosa sutures anymore.
struction. This is an advantage of closed surgery. 4. Sometimes the autorim flap is long and causes
You have finished the nose tip but you can con- bulging in the facet polygon. Rotate it with a
tinue the surgery. If the nasal dorsum is high doubled hook and cut the excessive tip. The
compared to the tip, you can resect somewhat autorim flap can sometimes be wider than
more. You can resume septum caudal resections. desired. In this case, you can make a cephalic
If there is no intercartilaginous incision, we will resection from the autorim flap.
close the tip incisions at the end of the surgery.
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.
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.
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.
On the other hand, in the example below, although In the photos taken with paraflash, the cephalic
the starting and ending points of the patient’s lat- malposition is hidden. Let’s examine the patient
eral crus are the same, the resting angles and with the most obvious cephalic malposition on
topographic anatomy are different. Since the which I operated recently. In the front view,
right lateral crus resting angle is good, it has sup- because of the convexity of the lateral crus, a
ported the ala in the basal view. However, the left shadow is formed behind the convex area, and
lateral crus resting angle is disturbed and convex. this increases the parenthesis look.
Because of this it looks like a cephalic malposi-
tion. If we repair the shape of the lateral crus, Patient Example
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.
13 Results 241
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 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.
Tenth-day photos.
First-month photos.
250 4 Surgery
14 Nasal Dorsum
14.2 Osteotomy
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.
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.
An 8 mm chisel is placed.
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.
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)
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.
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.
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.
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-
Important cedure. Bone thickness can change in most
Do not use a finger compress near the open patients. Neither is bone thickness similar along
roof. You may break the naso-maxillary the osteotomy line. With osteotomy, it is not easy
junction. Instead, do the compression on to perform a greenstick fracture. We can reduce
the maxillary bone. 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
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.
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
Note the amount of bone saw dust removed from In the endoscopic photo below, you can see the
the patient. left lateral osteoectomy line.
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
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.
Important
Nasal Dorsum Control
The wings of the Libra grafts, which are 2 At this point sit on your stool and scrutinize
mm thick near the keystone region, create an whether the Libra grafts fit into their places.
angle towards the anterior, as a result raising Examine your nasal dorsum profile. Libra grafts
the nasal dorsum by 1–2 mm. Because of should be fitted in the lateral view without creat-
this, you should remove 1–2 mm more from ing a hump. Raise yourself until you align the
the septum in the keystone region. Hence, nose tip with the cheek. In the oblique view, be
you will form a nasal dorsum groove in which sure that the small hump formed by the Libra
the nasal dorsum perichondrium will fit. 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.
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.
272 4 Surgery
Important
If you do not suture the edges of the Libra
graft to the upper lateral cartilages, the
9. Generally two fixing points are enough. First internal valve mucosa can swell and widen
execute a loop suture near the anterior angle. the roof. For suturing Libra grafts to the
Second is a horizontal mattress suture at the upper lateral cartilages, 6/0 PDS is appro-
caudal. This suture allows you to make addi- priate. Moreover, this can facilitate dissec-
tional resections if necessary. If you are tion in secondary surgeries.
removing cartilage from the Libra graft or
septum, you will not be cutting any sutures.
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.
Important
Work wet while scratching with the knife,
so that you can keep bone dust together.
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
5. If you want a more stable graft, you can use dorsum in patients with significant axis
coagulated blood. You can place it in the deviation, achieving a proper nasal dorsum
nasal dorsum retractor and insert it thus. will be very difficult. If the bones are too
Mithat Akan obtains a single-piece graft by deformed, taking 1–2 mm and raising this
mixing it with blood. area by 1–2 mm with cartilage and bone
graft will make things easier.
Öreroğlu AR, Çakır B, Akan M. Bone dust
and diced cartilage combined with blood glue: a
practical technique for dorsum enhancement. 14.6 Short Nasal Bones
Aesthetic Plast Surg. 2014 Feb;38(1):90–4.
Below you can see bone dust particles that In patients with short nasal bones, most of the
have been gathered by an osteoectomy performed nasal dorsum consists of cartilage. In these
with a 90° angled chisel. As the bone pieces in patients, the resected nasal dorsum cartilage is
this saw dust are very small, they can be used in longer. Because of this, Libra grafts prepared
the nasal dorsum. If you are using the osteoec- from this cartilage will be longer. With the Libra
tomy technique instead of osteotomy, bone dust graft technique, the responsibility of the surgeon
collected from the two sides will be enough for for determining the patient’s need of a spreader
dorsal camouflage. 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
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
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
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
7. Identify the excess mucosa in the membrane- undergone a surgery before and said that he
ous septum. By stretching the mucosa with was breathing less from his left nostril. You
5/0 Monocryl, stabilize the septum mucosa to can see the excess mucosa in the membra-
the septum cartilage with one loop suture. nous septum, the internal valve and the
8. Remove excess mucosa. long upper lateral cartilage.
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.
