Suleyman Tas - Rhinoplasty in Practice - An Algorithmic Approach To Modern Surgical Techniques-CRC Press (2022)

Rhinoplasty in Practice
Rhinoplasty in Practice
An Algorithmic Approach to Modern Surgical Techniques
by
Suleyman Taş, MD
TAS Aesthetic Surgery Clinic
Istanbul, Turkey
First edition published 2021
by CRC Press
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Library of Congress Cataloging‑in‑Publication Data
Names: Taş, Suleyman, author.
Title: Rhinoplasty in practice : an algorithmic approach to modern surgical techniques / by Suleyman Taş.
Description: First edition. | Boca Raton : CRC Press, 2021. | Includes bibliographical references and index.
Identifiers: LCCN 2021040459 (print) | LCCN 2021040460 (ebook) | ISBN 9781032004341 (hardback) |
ISBN 9781032004358 (paperback) | ISBN 9781003174165 (ebook)
Subjects: MESH: Rhinoplasty—methods
Classification: LCC RD119.5.N67 (print) | LCC RD119.5.N67 (ebook) | NLM WV 312 | DDC 617.5230592—dc23
LC record available at https://lccn.loc.gov/2021040459
LC ebook record available at https://lccn.loc.gov/2021040460
ISBN: 978-1-032-00434-1 (hbk)
ISBN: 978-1-032-00435-8 (pbk)
ISBN: 978-1-003-17416-5 (ebk)
DOI: 10.1201/9781003174165
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Videos are available on the Companion Website: www.routledge.com/cw/tas

Dedicated to
My beautiful wife Sema for being an inspiration for everything in my life,
my amazing brother Ahmet for making possible everything I could ever ask for, and
my dear son Selim for giving me the energy to make this world a better place.
Contents ContentsContents
Preface�� xi
1 Patient Selection in Rhinoplasty�� 1

1.1 Patient Identification�� 1
1.2 Physical Examination�� 1
1.3 Psychological Evaluation�� 1
1.4 Functional Evaluation�� 1
1.5 Aesthetic Evaluation�� 2
1.6 Simulation Study�� 2
1.7 Revisit�� 2
Appendix A: Psychological Evaluation Form for Patients to Complete at Their Preoperative Consultation�� 3
2 Closed Atraumatic Rhinoplasty�� 5

2.1 Description and Explanation of the Closed Atraumatic Technique�� 5
2.1.1 Why Does This Philosophy begin with the Closed Technique?�� 5
2.2 Stages of the Closed Atraumatic Technique�� 6
2.2.1 Local Injection�� 6
2.2.2 Incisions�� 7
2.2.3 Dissection Plane�� 8
2.2.3.1 Room Concept��10
2.2.4 Preservation�� 14
2.2.5 Reshaping�� 15
2.2.6 Reconstruction�� 16
2.2.7 Structure�� 16
2.2.8 Redraping and Closure�� 16
2.3 Open and Closed Rhinoplasty Comparison�� 22
2.4 Submembranous—SubSMAS Dissection Plane Comparison�� 23
3 Dorsum Surgery�� 25
3.1 Osteotomy�� 25
3.1.1 Osteotomy Complications and Their Prevention�� 25
3.1.1.1 Rocker Deformity�� 25
3.1.1.2 Nasolacrimal Duct Damage�� 25
3.1.1.3 Airway Problems�� 26
3.2 Osteoplasty�� 26
3.3 Maxilloplasty�� 27
3.4 Dorsum Surgery�� 27
3.4.1 Excisional Approach to the Dorsum�� 28
3.4.1.1 The History of Dorsum Excision�� 28
3.4.1.2 Composite Hump Removal�� 28
3.4.1.3 Component Hump Removal�� 29
3.4.1.4 Dorsum Reconstruction�� 30
3.4.1.5 Bone Dust Technique�� 33
3.4.1.5.1 Surgical Technique�� 33
3.4.2 The Dorsum Preservation Approach�� 36
3.4.2.1 The History of Dorsum Preservation�� 36
3.4.2.2 Dorsum Preservation Techniques�� 40
3.4.2.2.1 Down Techniques�� 40
3.4.2.2.2 Dorsal Roof Technique�� 58
vii
viii Contents
3.4.3 Dorsum Algorithm in Reduction Rhinoplasty�� 65

3.5 Dorsum Augmentation�� 66
3.5.1 Ultradiced Cartilage Method�� 66
3.5.1.1 Surgical Technique�� 66
4 Nasal Tip Surgery�� 73

4.1 History of Tipplasty�� 73
4.2 Surgical Anatomy and Related Deformities in Tipplasty�� 73
4.2.1 The Tripod Concept�� 74
4.2.2 Supratip Break Point�� 75
4.2.3 Nostril Image�� 75
4.2.4 Lateral Crus Malposition�� 78
4.2.5 Medial Crus Malposition�� 78
4.2.6 Bifid Nose Deformity�� 79
4.3 Tipplasty�� 80
4.3.1 Lower Lateral Cartilage Flaps�� 82
4.3.2 Lateral Crural Flap�� 83
4.3.3 ST Flap (Superior-Based Transposition Flap)�� 84
4.3.4 Reverse ST Flap�� 90
4.3.5 Anatomic Strut Concept�� 91
4.3.6 Algorithm of the Columellar Strut Concept�� 93
4.3.7 Anatomic Columellar Septal Extension Graft�� 94
4.3.8 The Mystery of the Pitanguy Ligament�� 95
4.3.9 Deep SMAS Suture�� 98
4.3.10 Perichondrio-SMASectomy�� 102
4.3.10.1 What Is the Soft Tissue Hump: Where and How Does It Form?�� 102
4.3.11 Soft Tissue Redraping�� 105
4.4 Use of Electrocautery in Rhinoplasty�� 108
4.5 Blinking Nose Deformity and Its Treatment�� 109
4.5.1 Surgical Anatomy�� 109
4.5.2 Surgical Technique��110
5 Alar Base Surgery�� 115

5.1 Alar Excision��115
5.1.1 Algorithm��116
5.1.2 Surgical Technique��116
5.2 Alar Base Narrowing Suture�� 120
5.2.1 Surgical Technique�� 120
5.3 Providing Symmetry on Vertical, Horizontal, and Sagittal Planes�� 120
5.3.1 Alar Base Retraction�� 122
5.3.2 Algorithm�� 124
5.3.3 Releasing the Levator Alaeque Nasi Muscle�� 124
5.3.3.1 Surgical Anatomy�� 124
5.3.4 Releasing the Piriform Ligament�� 129
5.3.5 Maxillary Hypoplasia Treatment�� 130
5.4 Releasing the Depressor Septi Nasi Muscle��131
Contents ix
6 Revision Rhinoplasty�� 137

6.1 Dissection Plane in Revision Surgery�� 137
6.1.1 If the Subperichondrial Plane Was Preferred in the First Operation�� 137
6.1.2 What Should Be Done When Dissection Is Interrupted Due to Fibrosis from Microperforations
Induced by the Sutures?�� 138
6.1.3 If the SubSMAS Plane Was Preferred in the First Operation�� 138
6.2 The Closed Rhinoplasty Approach for Challenging Cases�� 139
6.2.1 Discussion: Should the Open or Closed Technique Be Used in This Case?�� 139
6.3 Saddle Nose Deformity��142
6.4 Using Rib Cartilage in Revision Rhinoplasty�� 144
6.4.1 Harvesting the Rib Cartilage�� 146
6.4.1.1 Thorax Anatomy�� 146
6.4.1.2 Anatomic Landmarks�� 146
6.4.1.3 Determining the Incision��147
6.4.1.4 Surgical Technique��147
6.5 Costal Reconstruction in Revision Cases with Cleft Lip-Nose Deformity�� 149
6.6 Using Auricular Cartilage Graft in Revision Surgery�� 152
6.7 Diced Cartilage Flap Technique�� 152
6.8 Restoring Tip Mobility in Revision Rhinoplasty Patients�� 153
6.9 Treatment of Over-Rotated Noses�� 154
6.10 Fisherman Suture�� 158
6.10.1 Surgical Technique�� 158
7 Advanced Rhinoplasty�� 161

7.1 Male Nose��161
7.2 Female Nose�� 168
7.3 Algorithmic Approach in Reduction Rhinoplasty According to Skin Type��172
7.4 Rhinoplasty in Thin-Skinned Patients��172
7.5 Rhinoplasty in Thick-Skinned Patients��175
7.6 DUAL Plane Dissection�� 180
7.7 Asian Rhinoplasty��181
7.7.1 Nasal Tip Bulbosity��181
7.7.2 Septal Problems�� 182
7.7.3 Dorsal Augmentation�� 183
7.7.4 Wide Pyramidal Angle and Wide Base�� 183
7.8 African Rhinoplasty�� 184
7.9 Middle Eastern Rhinoplasty�� 185
Index�� 189

Preface PrefacePreface
After performing many extremity replantations and face recon- There is no other book like the one that you are holding
structions as a super-microsurgeon, I dedicated myself to rhi- because it is clear, informative, comprehensive, and algorith-
noplasty which had always attracted me with its aesthetically mic. In addition, tips and tricks from my years of practice on
challenging aspect. However, I struggled greatly to choose the thousands of cases are included for you to be able to master
right sources in order to master it. A simple PubMed/Google rhinoplasty in the best way possible. It is designed to be the
research can illustrate this task; there are more than 11,000 main and the optimum textbook of rhinoplasty, answering all
papers and 100 books on rhinoplasty. While this many sources your questions; thus one reading will not suffice and it should
may seem like a good thing, it comes with some disadvantages. be within your hands’ reach to revisit whenever you need it.
Information pollution, which is the emerging problem of this I hope this book will help you realize the motto “Happy
century, may be confusing and time-consuming for surgeons. Surgeon, Happy Patient” and light the way for those who con-
What we need is an algorithmic and holistic approach to be able stantly try to be ahead of their time.
to achieve the best rhinoplasty practice.
xi
1
Patient Selection in Rhinoplasty
Patient selection in rhinoplasty is much harder than choosing all published articles on the plastic surgery patient group in
the most beautiful contestant in a beauty pageant. Currently, order to manage preoperative patient identification, prepara-
there are a lot of application requirements in beauty contests, tion, and postoperative follow-up processes. A nose surgeon
but what are the conditions you need to meet for rhinoplasty? should analyze the patient like a psychologist/psychiatrist
Detecting the patient suitable for rhinoplasty is as vital as and have the necessary equipment to manage processes in a
knowing rhinoplasty itself. healthy way [5–6].
Patient selection can be investigated under seven subheads There are some critical questions that need to be answered—
[1]: whether the patient’s usual mode is depressive or high, whether
there are any underlying psychological processes (such as
1. Patient Identification a loss or divorce) to the decision to have an operation, and
2. Physical Examination whether there are any psychiatric diseases. The psychiatric
3. Psychological Evaluation diseases that need to be investigated before the operation are
as follows: body dysmorphic disorder, obsessive-compulsive
4. Functional Evaluation
disorder, and symmetry disease. The psychological evaluation
5. Aesthetic Evaluation form completed by patients before a consultation is shared in
6. Simulation Study Appendix A by the author.
7. Revisit
1.4 Functional Evaluation

1.1 Patient Identification
The functional importance of the nose cannot be ignored or
It is beneficial to know the patient’s job, social interactive separated from rhinoplasty. Today, aesthetic nasal surgery
status, intellectual status, economic status, academic status, includes a group of operations that are regarded as a contin-
etc. Even all these are not enough in today’s world; a patient’s uum with rhinoplasty, septoplasty, and concha surgery. The
social media status also provides very important information main issues that need to be determined are the duration of
about the patient. The questions are what the patient wants, for any functional problem, especially in which nostril it occurs,
how long she/he has wanted it, why she/he wants it, what is the at what times it disturbs the patient, and whether there is an
opinion of their relatives, etc. All these need to be addressed accompanying allergic disease or snoring.
before surgery. To evaluate the functioning of the airways, objective
methods such as rhinomanometry or acoustic rhinometry
and subjective scales such as NOSE (Nasal Obstruction
Symptom Evaluation) and VAS (Visual Analog Scale) can be
1.2 Physical Examination used. However, the evaluation of the airways with an office
Before examining the nose, the medical history should be taken endoscopy during examination by the surgeon and a physi-
in detail to rule out possible bleeding or healing problems after cal examination made in correlation with the comments of
the surgery [2–3]. Photographic and video documentation is a patients still remain among the most valuable functional
must in rhinoplasty because of simulation purposes, discuss- evaluation methods. The presence of allergic symptoms can
ing the aesthetic deformities and medico-legal reasons [4]. be seen in an endoscopic examination and can be supported
Inspection and palpation are the main methods during exami- with advanced investigations such as skin prick test. By
nation, which requires sensitivity; however, imaging studies knowing the optimum airway opening, pushing the concha
such as ultrasonography and computed tomography can be with the help of an elevator under endoscopy can help the
helpful in particular cases. surgeon understand how far current stenosis can relieve the
airway.
It is crucial to demonstrate the airways to patients and
explain what we will be doing during the operation. This
1.3 Psychological Evaluation approach helps patients to understand the problem and cooper-
It is an indisputable fact that psychological evaluation is ate with us. In addition, recording the airway and archiving the
extremely important in our profession. Therefore, the author records on a patient database will be beneficial in regard to any
has had a full-time psychologist in his clinic and has reviewed possible conflict that may emerge after the operation.
DOI: 10.1201/9781003174165-1 1
2 Rhinoplasty in Practice
second observation provides numerous advantages; the patient

1.5 Aesthetic Evaluation can be re-analyzed and reviewed as to whether their expecta-
tions are still the same, the right decision has been made, etc.
This begins with determining the points that visually dis- It is also very valuable since it provides opportunities to raise
turb patients. The objectivity of a patient’s statements can be any subjects not previously discussed and to answer any ques-
evaluated. The scenario making a patient happy should be tions arising in the patient’s mind after the first meeting.
learned from patients themselves. After getting answers to
these questions, surgeons should evaluate whether the expec-
tations of patient are realistic, before moving on to next step.
REFERENCES
Lastly, a facial analysis of the patient should be performed,
and it should be discussed to what extent the planned surgery 1. Taş S. Closed Atraumatic Rhinoplasty Course. Endorsed
will be aesthetically beneficial for the patient and whether it by RSE (Rhinoplasty Society of Europe) and ISAPS
should be combined with additional procedures for harmony (International Society of Aesthetic Plastic Surgery).
Istanbul, Turkey, Nov 16–17, 2019. https://drsuleymantas.
in the face.
com/course/ Accessed 11 Aug 2019.
2. Taş S, Top H. An Unexpected Complication after Periorbital
Tumor Surgery in a Patient Later Discovered to Have
1.6 Simulation Study Myelodysplasia. Arch Plast Surg. 2014 Mar; 41(2): 186–7.
doi: 10.5999/aps.2014.41.2.186. Epub 2014 Mar 12.
A simulation study is very helpful both for patients and sur- 3. Taş S. Severe Facial Dermatitis Following Rhinoplasty due
geons. By conducting a simulation study, we can have an to an Unusual Etiopathogenesis: Rosacea. Arch Plast Surg.
idea about what kind of change there will be on a patient’s 2015 May; 42(3): 362–4. doi: 10.5999/aps.2015.42.3.362.
face, whether a patient wants this change, and whether Epub 2015 May 14.
surgery will be worthwhile. It should be remembered that 4. Safaryan D, Santareno S, Taş S. Dynamic Video-
patients who are not satisfied with the simulation study will Photograph Studio: A New Rhinoplasty Documentation.
make the same statements to you after the operation; in Aesthetic Plast Surg. 2020 Mar 20. doi: 10.1007/s00266-
such conditions, it would be best for everyone that you do 020-01673-7. [Epub ahead of print].
not operate on them. 5. Taş S. Childhood Abuse, Body Shame, and Addictive
Plastic Surgery: The Face of Trauma. Aesthetic Plast
Surg. 2020 Dec; 44(6): 2328–9. doi: 10.1007/s00266-
020-01984-9.
1.7 Revisit 6. Constantian MB. Childhood Abuse, Body Shame,
Although all these evaluations are made in the first consulta- and Addictive Plastic Surgery: The Face of Trauma.
tion, the author suggests at least two visits before surgery. The Routledge; Newyork, 2019.
Appendix A: Psychological Evaluation Form for Patients
to Complete at Their Preoperative Consultation
Name and Surname:

Date:
1. Looking at the two nose photographs 14. Is there any movement that you need to repeat?
a. Which one is more beautiful? 15. If you were walking with a friend and a car hit your
b. Which one is more natural? friend and drove off, would you stay to help your
friend or would you run after the car to catch it?
c. Which one do you think was operated on by Dr.
Suleyman Taş? 16. Does the photograph below disturb you?
No: 1 No: 2
Examination Findings:
Planned Treatment:
2. How often do you visit a hairdresser?

3. Do you always visit the same hairdresser?
4. When you visit the hairdresser, which treatments do
you get usually?
5. While cutting your hair, how do you describe it to the
hairdresser?
6. Does the hairdresser cut your hair as you wish?
7. If your hairdresser does not cut your hair as you
wish, how do you feel?
8. Have you ever dyed your hair before?
9. If yes, how did it make you feel?
10. Have you ever made any changes on your face or
body before?
11. For how long have you been planning to have an
operation?
12. Why did you decide to have an operation?
13. Can you tell us about your expectations from the
operation?
3
2
Closed Atraumatic Rhinoplasty Closed Atraumatic RhinoplastyRhinoplasty in Practice
This chapter aims to explain the meaning, philosophy, and • Have good knowledge of anatomy
technical details related to Closed Atraumatic Rhinoplasty. • Know which anatomic structures will be affected
with the surgical intervention and how
• Think about how the path of the desired maneuver
2.1 Description and Explanation of the should be done without disturbing any tissue
Closed Atraumatic Technique • Analyze the gain vs loss relationship
• Attempt the least risky maneuver first
With records of nose surgery dating back to 3000 bc, the term
rhinoplasty has evolved over the years. Until the 19th century, • Preserve the anatomy and the functions
reconstruction operations performed due to trauma and tis- • Attempt to minimize risk in order to minimize tis-
sue loss in the nose were known as rhinoplasty. After Roe [1] sue damage by aiming for longer-term results and
performed the first nasal cosmetic surgery in 1887, the term by identifying and supporting any weaker anatomic
rhinoplasty started to be attributed to aesthetic rhinoplasty, structures
whereas operations for trauma and tissue loss were called
reconstruction operations. While the concept of rhinoplasty, This list clearly shows that atraumatic means first, do
based on fundamental surgical principles and a deep scien- not harm; preserve anatomy and functions; strengthen weak
tific background, will continue to evolve, the important thing or weakened structures; and aim for long-lastin results [2–16].
is to understand is the philosophy behind these fundamental
principles. Without the philosophy, complication rates will not Atraumatic approach in rhinoplasty =
decrease and the results will satisfy neither the surgeon nor not only preserve but also support.
the patient. (S. Taş)
Generally known as “good practice”, these fundamental
principles mean doing the right thing, at the right time, with The plastic surgery tissue reconstruction ladder, created by
the right technique. If not followed, the unwanted result and examining these principles, is actually the best example to
side effects are not called complications but malpractice. understand this issue. The reconstruction ladder was designed
These principles are: according to the complexity of the construction, the risk of com-
plications, and the rate of possible revision. This algorithmic
• Determining the right diagnosis and appropriate ladder ranges from primary repair to more complex procedures
treatment option such as grafting, flap surgery, and free tissue transfers, and aids
• Ensuring a sterile environment during the procedure plastic surgeons in determining the best treatment options for
success. In the same manner, rhinoplasty should have a specific
• Patient monitoring and systemic follow-up before,
algorithmic ladder, since it is a nasal contouring surgery and
during, and after the procedure
is different from rhino-reconstruction surgery. This distinc-
• Using atraumatic techniques in surgery tion should be clearly made, and the surgeon should determine
• Ensuring the integrity of the body against external when and how to use each of these techniques. Surgeons should
factors by closing the incisions realize that rhinoplasty is a nose shaping surgery and should
• Early postoperative and follow-up to obtain optimal protect the structures encountered while shaping. If these struc-
wound healing tures cannot be protected, then they should be reconstructed.
In the following section, the ladder designed for rhinoplasty
Upon a literature review, it can be seen that all publications, surgery will be elaborated.
techniques, congresses, and speeches made since the 1800s
were attempts to improve one of these basic principles. It is
2.1.1 Why Does This Philosophy begin
critical for the surgeon to adopt these principles and follow
with the Closed Technique?
any progress made in these areas. Progress on techniques will
continue to evolve, but if the principles are not adopted, each There are two approaches for exposure in rhinoplasty: the
new improvement will be in vain. open and closed technique. Roe initially performed rhino-
The first and foremost principle of medicine is Primum non plasty without any external incisions in 1887 [1]. Following
nocere or “First, do not harm”. this, in 1929 Rethi [17] performed the same surgery using
Atraumatic in medicine means designing the surgical inter- an open technique, which became progressively popular and
vention aimed for minimizing tissue damage. In order to do mainstream since it provided superior exposure, visuality, and
that, one should: served better for educational purposes.
DOI: 10.1201/9781003174165-2 5
Although many incisions have been presented in the litera-

ture for the open approach (step incision, inverted V incision,
V incision, Swiss incision, etc.), decortication is basically
made by a full thickness incision on the columella, which is
then continued with dissection from tip to dorsum.
Anatomic and microscopic research have helped us better
understand the importance of the columella. The columella
is one of the main aesthetic units in the nose, consisting of
the columellar artery, vein, lymphatics, and the Pitanguy liga-
ment. When the columella is incised, those important struc-
tures are cut as well. If the surgeon can perform the surgery
using the closed technique, those structures will be preserved.
However, when the open technique is preferred:
• The incision can be repaired by primary suturing

• The Pitanguy ligament can be repaired back
• However, the columellar artery, vein, and lymphat-
ics are still not repairable today in practice. In the
literature, to address this point, Pshenisnov [18] tried
to repair the columellar artery by microsurgery
FIGURE 2.1 External vascular anatomy of the nose.
Therefore, before choosing the open technique, the irrevers-

ible losses should be kept in mind. The question arises: “Can
the surgeon perform this surgery with closed approach in order
to prevent these disadvantages?”
The Closed Atraumatic Technique will be summarized in
eight steps with review of every detail of rhinoplasty from
local injection to mucosal closure.
2.2 Stages of the Closed Atraumatic Technique

Closed Atraumatic Technique
1. Local injection
2. Incisions
3. Dissection
4. Preservation FIGURE 2.2 Internal vascular anatomy of the nose.
5. Reshaping
6. Reconstruction
7. Structure
8. Redraping and closure
2.2.1 Local Injection

The main reasons for bleeding in rhinoplasty procedure
include undiagnosed bleeding disorders, hypertension, and
insufficient local injection use on the septum.
A local injection to the external side of the nose has a mini-
mal effect on bleeding during rhinoplasty and disrupts the
planes. Therefore, local injection made only on the incision
lines with maximum 2 cc of anesthetic is recommended. In
this way, distortion of the nose is prevented and the external
appearance of the nose does not change. On the other hand,
the main blood supply of the nose lies within the septum area;
therefore control of this area using 7–8 ml of injection is also
suggested (Figures 2.1–2.3). FIGURE 2.3 Vascular anatomy of the septum and Kiesselbach plexus.
Closed Atraumatic Rhinoplasty 7
FIGURE 2.4 Divisions of trigeminal nerve.
Due to the septum’s rich blood supply, tachycardia and

hypertension may be seen, so the adrenergic injection should
be made slowly. If tachycardia occurs, then the trigeminal FIGURE 2.5 Inferior intracartilaginous incision.
reflex [19] can be stimulated. A local injector in the spine
may often suffice; however, in order to fully stimulate this
reflex, a 0.1 cc bilateral injection to the spine (Figure 2.4)
can be made, resulting in a 20–30 beat per minute decrease
in heart rate.
Video 2.1 details the local injection application favored by
the author: 0.1 cc of 1/100 adrenaline in 20 cc of prilocaine,
forming a 1/200,000 adrenaline solution.
2.2.2 Incisions
Incisions placed in the cartilage are better at withstanding scar
contracture forces that may occur during the wound healing
period and reduce the possibility of distortion and asymme-
try. These incisions are called intracartilaginous incisions
(Figure 2.5) and should be preferred if possible.
Each incision is made for a specific reason, allowing the sur-
geon access to a specific part of the nose. The nose resembles (a)
a house with many rooms when the outer soft tissue cover
and bone-cartilage relationship is examined. Surgery using
the open technique will require cutting into many walls to
reach each room, whereas with the closed technique, which
uses fewer cuts, the operation would be limited to one or more
selected regions. This anatomic aspect of the nose is presented
as the “Room Concept” [7].
Fundamental Closed Atraumatic Rhinoplasty Incisions

(Figure 2.6a–b)
1. Inferior intracartilaginous incision

2. Superior intracartilaginous incision (b)
3. Hemitransfixion incision FIGURE 2.6 (a) Inferior and superior intracartilaginous incisions. (b)
4. Lateral osteotomy incision The hemitransfixion incision.
FIGURE 2.7 Classic rhinoplasty incisions.
FIGURE 2.9 The framework of the nose.
Classic Rhinoplasty Incisions (Figure 2.7)
1. Trans-cartilaginous incision
2. Inter-cartilaginous incision
3. Marginal incision
4. Trans-columellar incision
2.2.3 Dissection Plane

The blood supply of the nose is concentrated in the SMAS
layer. Except for the perforators transecting the bone and
the cartilage, there are no vessels between the cartilage and
its perichondrium nor between the bone and its periosteum.
Bone and cartilage tissue are nasal structures with the lowest
metabolism and receive their required nutrients by diffusion
from the membranes (Figures 2.8–2.9). Therefore, the sub-
FIGURE 2.8 The soft tissue envelope of the nose. membranous (subperichondrial and subperiosteal) dissection
FIGURE 2.10 How the perichondrium adheres tightly to the cartilage FIGURE 2.12 The subperichondrial plane is demonstrated without any
can be clearly observed; using special tools for dissection of the perichon- bleeding.
drium will eliminate the possibility of damage to the cartilage during this
procedure. The author designed TAŞ1® and TAŞ2® for this purpose [19].
FIGURE 2.13 The bloodless surgical plane created by the subperichon-

drial plane is observed on the upper lateral cartilage.
plane is the most bloodless surgical plane that can be achieved

FIGURE 2.11 Although the perichondrium is penetrated, see how the
(Figures 2.10–2.13).
perichondrium and cartilage still appear as the same anatomic unit. Second, Periosteal and perichondrial membranes wrap and secure
see the clean and bloodless surgical plane under the perichondrium, while the anatomic structures beneath them. If they are separated
a significant capillary network is observed over the perichondrium. from the underlying structures, damage to their membranes
(a)
FIGURE 2.15 The DUAL dissection plane described by the author is

demonstrated. There is a combined surgical dissection which includes a
subperichondrial dissection over the lower lateral cartilage, a subSMAS
dissection in the supratip area which has a thick soft tissue envelope,
and again a subperichondrial dissection in the keystone area where there
is a thin soft tissue envelope. Thus, the redistribution of the soft tissue
envelope in a homogeneous manner can be performed to achieve the best
redraping effect.
2.2.3.1 Room Concept

There is no continuous plane to follow through the entire nose,
as seen in cadaveric dissections. Regardless of the surgical
plane chosen, the areas of dissection are interrupted by what
resembles a wall-like structure. If the submembranous surgi-
cal plane is preferred, these walls will be thicker than the other
planes. Those walls need to be transected to continue the dis-
section. Each wall will be explained for each surgical plane
separately.
(b) • For the submembranous dissection plane:

FIGURE 2.14 (a) TAŞ1 and TAŞ2, surgical instruments invented by the 1. Scroll ligament: It exists bilaterally in the lat-
author, penetrate into the submembranous surgery plan atraumatically. eral borders between the tip and dorsum. This
(b) TAŞ1 has a sharper and more delicate tip and is designed to penetrate fibrous tissue wall is thicker in the submembra-
under the perichondrium. TAŞ2 has a blunt and hard tip to penetrate nous plane by the perichondrial layer of upper
under the periosteum. Its L-shaped tip fits into the border of the nasal and lower lateral cartilages.
bone, allowing the surgeon to cut the pyriform ligament and penetrate
under the periosteum in one move. In both tools, one side has a cutter and 2. Pyriform (pyramidal) ligament: It exists in the
the other side has a blunt surface to continue dissection. border between the cartilaginous and bony dor-
sum. This fibrous tissue wall is much stronger
in the submembranous plane than in the sub-
will be prevented during reshaping of the cartilage and bones SMAS plan because of the perichondrium of
(Figure 2.14a–b). All surgical stages of the submembranous the upper lateral cartilage. In fact, in the border
dissection plane are shown in Video 2.2 [10–11]. between the cartilaginous and bony dorsum,
However, this plane has some limitations in specific condi- the perichondrium of the upper lateral cartilage
tions. It creates a thick, soft tissue cover, which is an advan- is divided in two. While the superficial layer
tage for thin-skinned patients but a challenge for redraping in merges with the periosteum of the nasal bone,
thick-skinned patients. Therefore, the DUAL dissection plane the deep layer attaches under the nasal bone. The
is preferred for those cases (Figure 2.15). anatomic relationship of this “transition zone”
was shown in a clinical study published by the c omplete the dissection (rather than additionally using inci-
author (Figures 2.16–2.17) [10]. sions, as in the submembranous plane).
3. Pitanguy ligament: It exists in the central border The subSMAS plane is the generally accepted routine surgi-
between the tip and dorsum. This fibrous tissue cal plane in which it is easier to pass over the nasal bone from
wall is thicker in the submembranous plane than in the upper cartilage. But since it meets the supra-perichondrial
the subSMAS plane because of the perichondrial surgical plane on the nasal bones, an additional incision should
layer of lower lateral cartilages. Unlike other walls, be made to get through the subperiosteal plane, which is more
this wall is perpendicular to the dissection plane. bloodless (Figures 2.18–2.23).
• For subSMAS dissection plane:

The same anatomic structures (scroll ligament, Pitanguy
ligament, and pyriform ligament) form the nasal walls, but
compared to the submembranous plane these fibrous walls
in the SMAS plane are thinner; it requires pushing only to
FIGURE 2.16 The transition zone described by the author is schema-

tized. In the keystone area, the perichondrium is divided into two: the
superficial layer joins with the periosteum of the nasal bone, and the deep
layer goes under the nasal bone and covers the upper lateral cartilages
which overlap. Thus, if one prefers the subperichondrial plane, when the FIGURE 2.18 Room Concept: The nasal framework is divided into
dissection comes to that point, the superficial perichondrial layer should three different rooms by the soft tissue envelope: orange, nasal bones;
be dissected to go under the periosteum. On the other hand, if one prefers gray, upper and lower lateral cartilages; blue, pyramidal ligament; green,
the subSMAS plane, when the dissection passes the upper lateral carti- scroll ligament; red, deep SMAS attachments.
lage, the periosteum of the nasal bone must also be incised and switched
to the subperiosteal plane. The author termed this region the “transition
zone” due to its clinical and anatomic importance.
FIGURE 2.19 The nose of the cadaver was dissected through the sub-
membranous plane on the left side and the subSMAS plane on the right
side. While subSMAS dissection exposed the branches of the angular
FIGURE 2.17 A clean upper lateral cartilage-nasal bone passage can be artery (red arrow) on the right side, the vessel network (green arrow) was
achieved with atraumatic dissection performed by TAŞ 2. totally preserved by the submembranous plane on the left side.
FIGURE 2.20 The right side of the nose received subSMAS dissec- FIGURE 2.22 The right side of the nose received submembranous
tion and the left side received submembranous dissection. While the dissection and the left side received subSMAS dissection. Note how far
scroll ligament (blue arrow) and transition zone (red arrow) are clearly the perichondrium of the upper lateral cartilage (green arrow) keeps its
observed on the left side, there is no true ligament to pause the dissection existing relation to the nasal bone, although the upper lateral cartilage
in subSMAS plane, although the author noted the dissection was harder itself has ended, in comparison to the other side (yellow arrow). This
in those areas. finding again confirms the transition zone (red arrow) described by the
author. Detached scroll ligament (blue arrow).
FIGURE 2.23 The footprint of the scroll area (blue arrow) in SMAS
has ligamentous extensions (blue rectangle) as well as the transition zone
(red arrow). This observation is the same as for the retaining ligaments
on the face. Therefore, these ligaments were called by the author retain-
FIGURE 2.21 After dissecting the scroll area (blue rectangle) where ing ligaments of the nose. The importance of those retaining ligaments
the scroll ligament attaches, the thickness and route of the scroll ligament in clinical practice is as redraping issue. Ligamentous extension of the
can be clearly exposed (red arrow, transition zone). transition zone (red rectangle).
• For the sub-skin dissection plane: There is, however, a difference between face and nose
surgery here. In a face-lift, all retaining ligaments are dis-
Cadaveric studies have revealed that these walls are sected so the face can be effectively lifted. Unlike face-
similar to the subSMAS plane. lifts, nose surgery does not allow for the luxury of excessive
The nasal framework is divided into three rooms with skin and subcutaneous tissue removal. Therefore, it is man-
these ligaments: datory to redrape the excessive skin-subcutaneous tissue
in rhinoplasty. To prevent complications such as supratip
The upper room containing the nasal bones; deformity or postoperative droopy tip, these retaining liga-
The middle room including the upper lateral ments should be addressed (Figures 2.25–2.28). The sur-
cartilage; gical technical aspect of the concept will be elaborated in
The lower room including the lower lateral Chapter 4.
cartilage.
The upper room is separated from the middle room by the

pyramidal ligament and the middle room from the lower
room by the scroll and Pitanguy ligaments. The lower room
is further divided into two separate rooms by the Pitanguy
ligament.
So why are these walls, which are critical to preserve the
anatomy, dissected during rhinoplasty?
It seems illogical to cut them to complete a dissection as
they are responsible for the stabilization of the soft tissue.
They are strong or relatively weaker in not only one surgical
plane, but throughout them all. Thus, they are no different
from the retaining ligaments of the face (Figure 2.24). These
three ligaments (scroll, Pitanguy, and pyramidal) should also
be referred to as the “retaining ligaments of the nose” and as
such, directly affect the success of nose surgery. FIGURE 2.25 The retaining ligaments of the nose are demonstrated:
Pitanguy, scroll, and pyriform ligaments, respectively (red, green, and
turquoise); transition zone (gray-yellow transition in keystone area).
FIGURE 2.24 The retaining ligament has a body which forms a true
ligament, above which there are many extensions towards the skin; this
resembles a tree and its branches. FIGURE 2.26 The Room Concept is demonstrated in a patient.
FIGURE 2.29 SubSMAS dissection meets with the subperiosteal dis-

section after the dissection passed the nasal bones and reaches the maxil-
lary bone. (Blue arrow) Naked maxillary bone; (red arrow) nasal bone
periosteum; (green arrow) naked nasal bone; (yellow arrow) sutura
between the nasal and the maxillary bone.
bones, the dissection switches itself under the periosteum of

the maxillary bone. This shows that the periosteum of the
nasal bone is different from that of the maxillary bone and is
FIGURE 2.27 The retaining ligaments are demonstrated in a patient.
a fibrous layer that is more firmly attached to the wall of the
bone (Figure 2.29) [2].
2.2.4 Preservation
As much preservation as possible of all anatomic structures
during dissection and exposure is the key point of aesthetic
rhinoplasty procedures (Figures 2.30–2.33). Preservation
FIGURE 2.28 In this histological study of the author, it is clearly

observed how the perichondrium layer firmly adheres to the cartilage
tissue; in some areas their boundaries cannot be clearly selected as the
two tissues are intertwined. In contrast, the SMAS layer is loose fibrous
tissue, located at the right side. (Green arrow) The area where cartilage-
perichondrium border is clearly selected; (yellow arrow) the area where
cartilage-perichondrium border cannot be clearly selected; (purple
arrow) the hyper-intense area which refers to dense fibrous perichondrial
tissue; (turquoise borders) the localization of the perichondrial tissue.
Important Note: When dissecting the dorsum completely in

the subSMAS surgical plane and going over the periosteum of
the nasal bones, where the periosteum of the nasal bones ends
in a junction with the nasal process of the maxillary and nasal FIGURE 2.30 Subperichondrial dissection on the septal cartilage.
FIGURE 2.31 The lower lateral cartilage was exposed through the infe-
rior intracartilaginous incision with a submembranous dissection plane;
the dissection was terminated when it meets with the scroll ligament.
FIGURE 2.33 When one prefers to dissect the nasal dorsum from the
inferior intracartilaginous incision, the scroll ligament must be dissected:
(blue arrow) detached scroll ligament; (red arrow) the transition zone (not
yet penetrated).
2.2.5 Reshaping
Bone structures are the main support element of the nose; this
support is weakened when osteotomy is performed. Therefore,
it is very important to know the concept of osteoplasty. In the
first step, reshaping of the nasal and maxillary bones will be
a more conservative approach with osteoplasty techniques. If
osteoplasty is not enough, then osteotomy can proceed to get the
desired shape. When and how should osteoplasty be performed?
• With respect to the thickness of the nasal bones, they

can be flexed by osteoplasty in some specific cases, so
a more elegant structure can be achieved c ompared to
osteotomy. This may be a suitable method if a small
amount of narrowing without narrowing the volume
of the nasal cavity is desired.
• For nasal bones with C/S-shaped asymmetric bone
surfaces, using osteoplasty to obtain smoother bone
surfaces before an osteotomy will be more successful
in crooked noses (Video 2.3) [5, 9].
FIGURE 2.32 How the delivery technique can be applied by preserving
the scroll ligament (non-delivery technique).
• In patients with thick nasal bones, thinning the oste-
otomy line with osteoplasty before the osteotomy is a
good maneuver to prevent unexpected fractures dur-
ing osteotomy (Video 2.4).
of these structures allows the identification of underly- • The bone dust created when an osteoplasty is per-
ing variations and deformities, and thus makes their treat- formed with a manual rasp is also a very suitable graft
ment possible [20]. If the preservation of these structures material [9]. This dust is a special weapon providing the
does not allow for correction of the deformity, redesigning ability to handle secondary cases with an insufficient
these anatomic structures instead of excising them should primary graft source, without the need for more distant
be considered. graft sources such as rib and ear (Video 2.5).
2.2.6 Reconstruction 2.2.7 Structure
If it is not possible to preserve the anatomic structures and it Preservation alone is never enough; the nose should also
becomes necessary to use excision, it is mandatory to repair be supported after identifying the weak areas due to both
this area (Figure 2.34). The most logical and least harmful anatomic variations and maneuvers used during rhinoplasty.
course of action is to perform reconstruction using the tissues This approach is essential to achieve long-lasting anatomic
in that area (Figures 2.35–2.36) [6]. noses (Figure 2.37a–b) [4].
FIGURE 2.34 The endoscopic image recorded when all the anatomic
structures can be preserved.
FIGURE 2.37a Exposure of the lower lateral cartilages, while com-

pletely protecting the soft tissue on it, revealed the shape deformity of the
cartilage clearly. There is a concavity deformity due to weakness of the
lateral crus and a secondary flaring in the medial crus of the foot plates.
FIGURE 2.35 As a result of component excision from cartilage dor-

sum, the septal cartilage is exposed, the upper lateral cartilage is ready
for spreader flaps, and the nasal bone is ready for rasp/excision.
FIGURE 2.37b When the lateral crura are supported, the desired aes-
thetic triangular image in the lower crural ring is achieved, and the flar-
ing in the medial crus is also self-corrected since the actual problem was
treated.
2.2.8 Redraping and Closure

FIGURE 2.36 In cases where the dorsum cannot be preserved, the dor- The dictionary definition of “redrape” is to pull the skin tightly
sum is reconstructed. The cartilage dorsum was repaired with spreader during plastic surgery procedures. In most plastic surgery
flaps and the bony dorsum was repaired with bone dust instead of oste-
operations, the skin cover can be pulled tightly by excision of
otomies since the case had a narrow base. Thus, the bone defect was
repaired with bone and the cartilage defect was repaired with cartilage,
the excessive skin; however, this is not possible in rhinoplasty.
which are the same type of tissue. It should be remembered that the best Even if it were possible, it would not be done as it could cause
reconstruction in plastic surgery is reconstruction of the gaps with the the loss of three-dimensional definition of the nose. So how
same type of tissue. can redraping in the nose be done?
This issue is especially important in reduction rhino- infections, bleeding, edema, and late-term complications
plasties. Rhinoplasty only allows for elliptic alar skin exci- such as retraction and hypertrophic scarring (Figure 2.38).
sions. Unfortunately, this type of excision cannot be used for Likewise peroperative care—innovations which provide post-
redraping in reduction procedures as excessive skin occurs operative intensive and high quality care—should be followed
in the central part of the nose (dorsum and tip). In addition, as state of the art [21–24].
skin reduction in lateral rooms—going back to the Room As a result, using closed rhinoplasty with the atraumatic
Concept—does not affect the central rooms of the nose. philosophy will aid the surgeons in achieving a natural look-
The contraction capacity of the skin is also another issue. If ing, fast healing, long-lasting, functional, and highly aesthetic
one prefers the submembranous plane for dissection, no skin result (Figures 2.39–2.42, Videos 2.8–2.10).
contraction will be seen since the soft tissue cover is fully pro-
tected with the perichondrium-periosteum layer which cannot
shrink or stretch. In such cases, it is logical to use the DUAL
dissection plane (detailed in Chapter 7).
If redraping can be achieved by the redistribution of the
soft tissue cover without excision, this should be prioritized
(Video 2.6). However, if the skin cover is too thick, then peri-
chondrio-SMASectomy, as described in Chapter 4, should be
performed as a further step.
After these steps, the soft tissue cover will have a more
homogeneous distribution in thickness. However, redraping
can continue if the ligaments are preserved or repaired again.
According to the Room Concept, the excessive skin in the lower
third of the nose can be adapted to the nasal skeleton using the
Pitanguy and scroll ligaments, and the excess skin at the upper
two-thirds with the pyramidal ligament (Video 2.7).
Proper closure of the skin and mucosa incisions is essen-
tial to prevent short-term complications such as wounds,
(a)
(b)
FIGURE 2.39 (a, b) In a patient who underwent rhinoplasty with

FIGURE 2.38 In the operation of a secondary case with soft triangle a closed atraumatic approach, although she had thick skin and an alar
retraction, following the incision, many hair follicles were found in the excision was performed, she made a speedy recovery with a low level of
retracted side. edema and no bruising on the postoperative seventh day.

(a) (b)

(c) (d)
FIGURE 2.40 (a–d) Before and five years after the closed atraumatic rhinoplasty.
(a) (b)
(c) (d)
(e) (f)

(g) (h)
FIGURE 2.41 (a–h) Before and three years after the closed atraumatic rhinoplasty.

(a) (b)
FIGURE 2.42 (a–h) Before and four years after the closed atraumatic rhinoplasty.
(c) (d)
(e) (f)
(g) (h)
FIGURE 2.42 (Continued)

TABLE 2.1
2.3 Open and Closed Rhinoplasty Comparison Comparison of Surgical Approaches in Rhinoplasty
The outcome of an operation performed by ignoring the rela- Disadvantages of Disadvantages of Open
tionship of the soft tissue between the framework is unpredict- Closed Technique Technique
able. In the end, the patient will see her external nose in the It is more difficult to Columellar scar
mirror, not her inner framework. As described, a closed and learn and perform
atraumatic approach including choosing maneuvers carefully, Columellar artery/vein/lymphatic damage
following the given shape intensively during surgery, redrap-
If alar excisions are performed, there will be
ing the excess skin, and adjusting the thickness of the skin can no remaining main lymphatic vessel for
be the most efficient and logical way [2–3, 25]. drainage
Instead of the classic debate of the closed vs open technique, the The possibility of impairment in the tip
point here is to go a step further to see the big picture. In order for circulation when alar excisions are
a surgeon to fully evaluate this, one must have full experience in performed with defatting procedures
both techniques over a long time to see what is sufficient or insuf- The columella loses its chance of being a
ficient and what actually determines the result. It is this experi- single aesthetic unit when a columellar
ence that will be explained throughout this book (Figure 2.43). incision is performed in the open technique
Table 2.1 provides an objective comparison of the advan- Since the route of the dissection has to be from
tages and disadvantages of the open and closed techniques. the tip incision to the back, all walls of the
To best understand the advantages of the closed technique, soft tissue enveloped in the framework have to
refer to the tertiary rhinoplasty case with a total septal perfo- be dissected (remember the Room Concept)
ration and Binder syndrome for whom a reconstruction using Redraping is harder since it is more extensively
the closed technique, despite its technical difficulties, was pre- dissected than in the closed technique
ferred (see Chapter 6, Figures 6.4–6.9). The columella should be sutured back many
times in order to evaluate the shape given
during the surgery
Longer recovery period
FIGURE 2.43 Left, 11 years previously the author performed rhinoplasty surgery with open technique in a comfortable posture. Right, 7 years
previously the author performed rhinoplasty surgery with a closed technique, with postural difficulty for the neck and back of the surgeon. However,
postural difficulties should not discourage the surgeon from performing closed surgery.
TABLE 2.2 Rhinoplasty Society), ISAPS (International Society of

Comparison of Surgical Planes in Rhinoplasty Aesthetic Plastic Surgery) and RSE (Rhinoplasty Society
of Europe). Istanbul, Turkey, Nov 28–29, 2020. https://
Disadvantages of the Disadvantages of the drsuleymantas.com/course/ Accessed 28 July 2020.
Subperichondrial Plane SubSMAS Plane 4. Taş S. Response to Commentary on: Dorsal Roof Technique
It is more difficult to get to this plane Bleeds more for Dorsum Preservation in Rhinoplasty. Aesthetic Plast
Prevents shrinking effect in thick Swells more Surg. 2020 Mar 4. doi: 10.1007/s00266-020-01656-8.
skinned patients [Epub ahead of print].
In thick-skinned patients, additional Bruises more (if subSMAS 5. Taş S. The Alignment of the Nose in Rhinoplasty: Fix Down
debulking or plication procedures are dissection also prefers over Concept. Plast Reconstr Surg. 2020 Feb; 145(2): 378–89.
required to adapt the non-shrinking the bone) doi: 10.1097/PRS.0000000000006523. Epub 2019 Nov 19.
tissue to the framework
6. Taş S. Dorsal Roof Technique for Dorsum Preservation in
There will be more scarring
Rhinoplasty. Aesthet Surg J. 2020 Feb 17; 40(3): 263–75.
(in the reduction rhinoplasty
this can be preferred; see doi: 10.1093/asj/sjz063. Epub 2019 Feb 25.
DUAL Plane Dissection in 7. Taş S. Superior-Based Transposition Flap: A Novel
Chapter 7) Technique in Rhinoplasty. Aesthet Surg J. 2019 June 21;
It causes limited debulking in 39(7): 720–32. doi: 10.1093/asj/sjy197. Epub 2018 Aug 10.
thick-skinned patients 8. Taş S. The Pearls of Closed Rhinoplasty: “Atraumatic
Approach” Advanced Aesthetic Rhinoplasty and Face
Contouring Meeting. St Petersburg, Russia, Oct 24–27, 2019.
9. Taş S. The Use of Bone Dust to Correct the Open Roof
Deformity in Rhinoplasty. Plast Reconstr Surg. 2018 Sep;
2.4 Submembranous—SubSMAS 142(3): 629–38. doi: 10.1097/PRS.0000000000004706.
Dissection Plane Comparison 10. Taş S, Celik N. New Instruments for Submembranous
Both surgical planes have their cons and pros, and the surgeon Dissection in Rhinoplasty. Aesthet Surg J. 2017 July 1;
37(7): NP73–NP8. doi: 10.1093/asj/sjx084.
has to master them and know which one is more appropriate
11. The Name of the Invention. Apparatus Used in Nose
in certain cases. Table 2.2 provides an objective comparison
Surgery, Inventor: Süleyman Taş. Turkish Patent Institution
of the advantages and disadvantages of the submembranous
Registration Number: 2016/05472.
(subperichondrial-periosteal) and subSMAS planes.
12. Taş S. The Closed & Atraumatic Technique. Baku
Rhinoplasty Days: Baku-Azerbaijan, Aug 31–Sep 1, 2018.
VIDEOS 13. Taş S. The Closed Atraumatic Technique. Innovation in
Rhinoplasty 2: Istanbul, Turkey, June 3–4, 2018.
2.1 Local injection in closed rhinoplasty. 14. Taş S. A New and Simple Way to Hold Tendon Stumps
2.2 Surgical stages of the submembranous dissection plane. Atraumatically. J Hand Surg Am. 2013 Aug; 38(8): 1659.
2.3 Using osteoplasty to obtain smoother bone surfaces. doi: 10.1016/j.jhsa.2013.05.029.
2.4 Thinning the osteotomy line with osteoplasty. 15. Taş S. A New Way for Supporting Tip Projection in Closed
Rhinoplasty: Using the Medial Deep SMAS Layer. Plast
2.5 Harvesting bone dust.
Reconstr Surg. 2014 Jan; 133(1): 76e–7e. doi: 10.1097/01.
2.6 Redraping achieved by the redistribution of the soft prs.0000436809.88659.e0.
tissue cover. 16. Santareno S, Taş S. Concept of Anatomic Columellar Strut
2.7 Redraping with bone suture. Grafting in Rhinoplasty: An Algorithmic Approach. Aesthet
2.8 Result with closed rhinoplasty 1. Surg J. 2020 Jan 29; 40(2): NP65–NP71. doi: 10.1093/asj/sjz272.
17. May H. The Réthi Incision in Rhinoplasty. Plast Reconstr
2.9 Result with closed rhinoplasty 2.
Surg. (1946) 1951 Aug; 8(2): 123–31.
2.10 Result with closed rhinoplasty 3. 18. Pshenisnov KP. Commentary on “Comparison of Various
Rhinoplasty Techniques and Results of Long-Term”.
Aesthetic Plast Surg. 2015 Aug; 39(4): 478–82.
REFERENCES 19. Özçelik D, Toplu G, Türkseven A, Sezen G, Ankarali H. The
1. Roe JO. The Deformity Termed “Pug Nose” and Its Importance of the Trigeminal Cardiac Reflex in Rhinoplasty
Correction, by a Simple Operation. Med Rec. 1887; 31: 621. Surgery. Ann Plast Surg. 2015 Aug; 75(2): 213–8.
2. Taş S. Closed Atraumatic Rhinoplasty Course. Endorsed 20. Taş S. Isolated Congenital Partial Absence of the Lateral
by RSE (Rhinoplasty Society of Europe) and ISAPS Crural Cartilage. J Craniofac Surg. 2015 Oct; 26(7): 2231–
(International Society of Aesthetic Plastic Surgery). 2. doi: 10.1097/SCS.0000000000001740.
Istanbul, Turkey, Nov 16–17, 2019. https://drsuleymantas. 21. Taş S. The Effects of Vibration and Pressure Treatments
com/course/ Accessed 11 Aug 2019. in Early Postoperative Period of Rhinoplasty. Aesthet Surg
3. Taş S. Closed Atraumatic Rhinoplasty Course 2. Endorsed J. 2019 Aug 13. pii: sjz226. doi: 10.1093/asj/sjz226. [Epub
by ASPS (American Society of Plastic Surgeons), RS (The ahead of print].
22. Taş S. The Effects of Vibration Treatment in Rhinoplasty. 24. The Name of the Invention. Vibrating Nasal Splint, Inventor:
Aesthet Surg J. 2020 Mar 26. pii: sjaa049. doi: 10.1093/asj/ Süleyman Taş. Turkish Patent Institution Registration
sjaa049. [Epub ahead of print]. Number: 2016/14675.
23. The Name of the Invention. Nasal Silicon with Stabilization 25. Taş S. Response to “Anatomic Columellar Strut, An
System, Inventor: Süleyman Taş. Turkish Patent Institution Alternative Paradigm?” Aesthetic Surgery J. 2020 May 23.
Registration Number: 2016/14678. doi: 10.1093/asj/sjaa088. [Epub ahead of print].
3
Dorsum Surgery Dorsum SurgeryRhinoplasty in Practice
3.1 Osteotomy area while the open roof gets closed; thus, the phenomenon is
known as rocker. To prevent the occurrence of this complica-
The surgery used to cut bone is known as an osteotomy. tion, medial osteotomies that lie higher than the radix should
Performing this type of surgery smoothly and without creating not be made, or the edges of the lateral and medial osteotomies
additional fractures requires great skills, patience, and good should be determined with transverse osteotomies.
equipment. Osteotomies used to be performed with hand saws
in the 1900s; however, due to emerging bone defects through
their use, they were then performed with a chisel, then with 3.1.1.2 Nasolacrimal Duct Damage
4 mm guarded osteotomies, and then with 2 mm guarded oste- The canaliculi arising from the upper and lower lacrimal punc-
otomies. Today, power tools facilitate this stage and two spe- tum drain to the lacrimal sac formed by the frontal process
cific ones come to mind: ultrasonic devices and micromotors of the lacrimal bone and maxillary bone behind the orbital
(Videos 3.1–3.2). rim at the level of the medial canthus. The lacrimal sac and
Success in this classical osteotomy technique is based on post-lacrimal sac are a bone canal lined with a thin mucosa.
the sharpness of the device, hand sensitivity of the surgeon, This canal is called the nasolacrimal duct, and it moves down
and coordination with the nurse. However, all these potential 1.5–2 cm in the maxilla and opens to the lower meatus. Its
risks can be eliminated with the use of power instruments opening is approximately 16 mm inside from the front end of
(Figure 3.1) [1]. the lower concha and 3 cm inside from the nostrils and has a
mucosal fold (the valve of Hasner) [3–6].
3.1.1 Osteotomy Complications Various procedural routes such as “low to low”, “low to
and Their Preventions high”, “high to low”, and “high to low to high” have been
described for the lateral osteotomy line. However, the nasal
3.1.1.1 Rocker Deformity
When the middle line goes too high during medial osteotomy,
a condition called rocker deformity appears since the nasal
bone released through a lateral osteotomy is medialized using
the fingers at the level of the apertura pyriformis. This defor-
mity is a version of the open roof deformity occurring more
in the cephalic rather than the keystone area (Figure 3.2) [2].
Why is it known as rocker deformity? The word “rock”
means “to bewilder” in English. When osteotomies are done
too close to the roof after removing the hump, it is “bewilder-
ing” that a new open roof deformity appears in the cephalic
FIGURE 3.1 The correction of a severely crooked nose with asymmet-

ric osteotomies. FIGURE 3.2 Rocker deformity, red arrow.
DOI: 10.1201/9781003174165-3
25
closed with the lower concha lateralization, the tear drainage

to the nasal cavity is interrupted and if the patient bleeds from
the osteotomy line after the operation, this blood flows retro-
gradely to the eye from the lower punctum and may emerge
from it. This is quite a dramatic scene for the cosmetic rhino-
plasty patient.
The Following Should Be Done in These Cases
1. The eye should immediately be covered with a strip

and wet gauze since blood will cause irritation in the
eye. The patient should be monitored until discharge,
although the bleeding generally stops the next day by
the hemostasis mechanism of the body. If bleeding
continues, antibiotic eye creams and keeping the eyes
closed are recommended.
2. The surgeon should review their knowledge on lat-
eral osteotomy and anatomy.
If the nasolacrimal duct is damaged, or if there was already

an underlying nasolacrimal duct problem exaggerated by
rhinoplasty, silicone tube intubation is primarily made. This
procedure is sufficient in most patients and successful results
are obtained, but it may rarely be necessary to perform a
dacryocystorhinostomy.
FIGURE 3.3 Webster triangle, blue; valve of Halser; nasolacrimal duct;
and lowest level for safe lateral osteotomy.
3.2 Osteoplasty
baseline is solitary and is not an anatomical suture but a
bone groove that progresses between the frontal process of the If there is a convexity deformity on the lateral walls, it can be
maxillary bone and the main buttress of the maxilla. In low repaired by shaping the bone. Power burrs are very successful
osteotomies, the lowest it can get coincides with this line. The in this regard. However, maximum care must be taken to avoid
nasolacrimal duct is in the maxillary bone further lateral to this thinning the bone too much. The parameter here is that the
line. The point where the duct is closest to the nasal baseline bone should be left thick enough to perform a safe osteotomy
is at the level of medial canthal ligament, but here, it is 2 mm (Figure 3.4). If the convexity deformity is not very severe,
lateral to the medial canthal ligament (Figure 3.3). power rasps can be used for this purpose (Video 3.3).
3.1.1.3 Airway Problems