Patient Example
The patient below had two open rhinoplasty sur- Important
geries. Due to deteriorated muscle functions and In the dissected nose, the nose tip skin is
a lateral crus that was left longer than necessary prone to swelling and the internal valves
and had a wrong resting angle, the external valve are prone to collapsing. If you suture the
had narrowed. Moreover, as there is no primary intercartilaginous incision by taking the
repair in the scroll region and as the caudal edges scroll ligament in between, the internal
of the upper lateral cartilages are in excess, the valves will also open in the middle point.
internal valve had narrowed as well. Deterioration The middle part of the internal valve is
of the nose muscles could have increased the formed by the caudal edge of the upper
closing of valves. 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.
15 Internal Splints part at tip, the plastic will bend while inserting
the intracath in the nose, and it will remain out-
When you have finished the rhinoplasty, find the side. Insert the drains from the most lateral point
splints that you have put after the septoplasty and of the intercartilaginous incision towards the
fix them to the septum with 5/0 Prolene or 5/0 medial canthus. Turn the open side of the drain to
PDS. Close to the transfixion incision with the the bone in order to avoid clogging. Remove its
splint to ensure a better alignment of the wound needle and cut it so that 2 cm remains of the
edges. Do not tighten the knots too much. This mucosa. After two days remove them together
can cause pain. Do not use silk for fixation; as it with the internal splints.
is not slippery enough, it can cause pain while
removing the stiches.
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 ... The nose does not only consist of cartilage,
bone and skin, but also of ligaments. If you perform
1. repair the Pitanguy midline ligament without surgery under the perichondrium, soft tissues not
shortening. only act like a cover, but also help to give shape to
2. use the posterior strut technique also in open the nose with their special form. We have men-
surgery. The posterior strut fixes the Pitanguy tioned that the SMAS forms ligaments by thicken-
system in the midline. ing at the supratip and lateral supratip regions and
3. use 2–3 sutures or horizontal loop sutures, and that these ligaments enter between the cartilages.
not only one. This system forms a compartment for cartilages.
4. if you also repair the scroll sesamoid carti- In the model below you can see the spaces
lage, you will reach the original width of the between the cartilages and thickening in the soft
Pitanguy midline ligament and prevent it from tissues.
falling right or left of the septal angle.
20 Internal Taping
Relation between Pitanguy and scroll ligament 20.2 Importance of the Pitanguy
and cartilages. Ligament in the Supratip
Region
21 Redrape
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
21.4 Camouflage
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
Important
If the nostril sill is hanging, internal rota-
tion is added while advancing.
Important
Do not perform a resection without
markings.
Important
Cutting and stitching is the simple part.
The most important step is to apply the
marking in the right area.
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
Important
Ala will attach to the upper part of the lips
by embryological twisting and thinning.
Another Patient Example One-year photo of a patient who had nostril reduc-
tion by means of avulsion advancement flap.
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.
Important
Cut appropriate to nostril sill anatomy.
Consider how we settle the nostril sill flap
to the lips in cleft lip surgery.
23.5.2 Incision
Cut the ala through the marking so that it splits
23.5 Hanging Alae: Alar Rim Excision right from the middle using a no. 15 blade. Your
incision should be deep in the middle, but super-
Note Do not perform this procedure on your first ficial at the top and bottom. For the first 2-3 mm,
100 patients. cut obliquely towards the lateral in order to keep
Some patients have more skin, not cartilage. the lateral skin flip thin. Moreover, you can turn
This generates a flabbiness of the alae. Our the lateral flap easily while suturing.
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.
23.5.1 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
Patient Example
Patient example: Cleft lip nose case Patient Example: Composite Graft
Skin resection was performed directly from right The patient’s right nostril was contracted due to
nostril apex to improve nostril asymmetry. 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
24 Taping
25 Postoperative Care
Patient Example
Below you can see the two-day postop photo of a
patient who had osteoectomy and whose hump
was removed.
26 How to Correct
the Deviated Nose
26.4 Septoplasty
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
1. If you do not separate the septum from
Important the maxillary spine, you cannot correct
The nasal roof of patients with axis devia- the deviation easily. You will usually
tion should be opened asymmetrically. If need camouflage techniques.
you open it symmetrically, it will be asym- 2. The excess in patients with axis devia-
metrical after osteotomy. Therefore, if you tion is at the septum base. Emptying the
open it asymmetrically, then the roof will be posterior septum with L septoplasty
symmetrical, as desired, after osteotomy. 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 325
The anterior maxillary spina was dissected after The septum was stabilized to the periosteum
cartilage removal. According to the midline mark- above the maxillary spine by making two loop
ings, the anterior maxillary spine is made sym- sutures with 5/0 PDS. The knot was placed inside
metrical by thinning it from the right and left sides. the cavity.