For the lateral osteotomy line not to cause airway problems, it
is recommended that it should begin a bit higher than the nasal
baseline in the piriform apertura. The reason is the Webster
triangle (see Figure 3.3), and the protection of this area is a
common method for the prevention of airway problems due
to the narrowing induced by the lateral osteotomy [7]. In fact,
if the adhesion point of the lower concha bone stays on the
lateral osteotomy line, the airway narrows significantly. In the
scenario where the lower concha is included in the lateral oste-
otomy, there is also a risk of damage in the nasolacrimal duct
since it opens to the lower meatus.
Thus, if a lateral osteotomy line is formed which does not
pass beyond the medial canthal lateral above and does not
include the lower concha in the osteotomy line, the nasolac-
rimal duct is preserved, and the airway does not clog. It is
important for the surgeon to stay in this safe zone to prevent
severe osteotomy complications.
Important Notice: In cases where the osteotomy line is not
formed in this way, blood may seep from the patient’s eye after
the operation! How? If the valve of Hasner is damaged or it is FIGURE 3.4 Reshaping of the convex lateral nasal walls with osteoplasty.
Dorsum Surgery 27
If power instruments are not available, TAŞ3® can be used

for the shaping of lateral surfaces, and it also enables the accu-
mulation of bone powders that arise during this shaping with
the reservoir in the middle.
3.3 Maxilloplasty
Maxillary hypoplasia is the condition in which one of the
alar bases is more displaced than the other in such a way as
to include the upper part of the nasolabial fold in the sagittal
plane (Figure 3.5). If the maxillary hypoplasia is lesser than
2 mm, then the opposite maxilla can be deepened with a power
burr. Symmetry with the hypoplasic side is ensured and the
risks of grafting are not taken; thus, a more symmetrical and
successful result can be obtained (Video 3.4) [8]. If the maxil-
lary hypoplasia is more than 2 mm, then maxillary augmenta-
tion should be performed (detailed in Chapter 5).
It is always useful to check the osteotomy lines after the
osteotomy with palpation or endoscopically as roughness in
these lines can be smoothed and perfected using the maxil-
loplasty method (Video 3.5).
In crooked noses, the maxilloplasty technique can also be
used to prepare a groove for the nose to sit on after rotation to
reduce the difference between the maxilla on both sides (see
fix down technique).
FIGURE 3.6 (a) The historical categorization of dorsum surgery.

(b) The current categorization of dorsum surgery..
TABLE 3.1
The Current Techniques for Dorsum Surgery
Dorsum Preservation Dorsum Reconstruction
Techniques Techniques
1 Push down Excision + primer
suturation/osteotomies
2 Let down Spreader graft
3 Skoog technique Spreader flap
4 Retractable roof technique Camouflage surgery
5 Fix down Bone dust technique
6 Dorsal roof technique
and proposed closed roof techniques, popularizing the push

FIGURE 3.5 Maxillary hypoplasia, red arrow. down technique. Therefore, dorsum surgery historically
divides into the two main categories of open roof or closed
roof (Figure 3.6a) [9].
However, dorsum surgery today is categorized into those
that excise the dorsum and those that preserve it (Table 3.1).
This classification is not much different than the historical dis-
3.4 Dorsum Surgery
crimination of dorsum surgery. The only difference is that the
Looking back 70 years, dorsum surgery fell into two main cat- techniques that excise the dorsum now try to close the open
egories. The first was the hump removal technique which was roof that it formed, through osteotomies as well as spreader
popularized, well-described, and generalized by Joseph. Then, grafts/flaps. On the other hand, dorsum preservation tech-
Cottle showed that this technique caused open roof deformity, niques continue to use the push down modifications.
The new perspective here should be “not only to preserve as internal valve collapse and open roof syndrome occurred in
but also to support”, as required by the atraumatic philosophy. this period; however, nothing was proposed other than oste-
Dorsum preservation techniques do not mean that spreader otomies to close the open roof deformity that formed after
grafts, flaps, or other structural grafts are not required. Cartilages removal of the dorsum. In 1954, Cottle [9] began to replace
might have been thin before the operation or they might have the materials that were removed from the roof similar to an
enlarged due to performed modification, and in this case, thin onlay graft. After Sheen [13–14] described spreader grafts in
regions should be supported, and the preserved dorsum should 1978, these issues started to be overcome in earnest. Then, in
be remodified (Figure 3.6b) [10]. In the next pages of this chap- 1997, Ahmet Seyhan [15] started to use spreader flaps in an
ter, the following will be discussed: placing spreader grafts and attempt to eliminate roof issues occurring after excision. In
flaps on the totally preserved dorsum, suturing ethmoid grafts the 2000s, the composite removal of the dorsum gave way to
on the septum, combining other structural methods with preser- component excision, and roof repair became a routine pro-
vative methods, and various new structural methods. cedure after the removal of the hump [16]. Therefore, the
Important Note: Remember that in plastic surgery, if you history of dorsum excision shows that a practice that started
cannot create a surface that is aesthetically pleasing to the eye with only the removal of the dorsum turned into its removal
with lights and shadows, it does not matter whether you pre- and repair.
served anatomy or not. You cannot tell a patient that you have There have been numerous publications on dorsum surgery
preserved their dorsum but that no other modifications can be for asymmetrical and crooked noses describing various oste-
made or that you preserved their dorsum and their hump is gone otomy and shaping methods. Additionally, camouflage tech-
but their nose has expanded. Thus, when removing a hump, you niques were also improving during this period and the diced
must be careful to ensure others do not think the patient looked cartilage technique, which is now the most commonly used
better before the surgery. That is why it is important not only technique for this purpose, started to be used in plastic surgery
to preserve but also to attempt to obtain the best possible result in the 1940s [17]. In the 1950s, it found a wide application area
(Videos 3.6–3.9). The priority should be the frontal image of from ear reconstruction to bone defect and hernia repair. In
the patient, followed by the side and the base views. 1954, Peer [18] wrote a well-received publication on the use
of diced cartilage. In this, diced cartilage obtained from rib
cartilage is placed on an ear-shaped mold made from vital-
3.4.1 Excisional Approach to the Dorsum
lium with a perforated structure for the blood vessels to enter.
3.4.1.1 The History of Dorsum Excision This is then subcutaneously placed in the abdomen of the
The first hump removal surgery was executed by Roe [11] in patient and left there for five months, after which it is removed.
1891; all stages of the classical operation were detailed by The fibrosis and diced cartilage, which have taken the shape of
Joseph [12] in 1930 (Figure 3.7). Serious complications such the cartilage skeleton of the ear, are then used to form the skel-
eton of the atretic ear. In 1961, Limberg [19] designed a special
injector to inject diced cartilage and began to use it on the nose
for saddle nose repair. However, as the obtained results were
not ideal, this application was abandoned for quite some time.
Onur Erol’s [20] publication in 2000 related to a diced carti-
lage application known as the “Turkish Delight” attracted the
attention of surgeons to this interesting technique, causing it to
be frequently used in rhinoplasty and also to have more than
100 articles written about it.
In conclusion, dorsum excision is a surgical procedure which
may later require structural repair and camouflage techniques.
The most common technique is component hump removal,
which minimizes the amount of excision to be made on the
dorsum, followed by repair with a spreader flap, graft, or oste-
otomies. If any roughness is observed on the surface after the
reconstruction, the surface can be repaired with camouflage
techniques.
3.4.1.2 Composite Hump Removal

This is the removal of the hump with the mucosa under it
as one piece. In this case, the septum that forms the key-
stone region, upper lateral cartilage, and nasal bone with
the mucosa that covers it are removed (Figure 3.8a–b). It is
an outdated technique since it causes open roof syndrome,
FIGURE 3.7 The classical hump removal technique demonstrated by a deformity characterized by discoloration, pain, malforma-
Joseph. tion, and gap emergence as a result of direct skin contact with
Dorsum Surgery 29
FIGURE 3.9 Component excision material.
FIGURE 3.8 (a) The anatomy of the dorsum and internal vault. (b) Left,
component hump excision. Right, composite hump excision.
the mucosa and the skin after the operation on the skin of the
dorsum [9].
3.4.1.3 Component Hump Removal

This modification is quite important for reducing the amount
of tissue extracted to treat an arched or projected appearance
on the dorsum. First, the mucosa is preserved by forming tun-
nels into it on the surface of the upper lateral cartilages that
face the nasal cavity. Then, the upper lateral cartilages are
separated from the septum and the groove where they adhere
anatomically; the overlapping where the upper lateral carti-
lages progress under the nasal bone is preserved from the total
excision. Thus, only the septum and nasal bone protrusion that
causes the hump is revealed in the midline and it is excised
(Figure 3.9). After the dorsum descends to the intended level,
the upper lateral cartilages, which are relatively longer than
the new dorsum, are used as spreader flaps in closing the bone
roof thanks to the overlapping that progresses under the carti-
lage roof and partially under the nasal bone [16] (Figure 3.10).
The remaining gap in the bone roof is closed with medial and
lateral osteotomies. If the dorsum has not descended enough
to form a spreader flap, or in cases of asymmetry and trauma,
spreader flaps obtained from the septal cartilages are used to
close the gap on the dorsum (Figure 3.11). Sheen called this FIGURE 3.10 Spreader flap.
3.4.1.4 Dorsum Reconstruction

Reconstruction methods are often used when an excisional
approach is performed on the dorsum, when the dorsum needs
to be strengthened, or in cases where dorsum preservation meth-
ods are insufficient for nose shaping methods (Figure 3.12).
Dorsum repair with the spreader graft and flaps is essential
in rhinoplasty, and surgeons must know them well. Tips for
this technique are as follows:
• Reconstruction should be eased by minimizing the

defect to be formed while making the excision
• The complete volume of the defect should be esti-
mated and a graft/flap suitable to close the defect
should be prepared
• Graft places in the defects should be well stabilized
FIGURE 3.11 Spreader graft. • Sutures in spreader flaps should not be tightened too
much towards the keystone, as they may cause an iat-
the “spreader graft” since it expands the width of the internal rogenic inverted V appearance
valve angle [14]. • Spreader grafts should be placed according to the
bone roof rather than the cartilage roof; if there is a
(a) (b)
Dorsum Surgery 31
(c) (d)
(e)
FIGURE 3.12 (a–e) 42-year-old patient: the size of the nose is 7 cm, which emphasizes how severe a reduction should be made. The component hump
excision material (mostly cartilaginous) is seen. Views before and four years after are demonstrated.
region that cannot be covered with an osteotomy, the

spreader graft should reach this region • In the fixing of the grafts/flaps, the knot of the suture
• The thickness of the spreader flaps should also be should always be tied towards the inside
considered, and sutures that are as gentle and absorb- • Grafts and flaps should be combined in difficult
able as possible should be used for their fixation cases (Figure 3.13)
(a) (b)
(c) (d)
(e)
FIGURE 3.13 (a–e) 51-year-old patient: the component hump excision material (mostly bony) is seen. Views before and five years after are presented.
Dorsum Surgery 33
3.4.1.5 Bone Dust Technique

There are two main considerations when dorsum reconstruc-
tion with spreader flaps is preferred for dorsum surgery:
1. Thickness of spreader flaps: the thickness of the upper

lateral cartilages is approximately 1–1.5 mm. This
thickness can reach 3 mm when they are folded on
themselves with the spreader flap technique.
2. Length of spreader flaps: spreader flaps lie under the
bone and have a maximum length as long as the car-
tilage overlapping in the keystone. Therefore, defects
that emerge after hump removal cannot always be cov-
ered using spreader flaps. Osteotomies are performed FIGURE 3.14 The submucosal tunnel.
for this, but the osteotomy is contraindicated in noses
with a narrow roof. In these cases, long spreader
grafts that lie inside the bone are required, but it is
difficult to fix these and such long spreader grafts
cannot always be found. The bone dust technique [21]
can therefore be used to solve such handicaps.
3.4.1.5.1 Surgical Technique

The dorsum is dissected from the submembranous plane
through superior intracartilaginous and hemitransfixion inci-
sions. After the upper lateral cartilages are separated from the
septum, a submucoperichondrial tunnel is prepared under the
nasal bone by following the overlapping induced by the upper
lateral cartilages under the nasal bone (Figure 3.14). The depth FIGURE 3.15 After the cartilage hump is removed, the bone hump
and width of this tunnel are critical and should be prepared as appears. This is the tissue to be turned into dust with a rasp.
narrowly as possible. Additionally, this tunnel must never be
combined with the dissection that is made on the septal region, collected from between the teeth of the rasp with a green
otherwise the bone dust technique cannot be performed. needle tip, rather than putting the rasp in a water-filled bowl
After preparing the tunnel, the septum is descended to the as is the classical way. TAŞ3, designed for this job, bypasses
intended level and the cartilage part of the bone is excised; this part of the process. The rasping bite of TAŞ3 is specially
thus, the bone hump is exposed (Figure 3.15). The bone designed; thus, it does not scatter the dust but rather collects it
hump is then rasped, and the accumulated bone dust is in its own reservoir (Figure 3.16a–b). After the bony hump is

(a) (b)
FIGURE 3.16 (a) TAŞ3 A–D. (b) A significant amount bone dust material can be achieved by TAŞ3.
FIGURE 3.17 The bony hump is rasped until there is a flat appearance.
(a)
FIGURE 3.18 The cartilaginous roof is covered with spreader flaps.
(b)
FIGURE 3.20 (a, b) Schematic demonstration of the bone dust technique.
completely flattened (Figure 3.17), the excess of the upper lat-

eral cartilages is fixated on the septum in the form of spreader
flaps (Figure 3.18) and the bone dust is carefully placed to
the bone defect with the help of elevator (Figure 3.19). No
over-correction is made because this technique is powerful
enough when performed accordingly. The operation ends
FIGURE 3.19 The bony roof is covered with bone dust. after the incisions are covered (Figure 3.20a–b). All stages
Dorsum Surgery 35
of the surgical technique are shown in detail in Video 3.10

through endoscopy records.
In reconstructive surgery, defects should be repaired
with the same type of tissue as much as possible, which
ultimately leads to top-quality results. Cartilage defects

should be repaired with cartilage, and bone defects with
bone. The technique presented here works precisely with
this approach.
Bone dust can be obtained not only from the hump but
also from other regions during the surgery, such as rasp-
ing the convex surfaces of nasal bones, the lateral osteot-
omy lines, and maxillary crest. Bone dust is not a material
dispersing like powder, but is more like a paste when col-
lected. An ultrasound study at one year postoperatively con-
ducted by the author revealed the survival of the bone dust
(Figures 3.21–3.23).
FIGURE 3.21 The ultrasonographic study: blue arrow, glabella; yellow

arrow, dorsum; red arrow, the area where the bone dust was placed; green
bracket, the bone dust pouch. The flawless external line and stability on
the dorsum are remarkable.
(a) (b)
(c) (d)
FIGURE 3.22 (a–d) Before and five years after.

(a) (b)
(c) (d)
FIGURE 3.23 (a–d) Before and 3.5 years after.
date and how it has been used over time. Additionally, there is
3.4.2 The Dorsum Preservation Approach
only one source from which the entire literature can be under-
3.4.2.1 The History of Dorsum Preservation stood completely and accurately.
Interestingly, the history of dorsum preservation is as old as
the history of dorsum removal; however, the procedure was 1899 Goodale JL. [22] A New Method for the Operative

neglected and never became as widespread because it is more Correction of Exaggerated Roman Nose
difficult than dorsum removal and the technical aspects still
require development. In fact, it is a technique unknown to most Goodale described the first surgical “down” technique, in which
surgeons. Dorsum preservation will be narrated through analy- the hump was eliminated while the dorsum was preserved. The
sis of the English literature; thus, the reader will have a clearer surgical descriptions in this publication are the same as those
understanding of the stages this technique has undergone to used today in the procedure known as the “let down”.
Dorsum Surgery 37
1901 Goodale JL. [23] The Correction of Old Lateral

1954 Cottle MH. [9] Nasal Roof Repair and Hump

Displacement of the Nasal Bones Removal
Goodale used the let down technique to repair a crooked nose In this publication, Cottle emphasizes that the aim for elimi-
rather than the hump treatment, and this time it was not a sin- nating the hump should be to preserve, reform, or repair the
gle case, but a series with 22 patients. anatomical and functional integrity of the nasal roof. He pres-
ents seven possibilities for this purpose, which are as follows:
1914 Lothrop OA. [24] An Operation for Correcting the

Aquiline Nasal Deformity. The Use of a New Instru- 1. Remove the hump similar to the Joseph method but
ment. Report of a Case attach the bones to each other, so that it heals neatly
and no additional operations is needed
Although some studies suggest that Lothrop performed the 2. Eliminate the hump without removing any tissue
first let down technique, in fact Goodale had reported the first
3. Remove the hump, then modify it and put it back like
dorsum preservation operation 15 years before. The fact that
a graft
Lothrop explained the technique with a diagram in this pub-
lication is perhaps the most important factor causing him to 4. Remove the hump and replace an autologous bone or
be cited as the first (Figure 3.24). However, Goodale’s tech- cartilage graft instead
nique is explained and referred to even in Joseph’s book. In the 5. Remove the hump and replace an isogenous bone or
author’s opinion, Goodale is one of the four founders of aes- cartilage or animal cartilage instead
thetic rhinoplasty and his works should be understood in detail. 6. Remove the most protruding part of the hump and
Everything Lothrop did is technically the same as Goodale, use the cartilages to fill the formed defect
the only difference being that he removed a wedge from the 7. Combine the previously mentioned methods as
nasal bones for dorsum drop. indicated
In essence, Cottle describes the hump elimination technique

known as the “push down” in this publication (Figure 3.25). He
states that the concept of the push down comes from his obser-
vations of nasal fractures and that “The nose is broken in nasal
fractures, the septum and nasal bones are dislocated and sublux-
ated, and as a result, the nose moves laterally or inwards” [9].
Cottle describes the push down technique as follows:
1. After the right hemitransfixion incision, necessary

corrections are made in the septal gap. Nasal bones
are separated from one another or from the septum on
one or both sides. If previous septal corrections do not
allow the dorsum to move enough, a strip is removed
from the septum to achieve the desired reduction
which is usually done from the anterior border.
2. Then, lateral osteotomies are made under the perios-
teum and a 1 cm gauze strip is placed in the nose to
support the bone arc.
3. Lateral lamina infracture is performed.
4. The entire bone roof moves and down fracture is per-
FIGURE 3.24 The let down technique demonstrated by Lothrop. formed downwards
FIGURE 3.25 The push down technique demonstrated by Cottle.

This eliminates the hump without affecting the cartilaginous 1975 Huizing EH. [27] Push-Down of the External Nasal

dorsum so that the subcutaneous tissues are not damaged, and Pyramid by Resection of Wedges. Rhinology
the nose becomes narrower.
He states that numerous variations of this technique can be In this article, Huizing states that performing the push down tech-
made and proposes four methods: nique with a wedge excision on the nasal bones may prevent the
disadvantages of the push down. He later refers to this technique
1. If the patient underwent a septal operation before, as the “let down”. Huizing explains the following: “Lately, Cottle
there is no need for removing a strip described the push down technique. The technique is very good,
2. If septum surgery is not required and if the patient but the amount of reduction is limited in this technique. Adding
did not undergo a previous septal operation, a sep- wedge excision to this technique may increase this amount”.
tal strip (like the let down) can be removed directly Additionally, he states the disadvantages of push down as
under the roof rather than the septal gap follows: “Step formation may occur in the push down, and
push down performed with in-fracture may cause excessive
3. If a residual hump remains after performing this pro-
narrowing of the nasal valve while the push down performed
cedure, the roof can be trimmed by elevating the skin
with out-fracture may cause excessive expanding of the nose”.
4. The roof and one nasal bone can be separated from the He asserts that the high and narrow nose is an indication for
other nasal bone; thus, the nose can be rotated, and this the push down with wedge excision and emphasizes that the let
is a significant modification in especially deviated noses down should be used if the intended reduction cannot be achieved
with push down or if the internal volume of the nose becomes
Additionally, he states that descending the nasal roof is based very narrow with push down, and states the following: “It is not
on the nasal septum, nasal width, and the locations where lat- a hump removal technique. The hump should be eliminated with
eral osteotomies will be incised. If the lateral osteotomies are the classical method after reducing the dislocation of the pyramid
placed too far, the turbinates may prevent the downing of the with wedge excisions in a patient with a high and narrow nose”.
nose. If the osteotomies are placed more anterior in a broad
nose, a more severe down displacement can be obtained. An 1978 Ribeiro L. [28] Rhinoplasty—A New Approach in

unintended step can be prevented with the preservation of sub- the Repair of the Hump
cutaneous tissues.
Thus, Cottle gathers all down techniques, as well as describ- Ribeiro highlights the fact that Joseph’s technique causes open
ing all their possible modifications, under a single umbrella roof syndrome and recommends Cottle’s technique to prevent
and naming it the push down. The difference between this this. However, this technique descends the entire nose level
technique and Goodale’s is that it incorporates the septum in due to the multiple fractures it forms. Thus, he describes modi-
the nasal roof and presents the option of mobilizing the entire fications he has made in which he separates the nasal bone
nose. However, Cottle does not make any reference to previous from the nasal suture and leaves it adhered to the dorsum skin,
down techniques. then eliminates the hump by rasping it from the lower surface,
ensuring that it covers the dorsum like a cap. He performed
1966 Skoog T. [25] A Method of Hump Reduction in
this technique on 40 patients and reported that it caused prob-
Rhinoplasty: A Technique for Preservation of the Nasal lems in only four patients.
Roof
1987 American Rhinology Society. [29] Rhinology: The

Although Cottle proposed reducing and replacing the hump in Collected Writings of Maurice H. Cottle
1954, it was Skoog who put it into practice in 1966 and showed
how to perform it by schematizing and explaining it with sur- Unfortunately, Cottle was unable to gather his knowledge in
gery photos. In this publication, after the component removal one book. His presentation slides were posthumously collected
of the hump, Skoog closed the roof by flattening it outside and by the American Rhinology Society that he established. This
putting it back like a free graft. collection of slides shows that he explained the current push
down and let down techniques in detail.
1975 Barelli PA. [26] Long Term Evaluation of “Push

Down” Procedures 1988 Pirsig W, Königs D. [30] Wedge Resection in Rhino

Surgery: A Review of the Literature and Long-Term
Barelli states that Cottle’s “push down” technique and the con- Results in a Hundred Cases
cept of Rhinology are not well understood which is why they
are not very common. He goes on to explain Cottle’s technique In this publication, Pirsig and Königs [30] rename Huizing’s
again. While there are no objective data, the study reports on modified push down with wedge excision as “let down” and
a series of 100 patients, 12% of whom were treated with the present a case series of 100 patients who received this technique.
“push down”. There is no indication of how many revisions They state the following as the disadvantages of push down:
were made, but it is stated that revisions were minor and done
under local anesthesia, as described by Cottle, in an out-patient Its limitations in repairing the arched noses and in that the
environment. Barelli concludes by emphasizing the need for hump becomes visible after a few months were proved.
replacing the concept of hump excision with the “push down”. Also, the nasal functions are reduced due to the excessive
Dorsum Surgery 39
narrowing of the valve region and pyramid. When the compared to the asymmetric excisions made on the dorsum to
push down is combined with in-fracture, bilateral parana- even up the bone roof and that it can only be limited on the car-
sal step emerges. When it is combined with out-fracture, tilage part.
it causes the expansion of the nasal pyramid.
1999 Ishida J et al. [36] Treatment of the Nasal Hump

Lastly, they assert that the let down eliminates the disadvan- with Preservation of the Cartilaginous Framework
tages of the push down.
In this paper, Ishida describes his attempts at preserving the
1989 Daniel RK. [31] Rhinoplasty: The Retractable
middle roof by downing only the cartilage part and excising
Roof the bone part [36].
In this publication, Daniel presents a technique similar to 2003 Huizing EH, de Groot JAM. [37] Functional Re-

that described by Ribeiro [28] 12 years previously with a case constructive Nasal Surgery
series of 14 patients.
In this book, Huizing and Groot explain in detail both the classical
1993 Drumheller GW. [32] The Push Down Operation
Cottle technique and its modification with wedge excision, which
and Septal Surgery he published in 1975, and which was later named as “let down”.
Drumheller, a student of Cottle, describes the push down as it is 2003 Gola R. [38] Functional and Esthetic Rhinoplasty
performed today. He also performs the wedge excised push down
(let down) but describes it as a modification of Cottle’s push In this publication, and the book he would later write, Gola
down. He published further on this subject two years later [33]. demonstrates the down technique from every aspect and titles
his approach as “conservative rhinoplasty”. He divides the
1996 Sulsenti G, Palma P. [34] Tailored Nasal Surgery
down techniques into two: one performed under the nasal vault
for Normalization of Nasal Resistance and one performed on the septal base.
Gola makes no dissection on the dorsum in his technique.
In this publication, Sulsenti and Palma state that anterior strip exci- He only performs a septoplasty with removing a septal strip
sion can be used to eliminate the hump and restore the nasal valve. right under the dorsum, then makes lateral osteotomies inside
the nose without undermining the periosteum and performs
1997 Pinto RM. [35] On the “Let-Down” Procedure in
a transcutaneous transverse osteotomy with 2 mm chisel and
Septorhinoplasty pushes down the nose. If the hump cannot be eliminated with
this method, there are four other ways to achieve this:
In this paper, Pinto explains the let down technique very well.
He writes that there are two main rhinoplasty methods for 1. Open the dorsum and rasp it or make an excision
patients with arched or prominent noses: 2. Put a cartilage piece before the hump
3. Put diced cartilage inside the Surgicel
1. The classical approach, described by Roe (1887, 4. Use only a Surgicel
1891) and Joseph (1904, 1907, 1931)
2. The push down, described by Cottle Gola reports the residual hump as the only disadvantage of this
technique and states that the patient must accept this before
In the first approach, the hump is resected with a saw, the operation.
chisel or rasp, and in the second approach, the hump or
prominent pyramid is pushed down after making a suit- 2018 Saban Y et al. [39] Dorsal Preservation: The Push

able resection from the cartilage-bone septum. Down Technique Reassessed
Wedge resection/let down technique is a reasonable
modification of Cottle’s technique, and it was presented Based on their experience, Saban and colleagues recommend
by Huizing (1975). The bone and cartilage dorsum are using the push down technique if the dorsal height will be
pushed down after the wedge excision performed on the descended to 4 mm, and using the let down technique if the
bilateral bone roof base. height will be descended more than 4 mm.
Pinto states that he prefers excisional techniques for the treat- 2018 Taş S. [40] Dorsal Roof Technique for Dorsum

ment of a hump, but if the patient has a good dorsal profile and if Preservation in Rhinoplasty
the valve needs to be opened due to functional reasons, then he
prefers the let down procedure as it preserves the integrity of the In this publication, Taş presents the dorsal roof technique
nasal dorsum. Since a large amount of upper lateral cartilage will developed for enabling the use of the down technique on
be removed with the excisional technique in prominent noses, patients with an arched nose and wide pyramidal angle. The
he suggests combining the rasp/partial resection with let down ideal pyramidal angle is determined according to a tomogra-
for those cases. He states that the let down technique is easier phy study also done by Taş, where he also states that dorsum
preservation is not sufficient and shows for the first time how 2019 Tuncel U, Aydogdu O. [46] The Probable Reasons

dorsum preservation can be combined with structural philoso- for Dorsal Hump Problems Following Let-Down/Push-
phy. The dorsal roof technique eliminates the hump by nar- Down Rhinoplasty and Solution Proposals
rowing the nose and preserving the dorsum in wide pyramidal
angle noses and strengthens the roof using spreader flaps. In this article, Tuncel and Aydogdu recommend trimming the
Additionally, the “let up” technique is demonstrated for the dorsum from below and fixating it on the septum to prevent
first time with this publication. It describes how to heighten the hump recurrence after let down.
radix by placing a cartilage or bone graft between the dorsal
roof and ethmoid bone in patients with low radixes [41–42].
3.4.2.2 Dorsum Preservation Techniques
2019 Atolini et al. [43] Septum Pyramidal Adjustment
Now that the history of dorsum preservation has been reviewed,
and Repositioning—A Conservative and Effective the focus will shift to its technical aspects. This group of sur-
Rhinoplasty Technique geries is mainly divided into the down techniques (which has
three sub-techniques: the push down, let down, and fix down)
In this paper, Atolini et al. present the septum pyramidal and the dorsal roof technique. Today the Skoog technique and
adjustment and repositioning (SPAR) technique in English, the retractable roof technique have been abandoned.
first described by Dewes [44] in 2013 in Portuguese. It is a
push down modification which relaxes the septum using verti- 1. Down techniques
cal incisions. a– Push down (Cottle 1954) [9]
b– Let down (Huizing 1975) [27]
2019 Taş S. [45] The Alignment of the Nose in
c– Fix down (Taş 2019) [45]
Rhinoplasty: Fix Down Concept 2. Dorsal roof technique (Taş 2018) [40]
In this research, Taş emphasizes that the rhinoplasty litera-

3.4.2.2.1 Down Techniques
ture tries to eliminate the hump indexed only to the profile,
but the main duty of surgeons is forming symmetrical noses Indications
aligned not only from the profile but also from the frontal and 1. Projected nose
base angles, and explains how to use the down techniques for 2. Deviated nose
creating three-dimensional symmetric noses by classifying
crooked noses and describing a method for each nose type. Relative Contraindication
This classification has allowed for the first time the descrip- 1. Noses without projection and with excessive dorsal
tion of the crossed nose deformity and the deviated radix. It angulation: the down technique will always end up
describes for the first time how the nose can rotate in either with an amount of projection loss, so if the nose does
a clockwise or counterclockwise direction and what to do not have enough projection, then this technique is not
before and after this rotational movement. Additionally, this suitable to treat the hump. A certain amount must be
paper shows for the first time how to eliminate the hump downed to eliminate each hump, and this amount is
using septal rotation in the anterior-caudal direction, how a directly proportional to the angulation of the hump.
back cut incision enables this rotation, and how the spider For example, a nose with severe angulation may look
network suture supports and strengthens this rotation. After flat when it is downed 6 mm, while a slightly arched
alignment of the framework, Taş goes on to describe leva- nose may look flat when it is downed even 2 mm. The
tor muscle dissection and levator muscle plication and double surgeon should know this and should not try to down
layer grafting methods used to align the soft tissue envelope more than needed since this can cause aesthetically
in the same way. catastrophic complications such as hypertelorism
There are three main reasons why this technique is known (the distance between the eyes appearing wider than
as the “fix down”: normal), expansion on the dorsum and loss of the
dorsal lights.
1. The word “fix” implies correction because it is a
modification that extends multi-directionally on the “Do not down the nose more than the ideal pro-
down indications by correcting the main problems in jection or else the appearance of down syndrome
the down techniques such as the nasal roof alignment may be formed.”
problem and hump recurrence (S. Taş)
2. “Fix” also implies fixed because it leaves a fixed and
solid structure behind Exception: If the nose has some projection, you can down it
3. Finally, “fix” implies remediation because it fills slightly in combination with classical excisional techniques for
these gaps in rhinoplasty by combining down tech- the remaining angulation.
niques and structural grafting techniques (ethmoid
graft, invisible spreader graft, ST flap, premaxillar Exact Contraindication
graft, etc.) with an atraumatic philosophy 1. Noses without projection and with short nasal bones.
Dorsum Surgery 41
3.4.2.2.1.1 Deciding on Technique Selection anterior strip, making the job more difficult. This is a critical
factor in determining the preoperative selection of the down
The technique selection algorithm developed by the author technique. The most important question is whether septal sur-
for treatment of projected noses with the down techniques is gery is necessary or not. If it is necessary, then choosing the
presented in Figure 3.26. As seen in the algorithm, the most push down or fix down techniques is logical.
suitable technique selection varies based on the patient’s need If there is septal deviation:
for septal surgery, external deviation, dorsal curvature, radix The groundwork for the rotation of the septum is prepared
position, and facial properties. with the swing door technique by performing an inferior chon-
drotomy (separating the septal base from the maxillary crest
3.4.2.2.1.2 General Principles That Must Be Known in and vomer) and posterior chondrotomy (separating the posterior
Down Techniques of the septum from the ethmoid bone). The septum separated
from these pivot points recovers most of the time (Figure 3.27).
After performing septoplasty through hemitransfixion inci- However, there are some cases when it does not recover.
sions, the nasal roof can be separated with lateral, transverse, These are generally traumatic noses that have stayed in one
and radix osteotomies, making it mobile and fixed on the mid- position for a long period of time. Especially when the force of
line. Although it seems to be a simple process, it is not. The trauma was not enough to break the septum, it becomes crooked
down techniques are far more difficult than classical hump in the form of a C or S in the anterior-posterior direction or in
removal processes. There are many technical points to con- the caudo-cephalic direction due to the thickening in the peri-
sider and numerous modifications and variations that can be chondrium. In these cases, the down technique can still be used
made, all starting from the first incision. with combining of structural techniques. Following the scoring
on the concave side of C-shaped areas, invisible grafts should be
Incision sutured to the septum to prevent recurrence during healing time.
If a severe curvature is present or if it is thought that the
If the patient does not have septal deviation, then a one-sided nasal cavity cannot tolerate the narrowing of the internal vol-
hemitransfixion incision is sufficient for the down technique. ume by suturing a graft, the first option should be the ethmoid
In this case, a left hemitransfixion incision makes it convenient graft. In this case, the thin part of the ethmoid bone is gently
for a right-handed surgeon. prepared and stitched to the concave part of the septum after
creating holes with a power drill. If there is no option of an
Septum ethmoid graft, then cartilage grafts can be employed. These
invisible grafts that aim at solving the structural problems of
If there is severe septal deviation, it is logical to down the nose
by leaving the septum adhered to the dorsum and removing a
posterior strip from the base because almost all septal devia-
tions are bone-based (vomer, ethmoid, and nasal crest). Thus,
if there is already a need for performing a separation process,
there is no need to increase the number of separations with an
FIGURE 3.26 The technique selection algorithm for down techniques. FIGURE 3.27 Swing door technique.
the septum are stitched to the septum in the form of a horizon-

tal, vertical strip, or end block.
If there is no septal deviation:
Dissection of the septum on one side is enough to reduce the
projection, and is also logical in terms of preserving the blood
supply of the septum. If the projection will not be changed or
if the crookedness of the nose is not complicated, then there
is no need to open the septum. Dissecting the septum slightly
more than the amount of the reduction eliminates the mucosa
folding problem due to downing.
Although the patient does not need any septal surgery
before the operation, following the down technique, breathing
problems may occur due to reduction of the external pyramid
or the crookedness in the inside increasing or causing block-
age. Thus, the surgeon should be able to predict this and might
need to perform concha lateralization or submucosal excision.
The surgeon should always be careful to preserve the airway
by checking the nasal pathway at the end of the surgery.
FIGURE 3.28 Z plasty for radix osteotomy.
Ethmoid Incision
In the let down technique, the septum is separated from just
beneath the dorsum. However, this process is a transection and
is irremediable, and thus should be performed with great care.
During this process, the upper lateral cartilages can easily be torn
and damaged due to the movement of the scissors if the bone roof is
too narrow; the use of correct instruments is crucial. Thin-angled
concha and bone scissors are preferred to prevent these complica-
tions. After incising the cartilage, the ethmoid bone should also
be incised. This stage is the least controllable but the most impor-
tant of this technique. If the ethmoid bone is not incised from as
high as possible and does not meet the radix osteotomy as soon as
possible, the radix descends too much and causes severe compli-
cations that are difficult to repair. The upper part of the ethmoid
bone is thicker, thinning towards the inferior and thickening again
towards the front wall of the sphenoid sinus. Therefore, if the eth-
FIGURE 3.29 Oblique cut for radix osteotomy.
moid is incised from the middle part where it is the thinnest, the
remaining thin ethmoid piece will not provide enough support and
during the radix osteotomy the radix will drop so low that it can-
If the radix requires descending, then the classical horizon-
not be controlled. This point is quite critical. A frontal protrusion
tally incised radix osteotomy should not be used to prevent
as thick as possible should be left so that the radix does not drop
step deformity. If the surgeon uses a 1 or 2 mm chisel with the
uncontrollably and the remaining crista is able to carry the nose.
transcutaneous approach for the surgical radix osteotomy, per-
forming the radix osteotomy by making Z plasties will prevent
Bone Excision from the Ethmoid step deformation (Figure 3.28).
If the surgeon uses a surgical electrical or manual oblique
Bone excision from the ethmoid is required for severely pro-
saw, then the incision should be made as oblique as possible by
jected noses as the ethmoid is very thick in these types of noses
turning the angle of the saw to as caudal as possible. Therefore,
and prevents the requested reduction. However, excision from
radix osteotomy will prevent the formation of step by sliding
the ethmoid should progress conservatively due to the reasons
on the angled bone surfaces (Figure 3.29).
explained before. Thus, unlike what is seen in the literature,
If these are not considered, then the step formation appears.
excision from the ethmoid is unnecessary in most cases and
This requires the rasping of the protrusion that formed in the
may in fact cause severe complications.
radix after the osteotomy with a power burr or rasp, causing a
possible low radix deformity and requiring an augmentation.
Radix Osteotomy
If the radix does not need to be descended, then the ethmoid Dorsum Dissection
bone is incised right below the bony hump and is immediately
united with the radix osteotomy. It is the most important pre- If the nasal bones are extremely deformed, which is rare,
caution to preserve the height of the radix. extended dissection should be performed for reshaping these
Dorsum Surgery 43
areas with osteoplasty techniques. Otherwise, limited dissec- the pyriformis to prevent airway blockage after the down
tion will be logical to preserve the integrity of the tissues and technique.
to have more control while performing the redraping. If extended dorsum dissection is to be performed, lateral, trans-
If the dorsum is nearly flat and the nose is just projected, verse, and radix osteotomies can easily be made. But if extended
there is no need to open the dorsum. The nose projection can be dissection will not be performed, then an internal lateral osteot-
repaired with septum adjustment and external osteotomies with- omy incision and tunnel should be made for lateral osteotomies.
out making any dorsum dissection as described by Gola [38]. Dorsum dissection is sufficient for transverse and radix osteot-
Dorsum dissection is required in the following conditions: omy. The intraseptal dissection is used for medial osteotomy.
If dorsum dissection will not be performed, then lateral
• Rasping the dorsum osteotomies are made from the internal lateral osteotomy inci-
• Making partial/total excision from the dorsum sion while the transcutaneous approach is used for transverse
• Placing camouflage grafts in the dorsum and radix osteotomies.
• Redraping the excess skin
Wedge Excision
It is crucial to decide which is needed before the osteotomies,
The primary purpose should be to prevent any internal nar-
and to end the dissections before mobilizing the nose; other-
rowing that may form since it can cause functional problems.
wise it will be more difficult.
On the other hand, the internal nasal bones stabilize the nasal
roof and eliminate the risk of displacement. In the presence of
Osteotomies asymmetric maxillary apertures, the nasal frame may cause
the nose to be more crooked since it will go into the asymmet-
Lateral, transverse, and radix osteotomies are required to
ric maxillary aperture.
mobilize the framework as an enblock structure in the down
Bone excision from the nasal part of the maxillary bone can
technique.
prevent these problems.
If the pyramidal angle requires narrowing, then it is nec-
It is quite simple and logical to create a bilateral symmetric
essary to add medial osteotomies to the down technique.
wedge to the level at which the nose is intended to be low-
However, keep in mind that it causes a very mobile structure
ered in a non-deviated nose and a non-asymmetric maxillary
and keeping the nose in the midline will be quite difficult after
aperture. This can easily be done using the dissection pouch
performing so many osteotomies, and it will be logical to use
formed for lateral osteotomy.
the dorsal roof technique [40] or increase the stabilization of
If a deviated nose and non-asymmetric maxillary aperture
the framework back with the transnasal bone fixation tech-
are present, then a one-sided wedge excision should be made
nique [47] (Figure 3.30).
from the opposite side of the deviation (in other words, from
If the pyramidal angle is too narrow, then medial osteoto-
the side where the nose will be shifted).
mies should be added, or concha surgery should be performed,
If an asymmetric maxillary aperture is present (such
or the internal volume should be adjusted excising bone from
as crossed nose deformity), the best way to repair it is by
forming a gap on the medial wall of the cephalic part of
the maxillary bone enabling rotation of the cephalic part of
the nose, and removing a caudal wedge from the nasal part
of the opposite maxillary bone, enabling the rotation of the
caudal part of the nose [1, 45].
Fixation
The nasal roof which is completely mobilized should be fix-
ated again after the down process.
In the let down technique, the dorsum can be re-stabilized by
fixating the dorsum to the intact septum. In this process, mak-
ing a strained fixation of the dorsum in a more caudal location
more than the normal position can prevent dorsum curvature
formation. In addition to this caudal fixation, dorsum sutures
can be inserted for the most convex part of the dorsum.
Dorsum sutures are most easily obtained with the green
needle tip; 5/0 Polydiaxanone is sent from the tip of the needle
and transcutaneously inserted into the nasal cavity from the
most convex point of the dorsum. Then, the needle is gen-
tly pulled back from the nasal cavity, but not fully removed,
still remaining under the skin. At that time, the needle is slid
2–3 mm to the side to access the other side of the nasal cavity.
FIGURE 3.30 Transnasal bone fixation. The front needle of this suture stays in the other nasal cavity,
FIGURE 3.32 M suture.
the caudal and cephalic parts of the nose will be at the same
level as the central nose and the dorsum will be flattened. It is
quite effective and, when used in the correct way, can prevent
recurrences by holding the nasal hump like a long-term splint
(Figure 3.32). Its disadvantage is that it is not easy to apply in
the closed technique.
FIGURE 3.31 Cephalic dorsum stabilization suture.
3.4.2.2.1.3 Step-by-Step Push Down Technique

passes through the septum, and meets with the anterior part
Step 1: The septum is unilaterally dissected by enter-
of the thread. Then, it is knotted while a nurse’s finger presses
ing from the one-sided hemitransfixion incision. To
the dorsum [48]. There is no need to open the dorsum to insert
dissect the spine and maxillary crest area, a second
this suture. This process can fix the dorsum to the septum like
tunnel is opened in the base on the same side; these
a sewing machine (Figure 3.31).
two tunnels are then combined, so possible lacera-
However, all dorsum sutures should be made very carefully
tions of the septal mucosa are prevented.
because they may cause surface distortion on the dorsum.
In the push down technique, the nose is stabilized by fixing Step 2: The dorsum is dissected from the intercarti-
the septum from the inferior part to the spine. laginous incision and the lateral osteotomy lines are
In the fix down technique, the spider network suture crosses dissected from the vestibular incisions.
the septum from front to back by passing repeatedly between Step 3: Returning to the septal cavity again, first
the septum and spine, corrects the dorsal curvature problem the inferior chondrotomy separates the septum from
by making an anterior-caudal rotation, and fixes the entire sep- the maxillary crest, then the posterior chondrotomy
tum in the middle [1, 45]. separates the septum from the vomer and ethmoid.
The opposite surface of the ethmoid bone is accessed
through the posterior chondrotomy. Thus, a bilateral
Residual Hump dissection is made on the posterior septal region and
If the dorsum curvature is not corrected completely with the the anterior septal region is unilaterally dissected.
down technique during surgery, then the following can be per- This step attempts to preserve septal circulation at
formed: additional dorsum sutures can be used or partial exci- the maximum level.
sion and repair of the dorsum can be made directly. Moreover, Step 4: An inferior strip is removed from the septal
the hump can be eliminated by suturing an onlay graft just base to the amount of the intended downing. This
above the hump. An ultradiced cartilage graft injection can be excision can be made as a last step after mobilizing
used below or above the hump [1, 45]. Lastly, the M suture, as and downing the nasal roof and seeing the excess
described next, can be employed. part, but this is in practice up to the surgeon’s prefer-
ence. A bone strip equivalent to the amount of down-
ing can be extracted from the ethmoid bone using
M Suture bone scissors. However, if there is no need to down
Starting from the nasal cavity, the most curved part of the the radix, then the ethmoid bone is just incised with
dorsum, a 4/0 Polydioxanone suture comes out of the dorsum, bone scissors without removing any strip.
goes to the most caudal area of the nose, and after biting there Step 5: Medial osteotomies from the intrasep-
moves to the nasal cephalic where it bites the bone through tal region are made (if the pyramidal angle is to
the holes drilled on each side of the nasal bone, returns to the be narrowed). Then, lateral osteotomies are per-
dorsal curvature, enters the nasal cavity, and is knotted. Thus, formed. Transverse and radix osteotomies can also
Dorsum Surgery 45
be completed using a chisel with a more angled tip

when it reaches the level of the medial canthus from
the lateral osteotomy cavity. Transverse and radix
osteotomies can be made transcutaneously with a
2 mm chisel, power oblique saw, or manual oblique
saw that is inserted from the dorsum dissection
area.
Step 6: The bone roof is pushed into the maxillary
aperture with finger force and the septum is fixed to
the spine again with a suture.
The Technique Can Be Summarized as Follows

(Figure 33a–c)
1. Hemitransfixion incision
2. Dissection of the septum
FIGURE 3.34 The desmosis between septum and the maxilla.
(a)
3. Dorsum dissection through the intercartilaginous
incision
4. Dissection of the lateral osteotomy lines via the ves-
tibular incisions
5. Inferior chondrotomy
6. Posterior chondrotomy
7. Dissection of the other side of the ethmoid
8. Inferior strip excision
9. Ethmoid incision/strip excision
10. Medial osteotomies from the intraseptal region (if
the pyramidal angle is to be narrowed)
11. Lateral, transverse, and radix osteotomies
(b)
12. Pushing the bone pyramid in
13. Fixing the septum to the spine
This technique can be used in very difficult cases by per-

forming an extended septal surgery by opening four tunnels
instead of two (opposite septal cavity and opposite septal
base). The desmosis formed by the perichondrium of the sep-
tum and the periosteum of the maxillary crest sending cross
fibers to each other at this level can cause mucosal lacerations
in the dissection of this area (Figure 3.34). Opening separate
tunnels then uniting them can prevent this complication and
facilitate the dissection [49].
If rasping the dorsum is planned, this process should be
(c) done before bone mobilization (in other words, it should
be done after step 5 in this procedure; Figures 3.35 and
FIGURE 3.33 (a–c) Push down technique. 3.36).
(a) (b)
(c) (d)
FIGURE 3.35 (a–d) Before and three years after.

Dorsum Surgery 47
(a) (b)
(c) (d)
3.4.2.2.1.4 Step-by-Step Let Down Technique the dorsum. An incision is made on the ethmoid bone
with bone scissors or a thin chisel. Then, an anterior
Step 1: The superior part of both septal cartilage strip equivalent to the amount of dorsum downing is
cavities is dissected with a bilateral hemitransfixion removed from the septum that is left below. If only
incision. The dorsum is dissected with an intercar- the caudal part of the dorsum needs to be downed, the
tilaginous incision. The lateral osteotomy lines are anterior strip is limited to the cartilage part and only a
dissected with vestibular incisions. bone incision is made for the ethmoid part. If the radix
Step 2: Returning to the septal cavity, the septum is needs also to be downed, then an excision is made in
incised with angled thin concha scissors just below a way that includes the cartilaginous and bony parts.
However, preserving the septal angle should always be

considered, in order to prevent saddle nose deformity.
Step 3: Wedge excisions are performed from nasal
bones with bone scissors or power instruments less
than 1–2 mm than the intended amount of downing to
be made on the dorsum among the lateral osteotomy
lines; the lateral osteotomies are then completed.
Step 4: Radix and transverse osteotomies are made
with electrical or manual oblique saws by entering from
the dorsum dissection. The radix osteotomy should be
made at the oblique angle instead of the right angle
to prevent a step formation, as previously mentioned. (a)
If the surgeon does not have suitable instruments for
that purpose or if the dorsum is not dissected, then a
transcutaneous approach can be employed with using a
2 mm chisel externally. This osteotomy should be made
in a way that creates mild Z plasties, as mentioned ear-
lier, or else a step deformity may occur in the radix.
Step 5: The nose can be mobilized by pushing down
with finger pressure. The framework is placed at
the solid septal roof below, and a dorsum suture is
inserted with 4/0 Polydioxanone in such a way that
it first passes through the septum and then the most
curved point of the dorsum, so that the knot remains
in the septal space to fix it.
(b)
If the dorsum curvature cannot corrected this way, then the
following can be employed:
• Only the caudal parts of the upper laterals are stitched

together after they are separated from the septum. In
this way, a fullness can be achieved in the supratip to
help eliminate the curvature deformity.
• An onlay graft fitting the caudal dorsum completely can
be sutured. However, it should be adjusted very care-
fully and it should be fixed to the dorsum very carefully
to prevent the formation of step due to the graft.
• Another option is an ultradiced cartilage injection for
the depressed parts of the dorsum.
(c)
(Figure 3.37a–c) FIGURE 3.37 (a–c) Let down technique.
1. Dissection of the superior part of the septum from

the bilateral hemitransfixion incisions
2. Dorsum dissection through the intercartilaginous 7. Bilateral wedge excision from the ascendant part of
incision the maxillary
3. Dissection of the lateral osteotomy lines via the ves- 8. Transverse and radix osteotomies
tibular incisions 9. Pushing the bone pyramid in
4. Separation of the dorsum from the septum, right 10. Fixing the dorsum to the septum back
below the dorsum
5. Separation of the dorsum from the ethmoid Again, if rasping of the dorsum is planned, this process
6. Anterior strip excision should be done before bone mobilization (Figures 3.38–3.39).
Dorsum Surgery 49
(a) (b)
(c) (d)
FIGURE 3.38 (a–d) Before and four years after.

(a) (b)
(c) (d)

Dorsum Surgery 51
1. The superior pivot point is formed by the nasal pro-

cess of the frontal bone
2–3. Bilateral inferior pivot points are formed by the max-
illary buttress at the level of aperture pyriformis
4. The central pivot point is formed by the nasal spine
These pivot points are responsible for the correlation

between the nose and facial platform. If the platform is asym-
metric, it is impossible to create a symmetric appearance even
when the nose is symmetric in itself. It is also important to
obtain muscle balance as well as the symmetry of this platform
to achieve a symmetrical appearance [1, 45].
FIGURE 3.40 The pivot points of the nose (green triangles).
Classification of Deviations
3.4.2.2.1.5 Step-by-Step Fix Down Technique
Classification of Septal Deviations
Related Anatomy Septal deviations can be classified into six groups (Figure 3.41)
The nose stands in the middle of the face by the support [50]:
of the pivot points on the maxillary and frontal bones.
There are four pivot points that carry the nasal roof 1. Localized deviation or spur
(Figure 3.40): 2. Septal tilt
FIGURE 3.41 The classification of septal deviations by Guyuron.