Important Important
The maxillary spine is one of the basic The septum must be stabilized at this level.
points of the nose. The base must be sym- The septum can be mobilized during nose
metrical for fitting the septum symmetri- radix osteotomies. It is very difficult to sta-
cally. The midline at the forehead should be bilize the mobilized septum in the correct
taken as reference while thinning the maxil- position.
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.
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.
Important Important
If lateral osteoectomy is not applied ade- During this movement you should hear a
quately, especially at the medial canthus cracking sound from the bone.
level, the opening osteotomy will be unsuc-
cessful. The opening osteotomy increases In order to lay down the open left nasal bone onto the
the height of the bone that is opened. When corrected septum and right nasal bone, lateral and
we opened the roof, we took more of this transverse osteoectomy were performed. Since the
bone. If it is longer than desired, we can left nasal base is narrower, the base is thinned with a
perform additional resections up to 1–2 mm Çakır 90 chisel. Less bone was removed when com-
with bone scissors. Do not use a rasp at this pared to the right. Thinning was continued until the
level because the bone can be mobilized bone was fractured with finger pressure.
too much. Bone scissors are one of the saf-
est tools for performing a resection on a
bone that has been osteotomized.
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.
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
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.
27 Cartilage Grafts
Patient Example
Closed technique rhinoplasty was performed on
the patient.
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
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 339
Example
1. Remove cartilage and mucosa from the caudal For decreasing the width of the lateral crus from
septum for elevating the columella. Usually 15 to 8 mm, you should make a 7 mm cephalic
removing cartilage is not enough. Excess excision. In the autorim flap technique, with a
mucosa can push down the columella or dis- 3 mm autorim flap and 1 mm additional caudal
turb breathing by forming a thickness at the excision you can narrow 4 mm from the caudal
membranous septum in the long term. We 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.
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.
28.1.1 Surgery
Excess cartilage and mucosa at the septum cau-
dal side were resected and the nose tip cartilages
exposed.
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 349
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.
4 Case Analysis: Revision the resting angle. I used this doubled dome suture
of My Own Case only for a short time, since its planning and execu-
tion are difficult.
By making two cuts on the lateral crus, the noticeable if edema in the lip region pushes the
scroll facets were created. You can see the nose tip further than its position in surgery. This
Pitanguy midline ligament in between. A poste- is generally a temporary effect and requires some
rior strut graft was sutured to the septum. 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.
Appearance of the cartilages after tip surgery. 8 Case Analysis: Wide Dorsum,
Wide Radix, Bulbous
Overprojected Tip
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
Note
As I had not performed an L septoplasty in the first
surgery, there was enough graft in the septum.
Note
It is possible to perform an autorim flap in
patients who have a revision.
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.
Autorim flap.
First-year photos.
12 Case Analysis: Closed Approach Revision 379
380 5 Patient Analyses
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
First-year photographs.
382 5 Patient Analyses
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
13.3 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
First-year photos.
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.
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
24.1 Surgery
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
26.1 Surgery
– Closed rhinoplasty
– Mentum hyaluronic acid filling
– Ramus of mandible hyaluronic acid filling
– Orthognathic treatment
Hump
Bulbous tip
Thick skin
Droopy tip
Low radix
31.1 Surgery
32.1 Surgery
(strawberries, red radish, mulberry), Peonidin can wet the splint. However, do not expose it
(bogs cranberry), Petunidin (American grapes). to vapor.
Containing catechins: cocoa and green tea. – It is not necessary to apply cold or ice to your
Containing Omega 3: Walnut, almond, soy, face.
flax seeds, legumes. – Internal splints placed in the nose create a
flu-like feeling and cause a sneezing reflex.
34 After Surgery: A Few Notes Do not panic. Sneeze with your mouth open.
Sneezing will not disturb the nose.
– For the next five nights, sleep with three
pillows. – Do not exercise for one month.
– Do not stay in very warm places. – Do not swim in the sea for one month and in
– Keep away from bleeding-enhancing food for the pool for two months.
the first ten days. – Do not wear glasses for two months.
– Do not use vitamin pills or other nutritional – You can use lenses after nose surgery.
supplements. – It is not necessary to avoid the sun if you do
– Avoid activity that can increase your blood not have bruising. Do not sweat because of
pressure. Do not bend your head. heat.
– Try to remain in a vertical position except – You can use anti-edema foods like green tea,
when sleeping. chervil, and pineapple starting from the tenth
– You can go outside after the second day. days.
– Plastic splints are not affected by water. You
can shower every day for 2–3 minutes. You THANK YOU FOR YOUR ATTENTION.
Barış Çakır, MD. For inquiries and comments,
please e-mail drbariscakir@gmail.com.
Index
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
Triamcinolone, 314 W
Turkish Aesthetic Surgery Society, 161 Webster’s bone triangle, 92
Webster triangle, 92, 106, 254, 263
White steroid cysts, 296
U
Upper lateral cartilage polygons, 53, 85–86