3. C-shape deviation in the anterior-posterior direction Type 3:

Crooked nose (Type 3a: C-shaped, Type 3b:
4. C-shape deviation in the cephalocaudal direction S-shaped)
5. S-shape deviation in the anterior-posterior direction
If the radix is deviated from the midline, the asymmetries are
6. S-shape deviation in the cephalocaudal direction as follows:
Classification of External Deviations [45] Type 4: Deviated radix
The external deviations should be examined three-dimension- Type 5: Crossed nose
ally on X, Y, and Z planes.
Type 6: Crossed and crooked nose (combination of Type
In the X Plane (Coronal Plane—Frontal View) 3 and Type 5)
Axial deviations of the nasal dorsum can be categorized Type 7: Facial midline asymmetry
based on the radix, but the position of the radix might be
deviated; thus, categorizing the axial deviations on the X In the Y Plane (Sagittal Plane—Profile View)
plane based on the midlines of the forehead and philtrum is The radix is classified as follows based on its relationship with
more accurate. the forehead;
Crooked noses are categorized into seven types as follows
based on these two anatomical landmarks (Figure 3.42). 1. Normal radix
If the radix is at the same level with the midline of the fore- 2. High radix
head, the frontal appearance asymmetries are as follows: 3. Low radix
Type 1: Non-deviated The dorsum is also categorized on its shape as curved, pro-
Type 2: Deviated jected, and straight.
FIGURE 3.42 The classification of external deviations by Taş.

Dorsum Surgery 53
In the Z Plane (Axial Plane—Base View)

The examination of the relationship between both maxillas is
crucial to diagnose maxillary hypoplasia. Asymmetries in this
plane can affect the frontal appearance as alar base retractions
or rim asymmetries [51–52].
Surgical Technique
The entire nasal pyramid is freed from all pivot points using
the fix down method and fixed on the midline of the face
once again. At the same time, the method aims to fix soft
tissue asymmetries and respiratory issues, offering a holistic
rhinoplasty.
FIGURE 3.44 The anterior-caudal rotation of the septum with fix down
Step 1 Septum Surgery technique.
The septum is treated with the premaxillary-maxillary

approach through hemitransfixion incisions. Following the from the septum are fixed as invisible grafts to the deviated
posterior and inferior chondrotomies, the swing door method parts (Figure 3.44).
is used, and septal tilt issues are fixed. The ethmoid bone is
cut from a higher level using bone scissors. The bony part of Step 2 Dorsum Surgery
the septum (maxillary crest, vomer, and ethmoid bones) is
reshaped, and two equal airways are formed. If the septum 1.
No dissection concept: If the dorsum does not have
still has a crooked appearance, holes are formed using a drill any irregularity nor dorsum curvature deformity, the
on the tiny bone graft taken from the ethmoid bone, and fix down method can be performed by dissecting the
this plate is sutured on the concave surface of the septum lateral osteotomy lines without any dissection on the
(Figure 3.43). For simpler deviations, cartilage grafts taken dorsum.
2.
Dissection concept: Usually, only the d orsum is dis-
sected through the submembranous (subperichondrial-
subperiosteal) plane and the hump can be rasped. If
a traumatic nose deformity is present or if the nasal
bones have convexity problems, extended dorsum
dissection is performed, and convex surfaces of the
nasal bone can be fixed with osteoplasty techniques.
Following lateral, transverse, and radix osteotomies,
the entire framework is moved with the septum, and
the alignment process begins.
Step 3 Centering the Radix and Nasal Structure
If a simple deviated nose is present, a wedge excision per-

formed on the maxillary bone opposite the deviated side will
be sufficient to achieve a symmetrical framework.
However, if there is a crooked nose deformity, then incision-
scoring methods and invisible cartilage or ethmoid graft meth-
ods should be used along with the septum.
If there is a crossed nose deformity, a gap should be formed
between the medial canthus and nasal bone on the opposite side
of radix deviation to change the location of the radix. To fix the
deviation at the caudal section, a gap should be formed between
the maxillary buttress and the maxillary bone. Following these
FIGURE 3.43 The correction of right complete septal blockage with steps, the nose can be rotated clockwise or counterclockwise,
fix down technique. and a suitable position can be adopted. On the opposite side of
FIGURE 3.45 Rotational swift of the nose with fix down technique.
FIGURE 3.47 Horizontal swift of the nose with fix down technique.
FIGURE 3.46 Bone defects that form after the application of the fix FIGURE 3.48 Back cut incision to allow the anterior-caudal rotation of
down are covered with grafts or Surgicel. the septum in fix down technique.
bone modifications, the new dead spaces are filled with bone/
cartilage grafts or Surgicel (Figures 3.45–3.46).
In conclusion, the movement is the horizontal shift for
a deviated nose; rotational shift is employed for a crossed
nose deformity. However, an asymmetric face needs a com-
bination of horizontal and rotational shifts (Video 3.11)
(Figure 3.47).
Step 4 Profile setting
For dorsal curvature deformity, a back-cut incision running

from the posterior chondrotomy to under the dorsum is per-
formed, and efforts are made to ensure that the septum rotates
on the maxillary spine to achieve anterior-caudal rotation. As FIGURE 3.49 The fix up technique. The radix can be moved up by a
bone or graft to be placed between the nasal dorsum and ethmoid bone.
the keystone area becomes semi-mobile and flexible through
the back-cut incision, this septal rotation eliminates the dorsum
and dorsal curvature, meaning the dorsum can be treated with- The residual hump left in noses with severe curvature
out performing excision (Figure 3.48) (Video 3.12). deformity (which is very rare—3–5%) can be eliminated
If there is a high dorsum, a posterior strip excision from the with stitching an onlay graft to the supratip or with partial
base of the septum ensures the desired height for the nose. resection.
If there is a low radix, the bone/cartilage graft positioned
between the nasal bones and ethmoid bone/naso-frontal crest Step 5 Fixing the nasal framework
can increase the height of radix (Figure 3.49) (Let up [40], Fix
up method [45]) (Video 3.13). After the nasal structure is centered and the profile is set, the
Dorsal curvature is usually eliminated with anterior- septum is fixed with the spiderweb network suture. This suture
superior rotation of the septum and rasping of the dorsum. also enables a counterclockwise rotation of the profile, decreases
Dorsum Surgery 55
tension, and prevents recurrence with each bite. For that purpose,
a 4/0 Polydioxanone suture is used (Figure 3.50) (Video 3.14).
If there is a deviation on the spine, the deviated part can
be reshaped, or the septum can be stitched side by side on the
opposite side of the deviation. For more challenging spine
deviations, stabilization is ensured through bone grafts which
can be obtained from the vomer or maxillary crest during sep-
toplasty (Figure 3.51).
By anterior-caudal rotation of the septum, a significant
extension is achieved on the caudal septum, which can be
used to support the nasal tip, as with the septal extension graft
(Figure 3.52) [53].
FIGURE 3.50 The septum is fixated in the anterior caudal direction
with the spiderweb network suture. Each bite of this suture will release Step 6 Setting the soft tissue
the tension and turn the roof into a more solid structure.
Following the centering of the nasal framework, soft tis-
sue asymmetries become more visible. Therefore, this stage
should be performed as the last phase.

(Figure 3.53a–c)
(a)
FIGURE 3.51 Spiderweb network suture.
(b)
(c)
FIGURE 3.52 The caudal septal extension is achieved by the fix down
technique. FIGURE 3.53 (a–c) The fix down technique.
1. Bilateral hemitransfixion incision 12. Making the necessary bone excisions on maxillary
2. Bilateral superior intracartilaginous incision pivot points
3. Undermining upper lateral cartilages 13. Lateral, transverse, and radix osteotomies
4. Dissection of bilateral septum 14. Centering and descending the framework
5. Undermining the septum base with the premaxillary- 15. Inserting spider network sutures, enabling anterior-
maxillary approach caudal rotation of the septum
6. Inferior chondrotomy 16. Filling the dead spaces
7. Posterior chondrotomy 17. Suturing an onlay graft to the supratip if needed
8. Back cut incision 18. Intervention in the levator alaeque nasi muscle if needed
9. Inferior strip excision 19. Intervention in the maxillary hypoplasia if needed
10. Ethmoid bone incision/strip excision 20. Intervention in the rim retraction if needed
11. Completing dorsum dissection (Figures 3.54–3.56, Videos 3.15–3.16).
(a) (b)
(c) (d)

Dorsum Surgery 57
(a) (b)
(c) (d)

(a) (b)
(c) (d)
Important Note: A cadaver study conducted by the author • It should be noted that down techniques can be dan-
demonstrates hump correction with the fix down technique and gerous for patients with low radixes.
the operation mechanism of the technique (Video 3.17). As • Another issue is noses with wide pyramidal angles,
seen there, the localization and shape of this incision is quite typical of patients from India and other Asian and
important to allow anterior-caudal rotation and it should be Gulf countries. In these types of noses, a medial
designed according to the shape of the individual hump. osteotomy should be added to the current down
technique osteotomies so that the pyramidal angle
3.4.2.2.2 Dorsal Roof Technique can be narrowed, but this forms a very mobile
framework which can be very difficult to control
Down techniques are quite powerful, yet like any technique, (Figure 3.57–3.58).
they also have limitations:
Dorsum Surgery 59
Therefore, the dorsal roof technique (DR technique), which

combines dorsum preservation with structural rhinoplasty,
will be a good choice for such situations [40].
3.4.2.2.2.1 Surgical Anatomy

Dorsum integrity is of great importance to ensure the cor-
relation between the bone and cartilage parts of the nose.
The dorsum refers to the roof of the nose, and its edges
are formed by the dorsal aesthetic lines. The dorsum begins
from the radix and ends at the supratip, its upper third is
formed by the nasal bones and its lower two-thirds are
formed by the triangular cartilage. The dorsum has a trap-
ezoidal form that narrows in the radix, widens in the key-
stone, and narrows again in the supratip, instead of being
two parallel straight lines [40, 42]. The DR technique will
preserve this entire aesthetic unit and move it as one piece
(Figure 3.59).
The cartilage bone junction of the dorsum is located in the
keystone area, which has a more complex anatomy. The key-
stone is formed by the nasal bones, triangular cartilage (upper
lateral cartilages, septum), and perichondrio-periosteal liga-
FIGURE 3.57 Left, narrow pyramidal angle; right, wide pyramidal
angle.
ments in the transition zone. Thus, it is anatomically accurate
to call the dorsum a bone-cartilage-ligament complex. The
triangular cartilage progresses approximately 7 mm (it var-
ies between 4 and 10 mm) under the nasal bones and overlaps
in the keystone area of the dorsum. This overlap is of great
importance for the DR technique [54].
From the frontal perspective, the width of the inter-
canthal distance should be equivalent to one eye, and the
alar base width should be as long as both intercanthal dis-
tances. The nasal base width should be 80% of the alar base
width. Noses that are wider than these measurements are
called broad noses. The width of the keystone, which is the
FIGURE 3.58 Upper left, wide pyramidal angled nose (80 degrees).
Upper right, if the down technique is applied on such a nose, it should be
known that the pyramidal angle will not change, and the nose will also
look wider due to projection loss. Lower left, the pyramidal angle cannot
be changed with osteoplasty techniques. Lower right, such a nose can
successfully be treated with the DR technique.
The main reasons why these century-old down techniques

remain in the background compared to excisional techniques
are as follows:
1. Stabilization problems (recurrence of deviations or

formation of post-surgical deviations)
2. Incomplete elimination or recurrence of the hump
3. The possibility of causing more than necessary nose
reduction
FIGURE 3.59 The mobile segment, blue dotted area, that was formed
4. Causing an airway blockage due to inserted bone on the dorsum in the DR technique. It includes the entire dorsum as the
volume aesthetic unit and is in the shape of a trapezoid.
FIGURE 3.60 Ideal pyramidal angle is between 50–60 degrees.
broadest part of the dorsum, should be as long as the width

of the philtrum or the distance between tip defining points
at most; a dorsum wider than this is called a broad dorsum
[21, 40].
The radix level on a patient looking straight ahead should
be at the same level as the eyelashes from the profile image.
A radix lower than this is a lower radix, and a radix higher
than this is a higher radix. A straight line drawn from the radix
to the supratip should be tangential to the dorsum; any dorsal
shape that exceeds this positively has an angulation (curvature,
curved) deformity [45].
The angle between both nasal bones can be evaluated
from the oblique base perspective. The angle between both
nasal bones is called the pyramidal angle, and it should ide-
ally be between 50–60 degrees, as shown by the tomography
and clinical studies that the author conducted (Figure 3.60).
From this perspective, a wide-angled nose is known as a
“wide” pyramidal angle. This angle can easily be measured
on the nasal mold taken before an operation with a metal
nose splint and a protractor. Of course, the pyramidal angle
measured in this way will also add the thickness of the soft
tissue envelope over the nasal roof, so it will be a few degrees
higher than the clear angle measured with the tomography FIGURE 3.61 The pyramidal angle can be determined with a metal
(Figure 3.61) [40, 42]. splint and protractor before the operation.
3.4.2.2.2.2 Patient Selection more successful in repairing this angulation. This

is because the dorsum, which is separated from the
The Indication for the DR Technique constructed nasal circle in the DR technique, will be
This technique is suited to broad and projected noses. Attempts flattened without downing and will no longer have
may be made to treat this patient group with medial osteoto- an angular deformity, making this the logical way
mies added to down techniques; however, the nuance here is to treat angular deformity by ensuring its fixation on
as follows: the nasal roof again.
2. Broad noses generally have weak cartilage roofs, and
1. If there is angulation on the dorsum requiring, for if support of the cartilage part of the nose is required,
example, a 5 mm downing for repair, but its ideal the DR technique will be a more logical option
projection is higher, then the DR technique will be because it provides the possibility of spreader flaps.
Dorsum Surgery 61
The Contraindication for the DR Technique

The contraindication of the DR technique is noses with trau-
matic dorsum.
3.4.2.2.2.3 Surgical Technique (Figure 3.62a–c)

1.
Dorsum dissection
(c)
FIGURE 3.62c The final shape after the DR technique is the same with
the narrower version of the natural nasal anatomy.
(a)
FIGURE 3.62a Black line, mobilized dorsum segment in the DR tech-

nique; purple line, the lateral osteotomy; yellow line, the transverse
osteotomy.
FIGURE 3.63 Dorsum with a wide pyramidal angle.
The dorsum is dissected from the submembranous plane fol-

lowing superior intracartilaginous and hemitransfixion inci-
sions (Figure 3.63).
(b)
FIGURE 3.62b The mobilized dorsal segment is fixed to the septum

again.
2.
Preparation of the DR made in favor of the dorsal roof by following the dorsal aes-
thetic line instead of the classical component hump removal
After dissecting the mucosa of the joint between the upper
(being as close to the septum as possible). Thus, a dorsum with
lateral cartilage and septum, the upper cartilages are separated
dorsal aesthetic lines is obtained (Figure 3.65). After separa-
from the septum (Figure 3.64a,b). This separation process is
tion of the cartilaginous part, the nasal bone is incised with
bone scissors or a power instrument in a way to follow the
dorsal aesthetic lines, known as the dorsal osteotomy which
is more laterally located than the classical medial osteotomy
(Figure 3.66).
If the radix level is low, a radix osteotomy is fully made so
that let up can be performed by putting a graft under it (Video
3.18). If the radix level is high, a radix osteotomy can be made
as a greenstick fracture (Figure 3.67). If the radix level is nor-
mal, there is no need for a radix osteotomy.
After this step, the dorsum is separated from the septum
with scissors, ensuring that it has at least 2 mm thickness, thus
obtaining a dorsal roof.
(a)
FIGURE 3.64a Mucosal tunnels under the upper lateral cartilages.
FIGURE 3.66 Dorsal osteotomy.
(b)
FIGURE 3.64b The separated upper lateral cartilages.
FIGURE 3.67 Blue arrow, radix osteotomy; green arrow, dorsal

FIGURE 3.65 Cartilage portion of the DR. osteotomy.
Dorsum Surgery 63
3. Stabilization of the DR
Separation of the dorsal roof from the septum is generally
sufficient to achieve the projection to be downed, but if there is
a need for more projection loss, this can be provided by mak-
ing an excision from the septum.
In the case of a deviated nose, the dorsal roof is fixed to the
opposite side of the deviation side by side with the septum,
while it is fixed to the septum end-to-end if there is no devia-
tion (Figure 3.68).
The excess of the upper lateral cartilages arising from the
projection loss is fixed to the dorsal roof like spreader flaps
(Figure 3.69).
After fixing the dorsal roof, the bone roof is narrowed by FIGURE 3.69 The stabilization of spreader flaps.
osteotomies (Figures 3.70–3.73).
FIGURE 3.70 Final shape demonstrates the narrower, straight, and ana-
FIGURE 3.68 The stabilization of DR. tomical dorsum achieved by the DR technique.
(a) (b)
FIGURE 3.71 (a–b) Before and three years after.

(a) (b)
(c) (d)

Dorsum Surgery 65
(a) (b)
(c) (d)
Video 3.19 covers the entire surgical technique from start- which are the most common causes of rhinoplasty, is as
ing to the end, and Video 3.20 presents an animation detailing follows:
the principles behind the technique. 1.
Fix down technique (if there is only a hump/projec-
tion, then use the let down; if there is a projection
and septal surgery is needed or if it is a projected
3.4.3 Dorsum Algorithm in Reduction Rhinoplasty
and wide pyramidal nose, then push down; if there
In summary, the author’s algorithm created with an atrau- is a hump/projection and septal surgery is needed or
matic approach for the treatment of arched/projected noses, there is crookedness, then fix down)
2.
Dorsal roof technique (if there is a wide pyramidal
angle and arched nose without projection)
3.
Bone dust technique (narrow nose, osteotomy con-
traindicated but arched nose)
4.
Dorsal reconstruction (traumatic noses with surface
deformation in the dorsum)
3.5 Dorsum Augmentation

As dorsum augmentation techniques have a very wide spec-
trum ranging from implants to rib cartilage, the surgeon
should choose the most suitable technique for each case.
Augmentation techniques can be used not only in second-
ary cases or in cases of ethnic rhinoplasty, but also in cases
where reduction rhinoplasty will be applied (for instance,
isolated augmentation of the radix) or as a camouflage
method.
FIGURE 3.74 Cartilage paste.
For this purpose, the ideal material to be used:
• Must be easily obtained during the surgery 3.5.1 Ultradiced Cartilage Method
• Must be sufficient
Indications of This Technique
• Must be resistant to absorption problems
1. Surface irregularity and asymmetries
• Must not need a scaffold
2. Radix or dorsum augmentations
Thus, the most widely used material is diced cartilage (chopped
cartilage) [55]. 3.5.1.1 Surgical Technique
The diced cartilage method can be used in three different Cartilage excised during surgery (septal cartilage, trim materi-
ways: als, ear concha, rib cartilage, etc.) is very roughly (0.5–1 cm)
sliced and collected into an insulin injector at the end of the
1. Free operation. The number 15 scalpel is inserted perpendicularly
2. In Surgicel to the tip of the insulin injector. Likewise, an empty insulin
3. In fascia injector is prepared, then cartilage is injected from the full
injector into the empty one (Figure 3.75).
Here, Surgicel and fascia are used to mold chopped cartilage The scalpel at the tip of the insulin injector should coincide
as a scaffold, although the use of the mold will also logically with the transition from the full width of the tip of the injector to
increase the risk of absorption as it will prevent contact of the the narrow part so that when the cartilage reaches the narrowed
cartilage grafts with viable surfaces [56]. mouth, the scalpel can cut, but at the same time the plunger of
Therefore, free diced cartilage is more commonly used, but the syringe is not damaged by the scalpel. By repeating this
it must be reduced to 2 mm in size to avoid visibility and pal- process several times, a perfect cartilage graft is obtained in the
pation problems; this is a time-consuming and difficult pro- consistency of cartilage paste. The author named this material
cess. Moreover, in thin-skinned cases, even 2 mm cartilage and technique as “ultradiced cartilage” [58].
may be visible, so the use of fascia (temporal or rectus fascia) Up to 1 cc of ultradiced cartilage material can be prepared in
may be required [57]. less than 2 minutes from beginning to end (Video 3.22). Ultradiced
Cartilage paste (cartilage melt) can be obtained by curving cartilage is formed when the cartilage tissue begins to move into
the cartilage with a scalpel in a parallel fashion, which is the the other injector in the form of a linear line without dispersing
conventional method. However, it has not become widespread inside the injector (Figure 3.76). Generally, 7–8 transfers from
due to such reasons as damage to chondrocytes, loss of the one injector to another is sufficient to achieve this consistency.
ability to give volume due to the cartilage melting, the obtain- Ultradiced cartilage is compact, and when it is ejected from
able amount being limited to only 0.1–0.3 cc, and the time it the injector, it does not disintegrate. This can be explained
requires (Figure 3.74, Video 3.21). by Coulomb’s Law, which states that sufficiently small par-
Herein lies the reason for the ultradiced cartilage method ticles can attach to each other by electrostatic force and stand
[58], which overcomes all these problems. together (Figure 3.77, Video 3.23).
Dorsum Surgery 67
FIGURE 3.75 Preparation of ultradiced cartilage.
FIGURE 3.76 Formation of ultradiced cartilage inside the insulin FIGURE 3.77 Compact structure of the ultradiced cartilage, even when
injector. taken out.
FIGURE 3.78 The change in the cartilage volume with the process
indicates the elimination of the dead space between the cartilages by the FIGURE 3.79 Under the microscope: left, cartilage paste; center, ultra-
ultradiced cartilage technique. diced cartilage; right, classically diced cartilage graft (2 mm in size).
Using this process, 0.7 cc of ultradiced cartilage can examined and it was found that ultradiced cartilage obtained
be obtained from 1 cc of cartilage graft, which shows how cartilage particles of approximately 0.1 mm in size, 20–30
the dead space between the cartilage is eliminated by this times smaller than the cartilage obtained by a classical 2 mm
process (Figure 3.78). Most of the absorption problems seen in free diced method. In addition, it was found that ultradiced
diced cartilage arise from the fact that exactly how much aug- cartilage particles provide particles that are 5–10 times larger
mentation is necessary cannot be predicted because the dead than cartilage paste and have not lost their volume effect
spaces between cartilage cannot be prevented. Fortunately, (Figure 3.79). The author’s histological study revealed that
ultradiced cartilage technique eliminates this dead space. chondrocytes in ultradiced cartilage were intact and viable
In a microscopic study conducted by the author, classical (Figure 3.80). As a result, the ultradiced cartilage method
diced cartilage, ultradiced cartilage, and cartilage paste were can eliminate problems related to the free diced cartilage
FIGURE 3.80 The viability of the ultradiced cartilage is histologically presented.

Dorsum Surgery 69
(a) (b)
(c) (d)
technique such as absorption, visibility, and the need for scaf- 3.5 Maxilloplasty.
folding (Figures 3.81–3.82). 3.6 Aesthetically pleasing dorsums.
3.7 The push down technique.
3.8 The let down technique.
VIDEOS 3.9 Component excision.
3.1 Lateral osteotomy with micromotor. 3.10 The bone dust technique.
3.2 Transverse osteotomy with micromotor. 3.11 Treatment for an asymmetric face.
3.3 Osteoplasty with power rasp. 3.12 Septal rotation on the maxillary spine.
3.4 Deepening the hypertrophic maxilla. 3.13 Fix up technique.
(a) (b)
(c) (d)
FIGURE 3.82 a–d Before and six years after.
3.14 The fix down technique. 3.21 Obtaining cartilage paste by the classic method.
3.15 Application of the fix down technique step by step in 3.22 Ultradiced cartilage graft technique.
a primary rhinoplasty for severe deviation. 3.23 Ultradiced cartilage material.
3.16 Application of the fix down technique step by step in
a revision rhinoplasty for severely asymmetric nose.
REFERENCES
3.17 Hump correction with the fix down technique,
cadaver study. 1. Taş S. Closed Atraumatic Rhinoplasty Course. Endorsed
by RSE (Rhinoplasty Society of Europe) and ISAPS
3.18 Let up technique.
(International Society of Aesthetic Plastic Surgery).
3.19 Dorsal roof technique. Istanbul, Turkey, Nov 16–17, 2019. https://drsuleymantas.
3.20 Dorsal roof technique (animation). com/course/ Accessed 11 Aug 2019.
Dorsum Surgery 71
2. Toriumi DM, Hecht DA. Skeletal Modifications in 22. Goodale JL. A New Method for the Operative Correction
Rhinoplasty. Fac Plast Surg Clin NAm. 2000; 8: 413–31. of Exaggerated Roman Nose. Boston Med Surg J.
3. Paulsen F. Anatomy and Physiology of the Nasolacrimal Ducts. 1899; 140: 112.
Edited by Weber RK, Keerl R, Schaefer SS, Della Rocca RC, 23. Goodale JL. The Correction of Old Lateral Displacement of
Atlas of Lacrimal Surgery. Springer: Berlin, 2007: 1–13. the Nasal Bones. Boston Med Surg J. 1901; 145: 538–9.
4. Sarıaltın Y, Ortak T, Öz C, et al. Radiological Assessment 24. Lothrop OA. An Operation for Correcting the Aquiline
of the Lateral Osteotomy Line-Lacrimal System Distance Nasal Deformity; The Use of New Instrument; Report of a
on Three-Dimensional Models. J Craniomaxillofac Surg. Case. Boston Med Surg J. 1914; 170: 835–7.
2019 Oct; 47(10): 1608–16. 25. Skoog T. A Method of Hump Reduction in Rhinoplasty:
5. Yigit O, Cinar U, Coskun BU, et al. The Evaluation A Technique for Preservation of the Nasal Roof. Arch
of the Effects of Lateral Osteotomies on the Lacrimal Otolaryngol. 1966 Mar; 83(3): 283–7.
Drainage System after Rhinoplasty Using Active Transport 26. Barelli PA. Long Term Evaluation of “Push Down”
Dacryocystography. Rhinology. 2004 Mar; 42(1): 19–22. Procedures. Rhinology. 1975 June; 13(1): 25–32.
6. Tang C, Rickert S, Mor N, Blitzer A, Leib M. 27. Huizing EH. Push-Down of the External Nasal Pyramid by
Dacryocystorhinostomy with a Thulium: YAG laser— Resection of Wedges. Rhinology. 1975 Dec; 13(4): 185–90.
A Case Series. Ear Nose Throat J. 2018 Aug; 97(8): 28. Ribeiro L. Rhinoplasty—A New Approach in the Repair of
E39–E42. the Hump. Aesthetic Plastic Surg. 1978; 2: 409–18.
7. Webster RC, Davidson TM, Smith RC. Curved Lateral 29. Barelli PA, Kern EB, Loch WEE, Steiner A (Eds.).
Osteotomy for Airway Protection in Rhino-Plasty. Arch Rhinology: The Collected Writings of Maurice H. Cottle.
Otolaryngol. 1977; 103(8): 454–8. American Rhinologic Society: Kansas City, Missouri, 1987.
8. Taş S. The Alignment of the Nose in Rhinoplasty: Fix 30. Pirsig W, Königs D. Wedge Resection in Rhinosurgery:
Down Concept. Plast Reconstr Surg. 2020 Feb; 145(2): A Review of the Literature and Long-Term Results in a
378–89. doi: 10.1097/PRS.0000000000006523. Epub 2019 Hundred Cases. Rhinology. 1988 June; 26(2): 77–88.
Nov 19. 31. Daniel RK. Rhinoplasty: The Retractable Roof. Plastic and
9. Cottle MH. Nasal Roof Repair and Hump Removal. AMA Reconstructive Surgery. 1989 June; 83(6): 976–83.
Arch Otolaryngol. 1954 Oct; 60(4): 408–14. 32. Drumheller GW. The Push Down Operation and Septal Sur
10. Taş S. Response to Commentary on: Dorsal Roof Technique gery. Edited by Daniel RK, Aesthetic Plastic Surgery: Rhino
for Dorsum Preservation in Rhino-plasty. Aesthetic Plast plasty. Little, Brown and Company: Boston, 1993: 739–69.
Surg. 2020 Mar 4. doi: 10.1007/s00266-020-01656-8. 33. Drumheller GW. The Cottle Push Down Operation. The Am
[Epub ahead of print]. J Cosmetic Surg. 1995; 12(3): 255–61.
11. Roe JO. The Correction of Angular Deformities of the Nose 34. Sulsenti G, Palma P. Tailored Nasal Surgery for
by a Submucous Operation. Med Rec 1891; 40: 57. Normalization of Nasal Resistance. Facial Plast Surg. 1996
12. Joseph J. Nasenplastik und sonstige Gesichtsplastik nebst Oct; 12(4): 333–45.
einem Anhang uber Mammaplastik. Verlag von Curt 35. Pinto RM. On the “Let-Down” Procedure in
Kabitsch: Leipzig, 1928–1931. Septorhinoplasty. Rhinology. 1997 Dec; 35(4): 178–80.
13. Sheen JH. Aesthetic Rhinoplasty. Mosby Company: St. 36. Ishida J, Ishida LC, Ishida LH, Vieira JC, Ferreira MC.
Louis, 1978. Treatment of the Nasal Hump with Preservation of the
14. Sheen JH. Spreader Graft: A Method of Reconstructing Cartilaginous Framework. Plast Reconstr Surg. 1999 May;
the Roof of the Middle Nasal Vault Following Rhinoplasty. 103(6): 1729–33.
Plast Reconstr Surg. 1984 Feb; 73(2): 230–9. 37. Huizing EH, de Groot JAM. Functional Reconstructive
15. Seyhan A. Method for Middle Vault Reconstruction in Nasal Surgery. Thieme: Stuttgart, Germany, 2003.
Primary Rhinoplasty: Upper Lateral Cartilage Bending. 38. Gola R. Functional and Esthetic Rhinoplasty. Aesthetic
Plast Reconstr Surg. 1997; 100: 1941–3. Plast Surg. 2003 Sep–Oct; 27(5): 390–6.
16. Rohrich RJ, Muzaffar AR, Janis JE. Component Dorsal 39. Saban Y, Daniel RK, Polselli R, Trapasso M, Palhazi
Hump Reduction: The Importance of Main-Taining Dorsal P. Dorsal Preservation: The Push Down Technique
Aesthetic Lines in Rhinoplasty. Plast Reconstr Surg. 2004 Reassessed. Aesthet Surg J. 2018 Feb 17; 38(2): 117–31.
Oct; 114(5): 1298–308. 40. Taş S. Dorsal Roof Technique for Dorsum Preservation in
17. Gordon SD, Warren RF. Autogenous Diced Cartilage Rhinoplasty. Aesthet Surg J. 2020 Feb 17; 40(3): 263–75.
Transplants to Bone: An Experimental Study. Ann Surg. doi: 10.1093/asj/sjz063. Epub 2019 Feb 25.
1947 Feb; 125(2): 237–40. 41. Daniel RK. Commentary on: Dorsal Roof Technique for
18. Peer LA. Extended Use of Diced Cartilage Grafts. Plast Dorsum Preservation in Rhinoplasty. Aesthet Surg J. 2020
Reconstr Surg. (1946) 1954 Sep; 14(3): 178–85. Feb 17; 40(3): 276–80.
19. Limberg AA Jr. The Use of Diced Cartilage by Injection 42. Taş S. Response to Commentary on: Dorsal Roof Technique
with a Needle. 1. Clinical Investigations. Plast Reconstr for Dorsum Preservation in Rhino-Plasty. Aesthetic Plast
Surg Transplant Bull. 1961 Nov; 28: 523–36. Surg. 2020 Mar 4. doi: 10.1007/s00266-020-01656-8.
20. Erol OO. The Turkish Delight: A Pliable Graft for [Epub ahead of print].
Rhinoplasty. Plast Reconstr Surg. 2000 May; 105(6): 43. Atolini N Junior, Lunelli V, Lang GP, Melotti LF, Yamamoto
2229–41. TT, Muneroli EJ. Septum Pyrami-Dal Adjustment and
21. Taş S. The Use of Bone Dust to Correct the Open Roof Repositioning—A Conservative and Effective Rhinoplasty
Deformity in Rhinoplasty. Plast Reconstr Surg. 2018 Sep; Technique. Braz J Otorhinolaryngol. 2019 Mar–Apr; 85(2):
142(3): 629–38. doi: 10.1097/PRS.0000000000004706. 176–82.
44. Ferraz MBJ, Zappelini CEM, Carvalho GM, Guimarães AC, 52. Taş S. Correcting the Alar Base Retraction in Crooked
Chone CT, Dewes W. Cirurgia conservadora do dorso nasal— Nose by Dissection of Levator Alaeque Nasi Muscle.
a filosofia do reposicionamento e ajuste do septo piramidal Ann Plast Surg. 2016 Oct; 77(4): 383–7. doi: 10.1097/
(S.P.A.R.). Rev Bras Cir Cabeça Pescoço. 2013; 42: 124–30. SAP.0000000000000648. Epub 2015 Sept 10.
45. Taş S. The Alignment of the Nose in Rhinoplasty: Fix Down 53. Taş S. Response to “Anatomic Columellar Strut, An
Concept. Plast Reconstr Surg. 2020 Feb; 145(2): 378–89. doi: Alternative Paradigm?” Aesthetic Surgery J. 2020 May 23.
10.1097/PRS.0000000000006523. Epub 2019 Nov 19. doi: 10.1093/asj/sjaa088. [Epub ahead of print].
46. Tuncel U, Aydogdu O. The Probable Reasons for Dorsal 54. Taş S, Celik N. New Instruments for Submembranous
Hump Problems following Let-Down/Push-Down Dissection in Rhinoplasty. Aesthet Surg J. 2017 July 1;
Rhinoplasty and Solution Proposals. Plast Reconstr Surg. 37(7): NP73–NP8. doi: 10.1093/asj/sjx084.
2019; 144(3): 378e–85e. 55. Kreutzer C, Hoehne J, Gubisch W, Rezaeian F, Haack
47. Haack S, Hacker S, Mann S, Gubisch W. Bony Fixation of the S. Free Diced Cartilage: A New Application of Diced
Nasal Framework. Facial Plast Surg. 2019 Feb; 35(1): 23–30. Cartilage Grafts in Primary and Secondary Rhinoplasty.
48. Doğan T. Teorhinoplasty: A Minimalist Approach. Ema Plast Reconstr Surg. 2017; 140: 461–70.
Medical Bookstore: Istanbul, 2020. 56. Taş S. A New Technique to Correct Saddle Nose Deformity
49. Cottle MH, Loring RM, Fischer GG, Gaynon IE. The in Failure of Diced Cartilage Grafts: Diced Cartilage Flap.
Maxilla-Premaxilla Approach to Extensive Nasal Septum Aesthetic Plast Surg. 2015 Oct; 39(5): 764–70. doi: 10.1007/
Surgery. AMA Arch Otolaryngol. 1958 Sep; 68(3): 301–13. s00266-015-0530-8. Epub 2015 July 11.
50. Guyuron B, Uzzo CD, Scull HA. Practical Classification 57. Cerkes N, Basaran K. Diced Cartilage Grafts Wrapped in
of Septonasal Deviation and an Effective Guide to Septal Rectus Abdominis Fascia for Nasal Dorsum Augmentation.
Surgery. Plast Reconstr Surg. 1999 Dec; 104(7): 2202–9; Plast Reconstr Surg. 2016 Jan; 137(1): 43–51.
discussion 2210–2. 58. Taş S. Ultra Diced Cartilage Graft in Rhinoplasty:
51. Taş S, Colakoglu S, Lee BT. Nasal Base Retraction: A Fine Tool. Plast Reconstr Surg. 2021 Apr 1; 147(4):
A Treatment Algorithm. Aesthet Surg J. 2017 June 1; 37(6): 600e–606e. doi: 10.1097/PRS.0000000000007794.
640–53. doi: 10.1093/asj/sjw203. Epub 2020 Sept 22.
4
Nasal Tip Surgery Nasal Tip SurgeryRhinoplasty in Practice
4.1 History of Tipplasty a soft transition zone from the lateral crus to medial cannot be
formed in the reshaped cartilage—then a soft triangle retrac-
In 1887, tipplasty started with Roe’s [1] excision and mor- tion will appear.
celization methods. In 1931, Joseph [2] defined the first tip
suture as an orthopedic suture and described today’s sep-
tocolumellar suture in his book. In the 1940s, the nasal
tip started to be removed using the delivery technique. In
1950, Fred [3] advanced the suture techniques that Joseph
started; he also described the invaginating technique which
enabled the entrance of the caudal septum into the groove
between of the medial cruras. In 1999, Kridel et al. [4] revis-
ited this technique, referring to it as the “tongue in groove”
technique.
In 1957, Goldman [5] improved the incisional techniques by
introducing the dome division technique. In 1969, Anderson
[6–7] introduced the tripod concept, enhancing the correlation
between lateral and medial crus (crura) lengths, tip projec-
tion, and rotation; it is still known as Anderson’s tripod con-
cept today. In 1975, Sheen [8] described the shield graft and
detailed the use of the strut graft. In 1983, Peck [9] described
the onlay graft. In 1985, McCollough [10] used the dome
suture to narrow the dome area; it was later modified by Tardy
[11] and Tebbetts [12], becoming known as today’s interdomal
and intradomal sutures. Since publication in 2008, Tebbetts’s
book [12] has become a complementary instrument to these (a)
suture techniques; his “all-in-one” method to solving all issues
with sutures is known as suture rhinoplasty.
Today, reshaping and strengthening principles that adopt
autologous flap and graft techniques are preferred over the
subtractive approach [13–17].
4.2 Surgical Anatomy and Related

Deformities in Tipplasty
Sheen [18] divided the lower lateral cartilage (LLC) into three
anatomic parts—the medial, middle, and lateral crura—due to
the structural properties and soft angles of the cartilage here
where it passes from the lateral to medial crus. The anatomic
region known as the soft triangle forms between the columella (b)
and rim due to this divergence (Figure 4.1). In tip reshaping
surgery, if this divergence is in the middle—in other words, if FIGURE 4.1 (a–b) The anatomy of lower lateral cartilages.
DOI: 10.1201/9781003174165-4
73
FIGURE 4.3 The effect of medial overlapping.
of them due to overlapping or steal affects nasal tip projec-

FIGURE 4.2 Tripod concept. tion. If the procedure to be performed favors the medial crus,
the nasal tip rotation increases, but if it is against it, then
the rotation decreases. This concept is important for us to
4.2.1 The Tripod Concept
determine what is necessary in nasal tip reshaping surgery
The cartilage anatomy of the nasal tip is similar to a tripod, (Figure 4.3).
and this is very helpful to understand the mentality behind the When it is necessary to perform an upward tip rotation or
techniques used for adjusting the nasal tip rotation and projec- shorten the length of the lateral crus, lateral steal is a simple,
tion (Figure 4.2) [19]. Surgical techniques that operate with effective maneuver in this case. However, if the cartilage is so
this mentality are detailed in Table 4.1. stiff that it can be broken when lateral steal is attempted, then
Due to the hemi-circular geometric relationship between performing the lateral overlapping procedure will be more
the lateral and medial crura of the LLC, shortening on one logical (see Video 4.1).
TABLE 4.1
The Effects of Tipplasty Techniques on the Tripod
Lateral Dome Division/
Lateral Steal Medial Steal Overlapping Medial Overlapping Excision
Tip Rotation Increases Decreases Increases Decreases Does not change
Tip Projection Increases/Decreases Decreases Decreases Decreases Decreases
Lateral Crus Length Shortens Extends Shortens Does not change Shortens
Medial Crus Length Extends Shortens Does not change Shortens Shortens
Nasal Tip Surgery 75
4.2.2 Supratip Break Point

This point is desired by those wanting a more feminine or ele-
gant nasal tip. To form the supratip break point, the tip defining
point should be 2–3 mm higher than the septal angle in thin-
skinned patients and 5–6 mm higher in thick-skinned patients
(Figure 4.4). Although this point’s excessive definition can
cause fake saddle nose deformity, its fullness and height can
also cause supratip or parrot nose deformities. Supratip defor-
mities are generally iatrogenic as it is difficult to control this
area in thick-skinned patients.
4.2.3 Nostril Image

Detailed examination of the nostril and how it looks from
the front and side perspectives is important [18]. The nostril,
being elliptical in shape with 2–3 mm in the midpoint, has four
deformities regarding its profile image based on the long axis
(Figure 4.5) [20–21]. These deformities are:
• Hanging columella
• Hanging ala
• Retracted columella
• Retracted ala
FIGURE 4.4 The supratip break point.
FIGURE 4.5 The ideal nostril shape and the classification of the nostril deformities.
Nostril deformities are not always in the shape of an isolated

deformity, but can occur in a combination of these deformities
(Figure 4.6a–b). Treatment options for these deformities are
provided in Table 4.2.
Although a retracted ala (alar rim retraction) can be a pri-
mary deformity, it is mostly observed in secondary cases
(Figure 4.7), as an iatrogenic deformity which is a result of
an orientation defect in the area where the LLC is tangent to
the rim or the lack of cartilage/mucosa in this area. Based
on localization and severity of the defect, a rim graft, V-Y
advancement flap, double layer graft, or composite graft can
be used in its treatment.
FIGURE 4.7 Secondary rhinoplasty patient with severe nostril

asymmetry.
Rim grafts are sufficient in patients with mild alar rim

retraction. The cartilage graft obtained from the septal car-
tilage is placed on the pouch that is opened on the retraction
area in the rim. In cases with moderate alar rim retraction, if
the retraction localization is lateral to the area where the rim
is tangent to the LLC, then the soft tissue content of this area
allows for a V-Y advancement flap (Figure 4.8, Video 4.2).
(a) (b)
FIGURE 4.6 Secondary rhinoplasty patients: (a) rim retraction and

supratip deformity. (b) Columellar show deformity (hanging columella
and rim retraction).
TABLE 4.2
Nostril Deformities and Possible Treatment Options
Hanging Retracted
Columella Retracted Ala Hanging Ala Columella
Septo- Rim graft Vestibular skin Strut
columella excision
suture
Set back V-Y Skin excision Septal
advancement from the rim extension
flap graft
Tongue in Double layer RF
groove graft (radiofrequency)
application
Composite graft
(a)
FIGURE 4.9 Double layer graft.
However, if the retraction localization is medial to the area

where the rim is tangent to the LLC, a double layer graft
(b)
is the most suitable repair technique (Figures 4.9–4.10,
FIGURE 4.8 (a) V-Y advancement flap. (b) The immediate effect of V-Y Video 4.3) [22]. Auricular composite grafts are used in
advancement flap. severe cases.
(a) (b)
(c) (d)
FIGURE 4.10 (a–d) Before and 2.5 years after.
4.2.4 Lateral Crus Malposition

The lateral crus separates from the medial crus in the mid-
line at the dome point and extends laterally to the midline at
an angle of approximately 45 degrees. When it reaches the
lateral soft triangle or, in other words, the superior border
of the alar crease, it ends by turning into sesamoid cartilage
and ligamentous structures [23]. An angle between the lat-
eral crus and midline narrower than 30 degrees was defined
as cephalic malposition by Sheen [18]. Treatment is recom-
mended for this condition which ovalizes the nasal tip, creat-
ing a parenthetic effect (Figure 4.11). Major procedures such
as releasing the lateral crus from the soft tissue enveloping
them and from the mucosa under them and transpositioning
them in more caudal (lateral crural transposition) or minor
procedures such as the lateral steal are performed based on
the severity of the condition [24–25]. A cartilage flap lifted
from the cephalic part of lateral crus is another way to cor-
rect this condition [15].
4.2.5 Medial Crus Malposition

Although this deformity has not yet been defined in the lit-
erature, the medial crus can be mispositioned similarly to the FIGURE 4.11 Green line, ideal trace of the lateral crus; red line,
malposition of the lateral crus. The medial crus commonly cephalic malposition.
FIGURE 4.12 Caudal malposition. An angle wider than 30 degrees in

the caudal arc of the medial crus, yellow angle, indicates medial crus FIGURE 4.13 Long medial crus. The long medial crus deformity has
malposition. a normal angle in the caudal arc of the medial crus, yellow angle, and
should not be mistaken for medial crus malposition.
lays in such a way that it creates a caudal arc at an angle of

about 10–30 degrees on the vertical line drawn from the foot-
plate to the dome. Medial crus malposition can be seen if this
arc is wider than this angle, which will cause a hanging image
on the footplate which needs to be corrected (Figure 4.12). To
correct this deformity, medial crus are separated from where
they adhere to the footplate; if necessary they are shortened
and then re-stabilized at a more correct position and angle. In
the stabilization, the medial crus is re-fixed on the mucosa and
then the strut is fixed on the septal extension graft or caudal
septum (Video 4.4).
Medial crus malposition should not be mistaken for long
medial crus. Fortunately, the treatment for long medial crus
is quite simple; medial overlapping is sufficient to solve this
issue (Figure 4.13).
4.2.6 Bifid Nose Deformity

Insufficient adhesion of medial nose protrusions during
embryonic stages causes this deformity. It is characterized
by a small groove that lies on the tip area in minor cases,
but more severe defects in the adhesion of both sides may be
observed in major cases (Figure 4.14). Superficial SMAS tis-
sue can be hypoplasic in those cases. In the treatment, nasal
tip cartilages should be covered with camouflage materials FIGURE 4.14 The congenital bifid nasal tip deformity.
such as a fascia graft. In this way, cartilage visibility is pre-

vented and at the same time, nasal tip soft tissue defect in the
midline is replaced. Another way to correct this deformity is
preparing the deep SMAS layer like a flap and rerouting it
so that rather than passing behind the nasal tip cartilage, it
passes over (Figure 4.15) [26]. Thus, deep SMAS is trans-
formed into the superficial SMAS.
4.3 Tipplasty
“Rhinoplasty is an easy operation to do, but it is hard to
get good results.”
(G. Aufricht)
Seeing and understanding what is beautiful is the first require-

ment in creating beauty. Figure 4.16 details what makes a
nasal tip aesthetically beautiful and its anatomy. In order to
have an aesthetically beautiful nose:
1.
The soft tissue cartilage balance must be created;
excessive soft tissue or cartilage prevents achieving
this result.
FIGURE 4.15 The transposition of deep SMAS.
FIGURE 4.16 To obtain such aesthetically pleasing nasal tips, the nasal tip anatomy should be designed as marked. Gray, LLC; green, horizontal
scroll ligament; blue, vertical scroll ligament.
TABLE 4.3
Tipplasty Techniques
Incisional Soft Tissue Dynamic
Support Grafts Contour Grafts Suture Grafts Grafts Flap Techniques Techniques Techniques
Classical strut Shield graft Interdomal suture Cephalic trim ST flap SMAS- Dissection of
(floating or spine Intradomal suture Reverse ST flap perichondriectomy the
reclining) depressor
Anatomic strut septi nasi
muscle
Septal extension graft Onlay grafts: Lateral steal suture Lateral Turn in Redraping techniques Dissection of
Anatomic septal free, fixated on overlap Turn out the levator
extension graft cartilage roof, alaeque nasi
fixated on soft muscle
tissue with
guide sutures
Tongue in groove Free rim graft Septocolumellar Medial Lateral crural flap Alar excision Alar muscle
(Fred’s technique) Articulated rim suture overlap dissection
graft
Lateral crural strut Lateral spanning/ Set-back Camouflage methods:
crural suture technique diced cartilage,
Bone dust, soft
tissue grafts
(temporal fascia,
rectus fascia grafts,
fat injections)
Alar batten graft Deep SMAS layer Dome
suture division
technique
Premaxillary graft Flaring sutures Scoring
techniques
Intercrural suture
(to narrow the
footplate)
Alar base suture
Soft tissue sutures:
supratip suture,
scroll repair suture
2. The connection between the soft tissue and cartilage impossible, as stated by Sheen, but educating our
tissue must be solid. Because the grooves on the skin eyes and performing the necessary interventions
are formed by the ligamentous connections between without exceeding them into fantasy will give the
the skin and mucosa tissue, incision into them ovalizes desired aesthetic progress.
the nose and reduces definition. The reason for lack of
definition in the nose is not only the lack of cartilage, In tipplasty, there are many techniques described, indicat-
but also the ligamentous deficiency. If ligamentous ing the difficulty of nasal tip reshaping surgery. Due to bad
deficiency is not detected and if attempts have been results from tipplasty, surgeons preferred not to touch the
made to define the tip through only cartilage tissue nasal tip for a long period (between 1940–1980) or simply
support (especially in secondary surgeries), nasal tip settled for making a cephalic trim from the trans-cartilag-
definition may not be achieved (although a stiff, pro- inous incision. The seven methods used today have been
jected, and immobile nose is formed). categorized and summarized in Table 4.3. These tech-
3. The nose must be proportional. An effort to achieve niques will be further examined throughout this chapter
the golden ratio or similar ratios is meaningless and (Figure 4.17).
FIGURE 4.17 Upper, lateral overlapping and articulated rim graft; lower left, alar batten graft; lower right, lateral steal, medial overlapping, and
intradomal sutures.
The Main Approach to Modern Tipplasty Is as Follows order to achieve the elegant image provided by cephalic trim
as well as to prevent possible sequelae by supporting the LLC.
1. Inferior intracartilaginous incision Cartilage flaps described in the LLC are divided into four
2. Subperichondrial dissection main categories (Figures 4.18–4.20).
3. ST flap or cephalic trim
4. Lateral steal-medial overlap
5. Intradomal, interdomal sutures
6. Tongue in groove or anatomic strut graft
7. Rim graft or articulated rim graft
8. Perichondrio-SMASectomy
9. Closure
An entire closed technique tip surgery in the order described

is shown in Video 4.5.
4.3.1 Lower Lateral Cartilage Flaps

When the history of cartilage flaps lifted from the LLC is
examined, it is clear that these flaps were aesthetic interven-
tions made to form additional projection in the nasal tip [27].
The classic procedure in nose surgery known as cephalic trim
causes a more elegant aesthetic in the short term; however, it
also causes both functional and aesthetic problems such as
valve collapse and rim retraction due to the weakness it causes
in the LLC in the long term. Thus, cephalic trim material
started to be used as a cartilage flap to support the LLC in FIGURE 4.18 Cartilage flaps lifted from the lower lateral cartilages.
surface of the LLC with horizontal mattress sutures

without any undermining, and the horizontal scroll
ligament which provides the correlation between
lower and upper lateral cartilage is preserved.
4.
Superior based: Ozmen et al. [33] detailed the slid-
ing method in 2009, which the cephalic trim material
is incised and fixed to the pouch opened under the
LLC without distorting its relationship with the upper
lateral cartilage (ULC), and the horizontal scroll liga-
ment which provides the correlation between lower
and upper lateral cartilages is preserved. In the tech-
nique known as the superior-based transposition flap
(ST flap) by Taş (2018) [15], the cephalic trim mate-
rial is left adherent to the scroll area and this scroll-
based cartilaginous island flap is fixed over the LLC
by progressing it caudally. This technique was the first
report showing how the horizontal and vertical scroll
ligaments can be preserved simultaneously.
4.3.2 Lateral Crural Flap
FIGURE 4.19 The effects of cartilage flaps to the scroll junction. The lateral crural flap technique is easy to apply and may be
useful if the nose in question requires any of the following:
1. Cephalic trim
2. Lateral crural suture
3. Spreader flap
4. Nasal tip rotation
The lateral crural flap can meet all these needs [14, 34–35].
4.3.2.1 Surgical Technique

Following the dorsum reduction procedure, the planned
cephalic trim width and new dome point are marked. The cau-
dal-based flap is dissected so as to be 2–3 mm before the marked
dome point, to have a supratip break point (Figure 4.21). These
FIGURE 4.20 The effects of incisional and excisional maneuvers to the
scroll relationship.
1.
Anterior based: This cartilage flap was reported by
Garcia-Velasco et al. [27] and was used cosmetically
to provide tip projection in 1998. It was also used by
Boccieri [28] like a mini spreader graft in 2005. Taş [14]
modified this anterior-based cartilage flap in 2013 and
reported how to use it both aesthetically and functionally.
2.
Posterior based: The cephalic trim material is left
adherent posteriorly and is fixed on the pouch that
was opened under the main body of the LLC in this
flap, as described by Ashtiani et al. [29] in 2013.
3.
Inferior based: In this method, described by Tellioglu
et al. [30] in 2007 as turn in folding, the cephalic trim
material is partially incised to be folded underneath
the LLC and fixed on the pouch opened on the bot-
tom surface of the LLC. The cephalic trim material
is folded and fixed over the LLC in the method called
the turn over by Janis et al. [31] in 2009. In the hinged
method, by Sazgar et al. [32] in 2011, the cephalic
trim material is incised and folded toward the bottom FIGURE 4.21 The lateral crural flap technique.
(a) (b)
(c) (d)
FIGURE 4.22 (a–d) Before and six years after.
flaps are then cephalically shifted equivalent to the planned

4.3.3 ST Flap (Superior-Based Transposition Flap)
nasal tip rotation and are fixed on the septum.
Especially in cases with previous septoplasty, if the The LLC is the primary structure responsible for the shape
caudal septum support has disappeared, the patients com- and function of the nasal wings. Therefore, the power, orienta-
plain about nasal tip drop and that the nose looks wider tion, and shape of the LLC significantly affect the functional
and longer. Breathing problems are concomitant with this and aesthetic result [36].
deformity, even when the airway is open. In such cases, the In general, cephalic trim is one of the generally accepted main
desired result can be obtained using the lateral crural flap procedures in rhinoplasty to increase nasal tip rotation and pro-
without the need for complicated costal cartilage recon- vide a more aesthetic image [37]. Unfortunately, cephalic trim-
struction (Figure 4.22a–d). ming in the LLC may cause long-term sequelae and numerous
TABLE 4.4
The Indications and Contraindications of the ST Flap Technique
Are Summarized
Indications Contraindications
1 Weak LLC Secondary rhinoplasty
cases had previous
cephalic trimming
2 LLC requiring volume reduction
3 Bulbous or boxy tip
4 External and internal valve
insufficiency
5 Convexity or concavity
deformity in LLC
possible complications. Functionally, this is valve collapse, and

aesthetically, these can be listed as alar wing retraction, nasal
tip asymmetry, pinch nose deformity, and tip projection loss
[38]. Trimming of the LLC should be limited to certain mea-
surements such as leaving 6–7 mm in the main body.
FIGURE 4.23 Schematic drawing of the ST flap technique.

“What important is not what you removed but what you
left behind.”
(E. Kern)
On the other hand, concavity and convexity in the LLC cause

both aesthetic and functional problems. Camouflage surgeries
such as lateral crural strut, mattress sutures, overlapping the
LLC, and lateral crural grafts are described for concavity in
the literature [39–40]. Convexity in the LLC causes a volumi-
nous and rough nasal tip image. The most popular technique to
correct this is the domal suture technique [41]. Others include
the transdomal suture, lateral crural strut, lateral crural graft,
and alar batten graft [42–43].
One lingering question is whether a technique exists that
can strengthen the LLC instead of weakening it, solve the ori-
entation issue, correct the convexity and concavity problem on
the surface, and at the same time change the bulbous image of
the nose with a gentler and more triangular image and support
the middle vault by increasing the internal valve angle. The
answer is: the ST Flap [15] (see Table 4.4).

The surgical technique is presented in Figure 4.23, Video 4.6
(live surgical application) and Video 4.7 (animation of the sur-
gical technique).
After exposing the LLC (Figure 4.24), an incision is made in FIGURE 4.24 After the dissection, we can detect the convex and con-
the caudal part of the lateral crus leaving a 6 mm main body of cave surfaces of the lower lateral cartilage and weak areas that need to
the cartilage, just as in the classic trim, and the c artilage tissue in be supported.
FIGURE 4.27 It is suitable for the flap to be fixed on the point where it
can advance the furthest in narrow lower lateral cartilages.
FIGURE 4.25 The sizes of the flap are made as with cephalic trimming.
the cephalic part is dissected from below the vestibular mucosa
until the scroll area with sharp-edged scissors (Figure 4.25). It
is recommended as a parameter to leave a 6 mm main body
parameter in the LLC to prevent LLC instability that may
develop during the trim procedure.
This superior-based cartilage island flap is advanced cau-
dally and can be adapted to the main body of the LLC with 2–3
horizontal mattress sutures stitched with 6/0 Polydioxanone
while preserving its relationship with the scroll area. Thus, the
scroll area is left intact and is bypassed during the rhinoplasty
(Figure 4.26).
If a lateral steal process will be applied or if the adhe-
sion area of the LLC needs support, then the ST flap is
advanced both caudally and laterally and the LLC is medially
shifted.
In 1.2 mm or wider LLCs, a planned ST flap can be
advanced to the caudal edge of the LLC; however, if the LLC
is narrower than 1.2 mm, the ST flap (3 or 5 mm, depending
on how long a flap is obtained) is advanced caudally as much
as the width allows by leaving a 6 mm main body in the LLC
(Figure 4.27). In very wide LLCs, both the flap and the main
FIGURE 4.26 If there is sufficient lower lateral cartilage width, the body of the LLC can be trimmed and narrowed following flap
ST flap can be advanced to the caudal edge of the cartilage body. elevation.
The convexity or concavity problems of the LLC can be

corrected due to the adaptation of two separate surfaces in
ST flap technique. Concavity of the LLC can be corrected
by stitching horizontal mattress sutures so that the knot is on
the vestibular side while these two surfaces are held in a flat
position with forceps. Convexity can be corrected by stitching
the suture so that the knot is on the inner side (Figure 4.28,
Video 4.8).
Since the scroll ligament is cephalically adhered to the
internal valve, caudal movement of a scroll-based cartilage
island will increase the internal valve angle; thus, a serious
functional achievement will be obtained (Figure 4.29).
After application of the ST flap, the medial crura are
supported as if a columellar strut has been placed. The
ST flap technique not only affects the LLC but, if it is
duly performed, it also ensures the balance of the entire
ring. Additionally, an ST flap enables a certain amount of
tip projection to be obtained by supporting the lateral crus
(Figure 4.30).
The ST flap can be used in the treatment of primary rim
retraction. Figures 4.29 and 4.30 show cases with severe pri-
mary rim retraction and how rim transposition was corrected
following ST flap use.
How can these results be explained? Here is where the
Room Concept returns. In the presented case, there is a big
FIGURE 4.29 The internal valve angle, orange dotted lines, is widened
lower chamber that needs reduction. In fact, the widest area by an ST flap, green arrow.
of the LLC is the retraction area. So, how is rim retraction
FIGURE 4.30 The right lower lateral cartilage received an ST flap.
When the shape of the right medial crus is compared with the left, the
fact that this effect was obtained with only an ST flap shows how power-
FIGURE 4.28 The lower lateral cartilage prolapsed to the airway cavity ful this technique is. The right medial crus gained strength as if a strut
can be corrected with an ST flap. was placed.
possible? Look back to the description of rim retraction. Rim ratio and balance becomes proportional and balanced.
retraction emerges due to an orientation defect, or cephalic Notice that the rim retraction is corrected with an ST flap
malposition, of the area where the LLC is tangent to the rim and an aesthetically pleasing nasal tip is achieved. It is
or the lack of cartilage and mucosa in the retracted area important to remember that if cephalic trim was performed
causes this deformity. Thus, a scroll-based cartilage island here rather than an ST Flap, the rim retraction would have
flap lifted from this area will narrow the lower chamber and been aggravated post-surgery (Figures 4.31–4.33). See fur-
correct the rim retraction. So, the nasal tip with distorted ther Table 4.5.
FIGURE 4.31 A case with primary alar rim retraction and its correction with ST flap, small blue area. Direction of the ST flap movement, black
arrow; lower lateral crura, large blue area.
FIGURE 4.32 Another case with primary rim retraction and new design of an LLC was achieved by an ST flap, blue semicircle, which allowed the
surgeon to treat rim retraction.
(a) (b)
(c) (d)

TABLE 4.5
The Advantages and Disadvantages of the ST Flap Are Summarized
ST Flap
Advantages Disadvantages
1 It is the first and only tipplasty method that can preserve both horizontal and It can only be used in primary cases.
vertical branches of the scroll ligament.
2 It is a method that narrows the LLC as well as strengthens it. While it makes an anatomic change suitable to the tripod
concept since it transposes the central accumulation
laterally in bulbous nose structures, there may be a
mathematical expansion of the alar base, possibly
requiring an alar excision to eliminate this effect in cases
already with wide alar bases.
3 Narrowing on the nasal tip will be reflected on the external skin envelope To be able to apply this technique, the correlation
since the nasal tip is shifted without distorting the correlation between the between the cephalic part of the LLC and vertical scroll
cephalic trim material and soft tissue envelope. ligament must be preserved.
4 Convexity or concavity problems in the LLC are corrected due to the
adaptation of these two surfaces with different angles.
5 The orientation and cephalic malposition of the LLC can be corrected with
the transfer of the cephalic island flap, in case of cephalic malposition of the
LLC, to the localization where it normally should be.
6 According to Alexander’s tripod concept, while tip projection and rotation are
adjusted by supporting only the medial crus, it was shown for the first time
that tip projection and rotation can be adjusted using the lateral legs.
7 It is the only tipplasty technique that can increase the internal valve angle in
addition to supporting the external valve.
4.3.4 Reverse ST Flap

The ST flap, which is a scroll-based island flap lifted this time
from the LLC, can be used to support the internal valve by
shifting cephalically to the ULC. This technique is known as
the reverse ST flap (Figure 4.34).
(a) (b)
FIGURE 4.34 (a) Elevation of a reverse ST flap. (b) Adaptation of a reverse ST flap.
Indications of the Reverse ST Flap act as an alar batten graft, allowing the opening and
supporting of the middle vault. Thus, both tip bulbosity
1. If the relationship between the LCC and ULC is and middle vault stenosis are treated (Figure 4.35).
opposite interlocked, then the reverse ST flap is a per-
fect option. In this anatomic variation, the flap that is 4.3.5 Anatomic Strut Concept
lifted from the LLC is sutured over the ULC like an
onlay graft. Thus, the scroll relation is reversed with- “The length and divergence of the medial crus are the
out distortion and the relation becomes scrolled from most distinctive characteristics of an adult person.”
opposite interlocked/scrolled. (M.H. Cottle)
2. If middle vault stenosis accompanies a severe nasal tip
bulbosity, then the flap lifted from the bulbous nasal tip Anatomically between the medial crus, there is a dead space
will be sutured to the caudal end of the ULC and will filled by superficial SMAS tissue. During routine rhinoplasty,
(a) (b)
(c) (d)

techniques such as interdomal and intradomal sutures close

this dead space, creating the image of the operated or aesthetic
nose [44–46]. Since the strut graft, used to cover this space, is
a slat block prepared from septal cartilage, it distorts the diver-
gence angle on the middle crus and causes a non-aesthetic
appearance [16].
Considering the relationship between the medial crus,
important angles exist in the three-dimensional plane and the
gap between the medial crus has a trapezoidal shape. Thus, if
the strut to be used is suitable for the anatomic shape (trap-
ezoid) of this area instead of imposing a flat colon-like shape to
the middle crus, the best results can be achieved (Figure 4.36,
Video 4.9).
Definition of the anatomic strut, which has three features,
unlike the classic strut:
• Having the columellar break point on the area where

it comes across the columellar defining point
• Having horizontal arms forming a 30–40 degree
opening between the medial crus
• The angle between the main body of the strut and
its horizontal arms is equal to the divergence angle FIGURE 4.37 Keystone cartilage obtained after the component hump
between the medial crus and middle crus excision to create an anatomic strut.
There are three ways to form an anatomic strut:
1.
Keystone anatomic strut: If dorsal hump excision is
performed, an anatomic strut can be obtained mak-
ing use of the trapezoid shape of the keystone area
(Figure 4.37).
FIGURE 4.38 Anatomic strut from the lower septum.
2.
Lower septal anatomic strut: If an excision is
made on the base area where the septum sits on
(a) (b) the maxillary crest, similarly, an anatomic strut
can be obtained for the trapezoid shape of this area
FIGURE 4.36 (a) Classical strut. (b) Anatomic strut. (Figure 4.38).
FIGURE 4.39 The tailor-made anatomic strut.
FIGURE 4.40 It is seen how the divergence angle of the medial crus is
3.
Tailor-made anatomic strut: If the two previously
formed by the tailor-made anatomic strut.
mentioned options are not available, then the hori-
zontal arms of the anatomic strut can be formed
with a scalpel incision in the middle of the superior-
anterior surface of the strut after forming a side
curve on the classic strut obtained from the sep-
tum so as to p rovide the columellar defining point
(Figures 4.39–4.40).
4.3.6 Algorithm of the Columellar

Strut Concept (Figure 4.41)
If the patient has thin skin, the tailor-made anatomic strut
should be used as a softer strut because a stiffer strut may
cause visibility problems.
For patients with thicker skin, the keystone or lower sep-
tal anatomic strut should be used. Long-lasting results and a
natural look can be achieved with these as they are stiffer and
provide stability.
If either of the keystone or lower septal anatomic struts is
chosen, the following must be considered:
• Will the hump be removed?

• Is the patient too thick-skinned? FIGURE 4.41 The algorithm for the anatomic strut application.
(a) (b)
(c) (d)
FIGURE 4.42 (a–d) Before and one year after.
If the patient has moderately thick skin and will undergo hump 4.3.7 Anatomic Columellar Septal Extension
removal, then it is logical to use the keystone anatomic strut. Graft
However, if the patient has severely thick skin, the stiffer lower
septal anatomic strut will ensure formation of a more durable One often-discussed subject is whether it is better to use a sep-
nasal tip (Figure 4.42a–d) [16]. tal extension graft or columellar strut to achieve long-lasting
results in Asian populations where patients have a short medial

crus and thick skin [47].
An anatomic columellar septal extension graft is extended
and fixed on the septum version of the normal anatomic strut
graft (Figure 4.43). Thus, the septal extension graft and ana-
tomic strut concept can be combined, allowing the surgeon to
benefit from both (Figure 4.44a–d) [48].
4.3.8 The Mystery of the Pitanguy Ligament

The Pitanguy ligament was first presented by Ivo Pitanguy
in 1965 and was described as the derma-cartilaginous liga-
ment observed on bulbous noses where the subperichondrial
dissection is made. Additionally, the resection of this liga-
ment is recommended for the treatment of any postoperative
remaining supratip deformity and convexity in bulbous noses
[49–51]. Later studies have noted that this ligament does not FIGURE 4.43 Anatomic septal extension graft.
(a) (b)
(c) (d)

FIGURE 4.45 Pitanguy ligament in the closed technique.
contain cartilage and dermis and it is more of a fascia [52]; and nutritive tissue of the LLCs, and is responsible for sense,
when Pitanguy’s publications are examined, it is evident that movement capability, and the heating mechanism of the nasal
this ligament is actually SMAS tissue (Figure 4.45) [13]. tip [53]. This tissue can be left intact or with minimal distor-
Although this ligament should not be named as such due what tion in the closed technique [13].
it contains, it is nevertheless known as the Pitanguy ligament It does, however, need to be incised to expose the dor-
in the literature because of its historical importance. sum in the open technique. The Pitanguy ligament has
The Pitanguy ligament is an anatomic structure that can be two branches: superficial and deep. The superficial branch
found throughout all populations. The reason why there are extends down close to the columellar skin between the
numerous discussions about this ligament is that it was ini- medial crus, while the deep branch extends down right
tially thought to be a derma-cartilaginous ligament with no before the anterior caudal angle and also unites with the
cartilage and dermis tissues. Because this ligament was a depressor septi nasi muscle (Figure 4.46). This tissue is an
retaining ligament in the nose, its start and end points were envelope rich in blood vessels and lymphatics and can be
likely not fully understood at the time. However, this ligament used as a flap in reconstructive procedures (Figure 4.47).
is responsible for the relation between the nasal tip and nasal Additionally, it can be used for redraping since its start and
dorsum as Pitanguy stated. end points are known.
It is important to respect this tissue because it is neither The Pitanguy ligament in the open technique is shown in
a ligament nor a tendon. Pitanguy tissue is the blood carrier Video 4.10 and in the closed technique in Video 4.11.
FIGURE 4.46 Pitanguy ligament in the open technique and marking of deep and superficial SMAS layers with sutures.
FIGURE 4.47 The SMAS tissue is an important blood vessel carrier that extends from the nasal skin to nasal spine and that can be used in recon-
structive surgery by turning it into a flap.
TABLE 4.6 septal angle after extending cephalically, providing the rela-

The Indications and Contraindications of the Deep SMAS Layer tion between the nasal tip and nasal dorsum. The separation
Suture Technique Are Summarized of this adhesion point causes nasal tip dropping, vertical line
plication causes supratip definition, and horizontal line plica-
Deep SMAS Layer Suture tion causes bulging in the supratip.
Indications Contraindications What is critical is that this adhesion point can be trans-
1 Preserving nasal tip support Secondary cases without posed higher with the deep SMAS layer suture and, in this
mechanisms membranous septum case, nasal tip support and nasal tip rotation can be increased
2 Droopy nasal tip due to long Short nose while the length of the nose can be shortened [13]. The indica-
nose tions and contraindications of the technique are summarized
3 Type 2B saddle nose deformity Cases where nasolabial in Table 4.6.
angle need to be decreased

4.3.9 Deep SMAS Suture
The surgical technique is presented in Video 4.12. When a
The deep SMAS tissue encountered while passing from the hemitransfixion incision is made on the septal mucosa dur-
lower third of the nose to the middle third can also be used to ing a closed nose operation, the area where the deep SMAS
reshape the nose. Deep SMAS tissue that embraces the nasal adheres to the anterior septal angle under the mucosa will be
tip by wrapping the nasal tip cartilages adheres to the anterior exposed (Figure 4.48).
FIGURE 4.48 The attachments of deep SMAS tissue can be held with a loop suture.
FIGURE 4.49 Reattaching of deep SMAS tissue provides a significant amount of tip support and rotation if needed.
The deep SMAS can be used to determine the relationship 1. Repairing the ligament by determining the direct
and angle between the nasal tip and dorsum by holding it with anterior septal angle and former adhesion point;
a loop suture at this stage. After catching it with a 4/0 pds, the thus, the loss of support due to the hemitrans-
deep SMAS tissue in the subperichondrial plane is separated fixion incision on the deep SMAS tissue, which
from the anterior septal angle (Figure 4.49). plays an important role in nasal tip support, is
Two gains are made with this: prevented.
1. The deep SMAS tissue that embraces the nasal tip is 2. If there is still a need to shorten the length of the
now mobile and the nasal tip is mobile. nose or increase the nasal tip angle at the end of the
2. Due to the branches provided by the deep SMAS tis- operation, this suture is stitched on a more cephalic
sue to the skin, the supratip point can be determined point than the anterior septal angle in the nasal dor-
in thick-skinned patients. sum. Thus, the nasal tip rotation and length can be
adjusted. After determining this new point by pal-
A clamp is attached to this stitch and the operation continues. pation, the needle is passed through this point of
After making the necessary maneuvers on the nasal dorsum the nasal dorsum without knotting, a test is made,
and nasal tip, where to sew this stitch is decided during the and the shape that will be provided by the suture is
closing stage of the nose. Two paths can be followed at this seen. If the shape is as intended, then the suture is
point: knotted.
If the importance and effect of this suture are known, then

it is clear how effective it can be in revision surgery. In
revision surgeries with a droopy tip appearance, this liga-
ment’s relation with the supratip, anterior septal angle,
and nasal tip cartilages should be investigated and the
area where the disruption occurred should be revealed
(Figure 4.50).
This suture can be used in the treatment of saddle nose
type 2B, which is the distortion of the relation between the
nasal tip and dorsum due to fact that the caudal angle where
the deep SMAS is adhered to the anterior septal angle was
excised in a previous septoplasty. Therefore, reforming
this relation is the quickest way to correct this deformity
(Figures 4.51–4.52).
FIGURE 4.50 The efficiency of deep SMAS layer suture in the treat-
ment of a secondary case.
(a) (b)
(c)
FIGURE 4.51 (a–c) Before and five years after.

(a) (b)
(c)
FIGURE 4.52 (a–c) Before and three years after.

4.3.10 Perichondrio-SMASectomy
After discussion of nasal bone and cartilage humps in the
nose, the presence of soft tissue hump deformities and their
treatments should also be mentioned.
4.3.10.1
What Is the Soft Tissue Hump:
Where and How Does It Form?
Normally the SMAS tissue is divided into two layers in line
with the supratip break point and scroll ligament and is thick-
ened towards the caudal. However, if it becomes thicker at a
more cephalic level—that is, in the dorsum—then it is called a
soft tissue hump (Figure 4.53) [26].

The diagnosis can be made with the pinch test. When the FIGURE 4.54 A pinch test indicates the soft tissue hump.
nasal dorsum skin is pinched with two fingers, the keystone
skin folds and accumulates on itself due to its thin and elegant
structure. Normally, this accumulation extends to the supra- expecting that such a condition will be corrected with a few
tip, but in the presence of a soft tissue hump, this accumula- mm thinning to be made on the SMAS tissue is a quite opti-
tion ends in the middle of the nasal dorsum (more cephalic) mistic approach. Trimming the SMAS tissue, known as the
(Figure 4.54). debulking procedure, and multiple steroid injections during
SMASectomy can be performed to treat this, but it is dif- the postoperative follow-up period is a treatment approach
ficult to hold and excise the SMAS tissue since it is a spon- recommended in the literature [54]. However, this approach
giform tissue. Additionally, in clinical cases with soft tissue does not seem to provide sufficient success in this patient
hump, the skin and subcutaneous tissues generally have group; additionally, steroid injection also involves many spe-
hypertrophy. As regards the thickness of the SMAS tissue, cific risks.
Removal of the SMAS tissue with the perichondrium
is more suitable for a thick-skinned patient group, and
this approach can provide satisfying results (Figure 4.55,
Video 4.13). The need for steroids can reduced to zero with
this technique. Moreover, perichondriumectomy can be
FIGURE 4.53 There is a soft tissue hump in the lower part of the nose.
If a more definite dorsum and nasal tip are desired, this soft tissue hump
should be dealt with. Red line, the framework; black line, soft tissue hump; FIGURE 4.55 Note how the supratip skin is thinned after
green line, LLC; blue line, transition between ULC and nasal bone. perichondrio-SMASectomy.
FIGURE 4.56 Perichondriumectomy. (b)
(c)
(a) FIGURE 4.57 (a–c) A tertiary female patient with excessively

thick skin and supratip deformity (and in (a) the material of the
perichondrio-SMASectomy). The result indicates the efficiency of
perichondrio-SMASectomy.
safer than SMASectomy in terms of visibility problems if
patients need redraping and have moderate skin thickness
(Figure 4.56). • Perichondrio-SMASectomy rather than classical
Thus, the author classifies the soft tissue manipulation as: debulking procedure
• Perichondriumectomy The surgeon should choose one of them according to the case
• SMASectomy features (Figures 4.57–4.58).
(a)
(b) (c)
(d) (e)
FIGURE 4.58 (a–e) A male patient with thick skin needed severe reduction with perichondrio-SMASectomy. Before and two years after.
4.3.11 Soft Tissue Redraping The only thing that can be done for excess skin to date
is to cover the skin with skin strips and hope it sits in the
Soft tissue redraping is an issue which even an experienced framework. However, another perspective about redraping is
surgeon has difficulty performing and whose results cannot
be predicted.
“If a surgeon can manage the soft tissue, there is nothing

left to fear in rhinoplasty.”
(S. Taş)
Rhinoplasty can be divided into three categories based on the

changes of volume that can be made:
1. Reduction rhinoplasty
2. Augmentation rhinoplasty
3. Finesse rhinoplasty
The previously mentioned soft tissue redraping is necessary

for reduction rhinoplasty. Since no reduction is needed in the
nose volume in other procedures, no excess skin and soft tissue
appear. The most common type of rhinoplasty in the world is
reduction rhinoplasty. A good command of this subject will
directly affect the results to be obtained and the success of the
operation. However, there is not enough data on redraping in
the literature.
In almost all aesthetic surgeries such as abdominoplasty,
brachioplasty, mammoplasty, blepharoplasty, platysmaplasty,
and face-lifting, removing excess skin and leaving the skin FIGURE 4.59 A 50-year-old female patient’s arched nose with a droopy
stretched enables attainment of the intended result. However, tip is shown after a classical reduction rhinoplasty including the removal
of the hump, repair of the roof, and tipplasty. Since skin elasticity is lost
in rhinoplasty, only an alar excision is possible. Since reduction particularly in elderly patients, the shrinking effect of the skin cannot be
of the central part of the nose does not allow for the removal seen and excess skin, red arrows, shows itself in this way. This picture
of skin from there, there is a need for a different approach for highlights the importance of redraping, which makes the result more pre-
redraping (Figure 4.59). dictable for the recovery period.
being developed and can be seen in Video 4.14. The video c.

In the lateral-cephalic part of the nose: The piri-
presents the case of a 56-year-old female who had previ- form ligament that provides the involvement of
ously undergone the open technique. After dissection, when the nasal dorsum skin to the nasal bone on the
the thickness of the soft tissue envelope was redistributed, side can be used for this purpose.
the arched nose and nasal tip of the patient were instantly d.
In the lateral-caudal part of the nose: The verti-
corrected. cal leg of the scroll ligament that provides the
Therefore, the first principle to be understood from redrap- setting of the nasal tip skin on the scroll grooves
ing is to redistribute the soft tissue envelope that cannot be on the sides can be used to redistribute the nasal
removed. Moreover, the soft tissue envelope should be fixed on tip skin.
the underlying bone and cartilage tissue for long-lasting pres- e.
In the nasal base: Re-adaptation of the soft tis-
ervation of the given shape following the redistribution. How sue envelope from holes made on the maxillary
can this be achieved? To answer that, the anatomy should be bone. If an extended dissection was made, the
re-examined to identify suitable points. If suitable points are nasal base may have been widened because the
not selected, then retractions will appear on the skin. Thus, the nose skin expands to the sides even if the nasal
ligaments that provide the relation between the bone cartilage base is narrowed. This maneuver is useful for
roof and soft tissue envelope are necessary. The redistribution preventing this.
process can be performed using these ligaments, thereby re-
fixing the retaining ligaments of the nose similar to interior The surgeon should decide which of these maneuvers are
splinting. needed based on the location and amount of the excess soft
tissue envelope (Figures 4.60–4.62) [26].

The concept of redraping for rhinoplasty is categorized next.
Redraping
1. To redistribute the excess soft tissue envelope, firstly

the area with excess skin should be dissected.
2. Then, the excess soft tissue envelope should be re-
localized and re-fixed in place. This can be further
divided into five areas based on the anatomic struc-
tures and technique to be used.
a. In the central-cephalic part of the nose: The
transition zone providing the setting of the
nasal dorsum skin on the keystone can be
used to redistribute the nasal dorsum skin.
This suturation should be made with a gentle
suture like a 6/0 pds due to the thinness of this
tissue.
b. In the central-caudal part of the nose: The
attachments of deep SMAS tissue in the anterior
septal angle that provides the setting of the nasal
tip skin on the supratip can be used to redistrib- FIGURE 4.60 Excess soft tissue envelop was adapted with redraping
ute the nasal tip skin [13]. made on the lateral-caudal part.
(a) (b)
FIGURE 4.61 (a) Using the vertical leg of the scroll ligament for redraping in the lateral-caudal part of the nose. (b) Definition was achieved by
redraping, although a severe reduction has been carried out.
(a) (b)
(c) (d)
FIGURE 4.62 (a–d) Before and two years after.
4.4 Use of Electrocautery in Rhinoplasty

Pinpoint monopolar cautery is commonly used to perform a
bloodless operation in rhinoplasty ranging from mucosal inci-
sion to subcutaneous dissection. Thus, electrocautery can be
used in a suitable energy and mode in rhinoplasty. The most
important benefits are:
1. Due to the resistance of the cartilage-bone tissue,

while the perichondrial and periosteal membranes
can easily cut with electrocautery, the bone and car-
tilage tissues persist; thus, it would be easier to per-
form a submembranous dissection.
2. In the case of a thick ala and footplate or in soft tis-
sue asymmetries (Figure 4.63), electrocautery can
be used for tightening the subcutaneous tissue with a
very low energy level; thus, small asymmetries can
be corrected without performing excisions or graft- FIGURE 4.63 Tissue excess in the ala and sill area negatively affects
ing (Figure 4.64, Video 4.15). the aesthetic nostril image and the function because of bulging.
nasalis muscle has been named the blinking nose deformity. In

this scenario, the nasal tip acts like a pulsative organ and plays
rhythmically with the eyelid movements. The diagnosis of the
deformity is made with inspection (Video 4.16).
The mechanism behind blinking nose deformity is
probably the same as that of unintentional facial tics. The
clinical importance of this deformity is that the nasal tip
and dorsum are dissected in rhinoplasty, and the nasal tip
skin may not settle on the supratip groove properly due to
the muscle that contracts on the nasal tip with the blinking
movements in the recovery period, creating the appearance
of a supratip deformity. Therefore, the author recommends
to inject botulinum toxin and deactivate the muscle until the
recovery period of the muscle is completed or dissect it dur-
ing the operation.
The responsible muscle in 51 of the 52 patients treated by
the author for this deformity was the dilator naris anterior
muscle. In one instance, it was the transversalis nasalis mus-
cle. Almost half the cases were bilateral muscle activity, and
the remaining were unilateral. Twelve percent of the patients
were male and 88% were female. None of the patients was
aware of this deformity until it was mentioned by the author;
thus, patients are generally not uncomfortable about this
deformity.
The treatment of this deformity is of great importance in
thick-skinned patients because if there is blinking nose defor-
mity in this group for whom the risk of postoperative supratip
deformity is high and it is not treated, then the occurrence of
(a) supratip deformity is inevitable.
4.5.1 Surgical Anatomy

The dilator naris anterior muscle is actually a pair of muscles
adhered to the rim skin and crossing the LLC located on both
laterals of the nasal tip (Figure 4.65). The main dilator of
the nasal tip is the dilator naris posterior. Thus, no complica-
tions occur due to the dissection of the dilator naris anterior
muscle.
(b)
FIGURE 4.64 (a) Using electrocautery for sill bulging. (b) Before and
two years after.
4.5 Blinking Nose Deformity and Its Treatment

The contraction correlated with the bilateral or unilateral
blinking of the dilator naris anterior muscle or transversalis FIGURE 4.65 The muscle anatomy of the nose.
4.5.2 Surgical Technique

Preoperatively marking the path of the muscle while see-
ing the contraction of the muscle when the patient is awake
will ease finding the muscle during the operation. After
performing tipplasty on the submembranous plane by enter-
ing from the inferior intracartilaginous incision, and before
proceeding to the closure, a retrograde dissection is made
towards the rim and the muscle is exposed (Figure 4.66,
Video 4.17). This muscle which vertically passes the LLC is
cauterized and then dissected. A piece can be removed so that
its edges will not adhere to each other again (Figure 4.67,
Video 4.18).
Important Note 1: A botulinum toxin injection was pre-
ferred in the case where the transversalis nasalis muscle was
responsible. This case is shown in Video 4.19.
Important Note 2: If a blinking nose deformity is not
treated, a supratip deformity will appear despite all measures
taken. This case sample is shown in Video 4.20. A 28-year-
old male patient was operated on two years previously, and
the supratip deformity is visible despite the skin care and
banding techniques used in the postoperative period. The
powerful contraction of the muscle is remarkable. The con- FIGURE 4.66 Upper, exposing dilator naris anterior muscle. Lower,
traction does not allow the dissected supratip skin to settle on the route of the muscle is indicated by the scissors.
this groove, the skin shortens itself, and the supratip between
both parts of the dilator naris anterior muscle is herniated.
The patient received botulinum toxin and steroid injections,
which were beneficial. 4.10 The Pitanguy ligament in the open technique.
4.11 The Pitanguy ligament in the closed technique.
VIDEOS 4.12 Treatment of deep SMAS tissue.
4.1 Lateral overlapping procedure and suture. 4.13 Perichondrio-SMASectomy.
4.2 V-Y advancement flap. 4.14 The effect of redraping in rhinoplasty.
4.3 Double layer graft was applied in the shown case. 4.15 Correcting small asymmetries.
4.4 Correction of caudal malposition. 4.16 Blinking nose deformity.
4.5 Closed technique tip surgery. 4.17 Exposure of dilator naris anterior muscle.
4.6 ST flap. 4.18 Blinking nose deformity by transversalis muscle,
4.7 ST flap (animation). which needs botulinum toxin injection.
4.8 Correction of convexity of the LLC. 4.19 Unilateral blinking nose deformity.
4.9 The anatomic strut. 4.20 Blinking nose deformity causing supratip deformity.
(a) (b)
(c) (d)
REFERENCES 4. Kridel RW, Scott BA, Foda HM. The Tongue-in-Groove

1. Roe JO. The Deformity Termed “Pug Nose” and Its Technique in Septorhinoplasty. A 10-Year Experience. Arch
Correction, by a Simple Operation. Med Rec. 1887; 31: 621. Facial Plast Surg. 1999 Oct–Dec; 1(4): 246–56.
2. Joseph J. Nasenplastik und sonstige Gesichtsplastik nebst 5. Goldman IB. The Importance of the Medial Crura in Nasal-
einem Anhang uber Mammaplastik. Verlag von Curt Tip Reconstruction. AMA Arch Otolaryngol. 1957 Feb.
Kabitsch: Leipzig, 1928–1931.
65(2): 143–7.
3. Fred GB. The Nasal Tip in Rhinoplasty: Use of the
Invaginating Technique to Prevent Secondary Drooping. 6. Anderson JR. The Dynamics of Rhinoplasty. In: Proceedings
Ann Otolaryngol. 1950; 59: 215–23. of the Ninth International Congress of Otorhinolaryngology,
Exerpta Medica International Congress Series, No. 206, 27. Garcia-Velasco J, Vidal JT, Garcia-Casas S. Increasing
Amsterdam, Exerpta Medica, 1969: 708–10. the Length of the Middle Crura for Better Tip Projection
7. Anderson JR. A Reasoned Approach to Nasal Base Surgery. in Primary Rhinoplasty. Aesthet Plast Surg. 1998; 22: 253–8.
Arch Otolaryngol. 1984; 110: 349–58. 28. Boccieri A. Mini Spreader Grafts: A New Technique
8. Sheen JH. Achieving More Nasal Tip Projection by the Use Associated with Reshaping of the Nasal Tip. Plast Reconstr
of a Small Autogenous Vomer or Septal Cartilage Graft. Surg. 2005; 116: 1525–34.
A Preliminary Report. Plast Reconstr Surg. 1975 July; 29. Ashtiani AK, Bohluli B, Bateni H, Fatemi MJ, Sadr-
56(1): 35–40. Eshkevari P, Rashad A. Lateral Crural Transposition
9. Peck GC. The Onlay Graft for Nasal Tip Projection. Plast Flap in Tip Correction: Tehran Retrospective Rhinoplasty
Reconstr Surg. 1983 Jan; 71(1): 27–39. Experience. Ann Plast Surg. 2013; 71: 50–3.
10. McCollough EG, English JL. A New Twist in Nasal Tip 30. Tellioglu AT, Cimen K. Turn-in Folding of the Cephalic
Surgery. An Alternative to the Goldman Tip for the Wide or Portion of the Lateral Crus to Support the Alar Rim in
Bulbous Lobule. Arch Otolaryngol. 1985 Aug; 111(8): 524–9. Rhinoplasty. Aesthet Plast Surg. 2007; 31(3): 306–10.
11. Tardy ME Jr, Patt BS, Walter MA. Transdomal Suture 31. Janis JE, Trussler A, Ghavami A, Marin V, Rohrich RJ,
Refinement of the Nasal Tip: Long-Term Outcomes. Facial Gunter JP. Lower Lateral Crural Turnover Flap in Open
Plast Surg. 1993 Oct; 9(4): 275–84. Rhinoplasty. Plast Reconstr Surg. 2009; 123: 1830–41.
12. Tebbetts JB. Primary Rhinoplasty: Redefining the Logic 32. Sazgar AA, Most SP. Stabilization of Nasal Tip Support in
and Techniques. 2nd edition. Mosby: St. Louis, 2008. Nasal Tip Reduction Surgery. Otolaryngol Head Neck Surg.
13. Taş S. A New Way For Supporting Tip Projection in Closed 2011; 145: 932–4.
Rhinoplasty: Using the Medial Deep SMAS Layer. Plast 33. Ozmen S, Eryilmaz T, Sencan A, Cukurluoglu O, Uygur
Reconstr Surg. 2014 Jan; 133(1): 76e–7e. doi: 10.1097/01. S, Ayhan S, Atabay K. Sliding Alar Cartilage (SAC) Flap:
prs.0000436809.88659.e0. A New Technique for Nasal Tip Surgery. Ann Plast Surg.
14. Taş S. Modification of the Lateral Crural Suspension Flap. 2009 Nov; 63(5): 480–5.
J Oral Maxillofac Surg. 2014 May; 72(5): 846–7. doi: 34. Bohluli B, Varedi P, Nazari S, Bagheri SC. Lateral Crural
10.1016/j.joms.2013.10.027. Epub 2014 Mar 3. Suspension Flap: A Novel Technique to Modify And
15. Taş S. Superior-Based Transposition Flap: A Novel Stabilize the Nasolabial Angle. J Oral Maxillofac Surg.
Technique in Rhinoplasty. Aesthet Surg J. 2019 June 21; 2013 Sep; 71(9): 1572–6.
39(7): 720–32. doi: 10.1093/asj/sjy197. Epub 2018 Aug 10. 35. Kuran I, Öreroğlu AR, Efendioğlu K. The Lateral Crural
16. Santareno S, Taş S. Concept of Anatomic Columellar Rein Flap: A Novel Technique for Management of tip
Strut Grafting in Rhinoplasty: An Algorithmic Approach. Rotation in Primary Rhinoplasty. Aesthet Surg J. 2014 Sep;
Aesthet Surg J. 2020 Jan 29; 40(2): NP65–NP71. doi: 34(7): 1008–17.
10.1093/asj/sjz272. 36. Tardy ME. Sculpture of the Nasal Tip. Saunders:
17. Taş S. Response to “Anatomic Columellar Strut, an Philadelphia, PA, 1996. Rhinoplasty: The Art and the
Alternative Paradigm?” Aesthetic Surg J. 2020: 1–3. doi: Science; vol. II.
10.1093/asj/sjaa088. 37. McCollough EG, Mangat D. Systematic Approach
18. Sheen JH, Sheen AP. Aesthetic Rhinoplasty. 2nd edition. to Correction of the Nasal Tip in Rhinoplasty. Arch
Quality Medical Publishing: St Lois, 1998. Otolaryngol. 1981; 107: 12–16.
19. Gunter JP, Yu YL. The Tripod Concept for Correcting 38. Nagarkar P, Stark RY, Pezeshk RA, Amirlak B, Rohrich RJ.
Nasal Tip Cartilages. Aesthet Surg J. 2004; 24: 257–60. Role of the Cephalic Trim in Modern Rhinoplasty. Plast
20. Gunter JP, Rodrich RJ, Friedman RM. Classification Reconstr Surg. 2016; 137: 89–96.
and Correction of Alar Columellar Discrepancies in 39. Gunter JP, Friedman RM. Lateral Crural Strut Graft:
Rhinoplasty. Plast Reconstr Surg. 1996; 97: 643–8. Technique and Clinical Applications in Rhinoplasty. Plast
21. Guyuron B. Alar Rim Deformities. Plast Reconstr Surg. Reconstr Surg. 1997; 99: 943–55.
2001 Mar; 107(3): 856–63. 40. Gruber RP, Nahai F, Bogdan MA, Friedman GD. Changing
22. Taş S. The Alignment of the Nose in Rhinoplasty: Fix Down the Convexity and Concavity of Nasal Cartilages and
Concept. Plast Reconstr Surg. 2020 Feb; 145(2): 378–89. Cartilage Grafts with Horizontal Mattress Sutures, part
doi: 10.1097/PRS.0000000000006523. Epub 2019 Nov 19 II: Clinical Results. Plast Reconstr Surg. 2005; 115:
23. Hamra ST. Repositioning the Lateral Alar Crus. Plast 595–608.
Reconstr Surg. 1993 Dec; 92(7): 1244–53. 41. Tebbetts JB. Shaping and Positioning the Nasal Tip Without
24. Constantian MB. The Boxy Nasal Tip, the Ball Tip, and Structural Disruption: A New, Systematic Approach. Plast
Alar Cartilage Malposition: Variations on a Theme-a Study Reconstr Surg. 1994; 94: 61–77.
in 200 Consecutive Primary and Secondary Rhinoplasty 42. Tardy ME, Garner ET. Inspiratory Nasal Obstruction
Patients. Plast Reconstr Surg. 2005; 116(1): 268–81. Secondary to Alar and Nasal Valve Collapse: Technique for
25. Davis RE. Lateral Crural Tensioning for Refinement of the Repair Using Autogenous Cartilage. Oper Tech Otolaryngol
Wide and Underprojected Nasal Tip: Rethinking the Lateral Head Neck Surg. 1990; 1: 215–18.
Crural Steal. Facial Plast Surg Clin North Am. 2015; 23: 23–53. 43. Toriumi DM, Josen J, Weinberger M, Tardy ME Jr. Use of
26. Taş S. Closed Atraumatic Rhinoplasty Course. Endorsed Alar Batten Grafts for Correction of Nasal Valve Collapse.
by RSE (Rhinoplasty Society of Europe) and ISAPS Arch Otolaryngol Head Neck Surg. 1997; 123: 802–8.
(International Society of Aesthetic Plastic Surgery). 44. Rohrich RJ, Liu JH. The Dorsal Columellar Strut:
Istanbul, Turkey, Nov 16–17, 2019. https://drsuleymantas. Innovative Use of Dorsal Hump Removal for a Columellar
com/course/ Accessed 11 Aug 2019. Strut. Aesthet Surg J. 2010; 30(1): 30–5.
45. Topkara A. Three-Dimensional (3D) Columellar Strut Graft 50. Pitanguy I, Salgado F, Radwanski HN, Bushkin SC.
In Rhinoplasty. Aesthet Surg J. 2017; 37(4): 398–406. The Surgical Importance of the Dermocartilaginous Ligament
46. Robotti E, Choc IS, Jaber O. Use of the “Septal T” as a of the Nose. Plast Reconstr Surg. 1995 Apr; 95(5): 790–4.
Spacer and Conformer for a Properly Contoured Nasal Tip 51. Pitanguy I. Revisiting the Dermocartilaginous Ligament.
in Rhinoplasty. Aesthet Surg J. 2017; 37(1): 122–7. Plast Reconstr Surg. 2001 Jan; 107(1): 264–6.
47. Lehao W, Huan W, Jianjun Y. Anatomic Columellar 52. Han SK, Jeong SH, Lee BI, Kim WK. Updated Anatomy of
Strut, an Alternative Paradigm? Aesthet Surg J. 2020. doi: the Dermocartilaginous Ligament of the Nose. Ann Plast
10.1093/asj/sjaa024. [Epub ahead of print]. Surg. 2007 Oct; 59(4): 393–7.
48. Taş S. Response to “Anatomic Columellar Strut, an 53. Pshenisnov KP. Commentary on ‘‘Comparison of Various
Alternative Paradigm?” Aesthetic Surg J. 2020: 1–3. doi: Rhinoplasty Techniques and Results of Long-Term’’.
10.1093/asj/sjaa088 Aesthetic Plast Surg. 2015 Aug; 39(4): 478–82.
49. Pitanguy I. Surgical Importance of a Dermocartilaginous 54. Chu E, Davis RE. SMAS Debulking for Management of the
Ligament in Bulbous Noses. Plast Reconstr Surg. 1965 Thick-Skinned Nose. JAMA Facial Plast Surg. 2015 July–
Aug; 36: 247–53. Aug; 17(4): 305–6.
5
Alar Base Surgery Alar Base SurgeryRhinoplasty in Practice
5.1 Alar Excision Sheen [2] categorized the orientation of alar wings into
three (Figure 5.2):
The nasal tip is anatomically formed by the ala, tip, colu-
mella, footplate, sill, soft triangle, rim, and alar sulcus areas Type A: Divergent (flared)
(Figure 5.1). The nasal base is formed by the ala, sill, and Type B: Straight
footplate. These three anatomic structures do not contain any
Type C: Convergent (acute)
cartilage or bone tissue, only skin as well as soft and fibrous
tissues. Type B is accepted to be the most aesthetic among these.
Alar excision was first reported by Weir [1] in 1892. The Medialization of the nostrils, or narrowing the base, is only
excision techniques used since then have improved in many recommended for Type A. Interventions to be made to nar-
areas such as quality and scar concealment. row the alar base may result in Type C, which is another base
Alar excision is made for the following reasons: anomaly if the soft tissue balance is not adjusted or if the
sutures are not duly stitched.
1. Narrowing the alar base
2. Rotating the ala up and/or down The Indications for Performing an Alar Base Excision for
3. Correcting alar asymmetry Aesthetic Purposes
4. Adjusting nostril size
5. Adjusting the nasolabial sulcus adhesion point of the 1. Cases in which there is a wide alar base (where the
ala alar base is wider than the intercanthal distance); the
6. Repairing cleft lip-nose cases decision whether this distance is normal should be
made by comparing it with the horizontal length of
In all these conditions, alar base excision should be designed the eye
especially for the individual patient. 2. Cases in which the alar wings are beyond the inter-
canthal distance despite the fact that the alar base
(the adhesion base of the wings) is within this dis-
tance; this is known as alar flaring
In some cases, although alar excision may not have been

necessary pre-surgery, since the nasal base widens as nose
projection decreases, alar excision may need to be made
at the end of the surgery. Therefore, patients should be
FIGURE 5.1 Alar base anatomy: yellow, lobule; orange, columella;

pink, footplate; blue, sill; red, ala; white, rim; green, soft triangle/facet; FIGURE 5.2 Alar wing orientation: Type A, flaring base; Type B, nor-
turquoise, columellar base; black, nostril. mal; Type C, improperly narrowed.
DOI: 10.1201/9781003174165-5
115
informed that as situations change, the possibility of alar

excision as the last stage of surgery is possible. If there
is too much tissue swelling at the end of the surgery, or
if the surgeon is not certain whether to perform the exci-
sion, the literature agrees that alar excision should not be
done because it can be performed more clearly in the future
under local anesthesia [3].
5.1.1 Algorithm
An algorithm formulated by Taş to narrow the alar base
for cosmetic purposes is shown in Figure 5.3. According
to that:
• If there is a wide alar base deformity, in order to

understand whether the deformity can be solved
using an alar base narrowing suture or whether alar
base excision is needed (and if so, what type of exci-
sion should be made), the surgeon should use the
finger test. If the test indicates excessive skin, a chili-
fashion excision should be done to narrow the base.
FIGURE 5.4 A chili-fashion excision narrowing the alar base is shown
If there is no excessive skin, the alar base narrowing
in a patient with wide alar base.
suture will be enough (Figure 5.4).
• If there is alar flaring, a banana-fashion excision,
which is more suitable for alar base anatomy, should
the marking, it will distort the tissues and prevent the surgeon
be made to create an invisible scar by preventing
from noticing whether any redistribution-shifting is necessary
suture line tension (Figure 5.5).
on the incision lines during closing or whether possible asym-
• If there are both wide base and alar flaring, then a metries may form.
combination of the banana-fashion excision and alar Marking is the most important stage in alar base excision.
base narrowing suture is recommended. If marking is not done carefully, asymmetry is inevitable. The
first anatomic landmark to be considered while planning the
alar base excision is the alar groove. In this way, the scar set-
tles on the groove and becomes invisible no matter how the
Video 5.1 details the surgical technique. First, as opposed to incision is made.
the norm, no local injection should be made on the excision
line after marking. Although a local injection does not distort
FIGURE 5.5 A banana-fashion excision shortening the alar wing length

FIGURE 5.3 Alar excision algorithm. is shown in a patient with alar flaring.
Alar Base Surgery 117
To determine excess skin on the alar base, push the wing

toward the midline with one finger. Any skin fold on the alar
base may give an idea about the amount and line of tissue to
be removed [4].
Alar excisions higher than the level where the alar groove
meets the nasolabial groove tend to be exposed, meaning
that excisions should not be done higher than this point. In
addition to exposing the scar, excisions superior to the alar
groove may cause the lateral nasal artery to be cut and risk
circulation on the nasal tip, particularly in open technique
surgeries [5].
As noted, the chili- or banana-shaped excision are recom-
mended instead of the classical elliptical excision because the
elliptical excision may cause tension on the midline, creating
the possibility of a visible scar. However, chili- or banana-
shaped excisions cause the least strain, resulting in a higher
scar quality (Figure 5.6). After making the skin incision
with a scalpel, electrocauterizing with a micro-needle for the
excision will prevent bleeding. The excision should be made
containing the skin and subcutaneous tissue, but the muscle
should be preserved.
Following bleeding control, subcutaneous sutures are
FIGURE 5.6 Upper left, a patient with wide base, alar flaring, severe inserted. Using a minimum of two sutures is one of the most
nostril asymmetry, and thick skin at the start of the operation. Upper effective factors on scar quality. The subcutaneous suture is
right, the patient marked for banana-fashion excision at the end of the
stitched with 4/0 Poliglecaprone and placed in such a way
operation. Lower left, after the excision planned from the right alar wing,
the new alar border is demonstrated with a finger, and it can be seen how that the knot is on the inside to prevent suture reaction and
effective the alar base narrowing has been. Lower right, the final result. extrusion.
It should be remembered that the inner diameter of the ellip-
tical incision is always wider than the outer diameter during
Some surgeons recommend preserving the groove and closing due to the anatomical structure of the nostril base.
locating the incision 1–1.5 mm above the groove, but this Therefore, the redistribution technique—among the most
will cause worse scarring; therefore, using the existing basic principles of plastic surgery—should be used for clos-
natural path for this purpose is more logical. After the alar ing the incision to prevent dog-ear formation. Skin sutures are
groove is marked, the line of the tissue to be removed is stitched using 6/0 proline and should be removed on the sev-
determined. enth day to avoid stitch marks (Figure 5.7–5.8).
(a) (b)
(c) (d)

(a) (b)
(c) (d)

5.2 Alar Base Narrowing Suture

This suture is of great importance, particularly in ethnic rhino-
plasty, because it prevents making excisions on the sill area and
enables the aesthetically intended narrowness (Figure 5.9).
The alar base is an equilateral triangle from below, and if the
alar base distance is made narrower than the sidewall distance,
then a condition called the bowling pin deformity [2] appears.
This deformity is called such because the condition resembles
a reverse bowling pin. FIGURE 5.10 Schematic drawing of the alar base narrowing suture.
Some surgeons are of the opinion that the alar base suture
will provide a more effective narrowing when performed after 3. The needle of the suture goes subcutaneously from
the release of both sides of the alar base [6]. the right elliptical incision, exiting from the hemi-
transfixion incision
5.2.1 Surgical Technique 4. The needle of the suture passes through from the
hemitransfixion incision to left elliptical incision
Firstly, the alar base is narrowed from the sides with two fin- 5. The left alar base is gripped, and the needle goes back
gers and placed in the intercanthal distance. Whether there subcutaneously to exit from the hemitransfixion incision
is folded excess skin on the alar groove should be checked.
6. The suture is stitched; the knot is fixed on the caudal
If there is, it indicates that both alar and alar base narrowing
septum to prevent mucosa irritation
sutures are required (Video 5.2).
If no skin excision is required, then a bilateral small ellipti-
cal incision is made on the vestibular side of the alar groove,
providing sufficient area to grip the alar base with a suture. 4/0 5.3 Providing Symmetry on Vertical,
Polydioxanone should be used for this procedure because other Horizontal, and Sagittal Planes
permanent sutures may cause problems in the long term.
Nasal asymmetries are divided into static and dynamic prob-
lems based on the mechanics of how they arise. Static prob-
The Suture Follows These Stages (Figure 5.10) lems include asymmetries where bone, cartilage, and ligament
1. The needle of the suture first enters from the hemi- tissue are affected; dynamic problems include asymmetries
transfixion incision and goes subcutaneously, exiting due to muscle tissue.
from the elliptical incision made on the vestibular As the nose is a 3D structure existing on three planes, each
base plane should be examined separately in order to better under-
2. The needle of the suture bites the right alar base stand nasal asymmetries (Figure 5.11). Thus, the asymmetries
FIGURE 5.9 The efficiency of alar base narrowing suture in an ethnic

rhinoplasty patient. FIGURE 5.11 Three-dimensional anatomical planes of the nose.
are divided into three: vertical, horizonal, and sagittal plane

asymmetries (Figure 5.12).
Vertical plane asymmetries are further divided into two
subgroups of the deviated nose and crooked nose, which were
elaborated in Chapter 3 (Figures 5.13–5.14).
Horizontal and sagittal axis asymmetries are not well-
defined in the literature. However, a number of studies have
been published by the author to clarify them [7–9].
FIGURE 5.12 Three-dimensional and component classification of nasal

asymmetries.
(a) (b)
(c) (d)

(a) (b)
FIGURE 5.14 (a–b) Before and 2.5 years after.
5.3.1 Alar Base Retraction such excisions on the already retracted side will pull up the
nose instead of pulling down the alar base and will increase
Horizontal plane asymmetries are clinically encountered with the asymmetry.
alar base retraction. The cephalic malposition of the alar base The diagnosis is clinically made using the alar base pull
on the vertical plane is called alar base retraction [7]. It can down test (Video 4.3). The deformity is exaggerated when the
easily be detected by drawing a line which is tangential to patient smiles. The deformity is limited to the nasal base in
the nasal base (Figure 5.15). Its classic treatment in the lit- mild cases; alar base retraction in severe cases may include
erature is an elliptical excision from the alar base. However, the nasolabial groove, upper lip, and lip closure of that side
(Figures 5.16–5.17) [7–8].
FIGURE 5.15 A case with right alar base retraction. Red horizontal
lines, height of the right alar base, compared to the left alar base. The FIGURE 5.16 Upper left, a patient with left alar base retraction. Upper
fact that the right upper cupid bow is higher than the left one shows the right, exaggerated deformity when the patient smiles. Lower left, alar
severity of the deformity. Blue line, the vertical axis; yellow arrow, the base pull down test. Lower right, alar base pull down test while the
gap on the right lip closure. patient is smiling.
(a) (b)
FIGURE 5.17 (a–b) Before and five years after views of the patient shown in Video 5.3; the upper lip has been corrected as well as the left alar base.
Soft tissue anatomy of the alar base contains static and

dynamic components. The pyriform ligament is the most
important structure of the static component (Figure 5.18).
The dynamic component of the alar base contains four mus-
cle groups which are depressors, elevators, compressors, and
dilators. The most important of them, which determines the
position of the alar base, is the levator alaeque nasi muscle
(LANM). This muscle originates from the frontal process of
the maxillary bone and passes caudally along the base line of
the nose, dividing into the medial and lateral before adhesion.
The medial part adheres to the lateral nostril while the lateral
part adheres to the orbicularis oris muscle. Therefore, short-
ness of this muscle may affect the upper lip (Figure 5.19).
The LANM is innervated by the zygomatic and superior buc-
cal branches of the facial nerve. Arterial circulation is provided
by the infraorbital branch of the facial artery and maxillary
FIGURE 5.18 Left, pyriform ligament (L), nasal muscle (NM), vault
(V). Right, transversalis muscle (TN), levator alaeque nasi muscle (LA), FIGURE 5.19 LLANM is presented. As can be seen, there is only one
levator labii superioris muscle (LL), depressor septi nasi muscle (DS), muscle that crosses the nose in vertical plane; thus, focusing on this mus-
orbicularis oris muscle (O), alar muscle (A), levator anguli oris (L). cle for an asymmetry that formed on the horizontal plane will be logical.
artery. In daily life, this muscle forms the facial expressions 2. If the alar base retraction is 2 mm or less:
related to sneering and snoring. Previous electromyographic a. If the nose is crooked, again dissecting of the
studies have revealed that the LANM is primarily a mimetic LANM should be performed.
muscle and has no functional contribution [10]. Again, if func- b. If the nose is deviated, then the alar base should
tional loss is suspected, the risk can be eliminated by placing a be released with a rim graft insertion. The reason
rim graft on the side where the muscle is dissected. for placing a rim graft even though no muscle is
The effects of the perinasal muscles, which constitute the incised is that rim graft eases the alignment of a
dynamic component of the soft tissue anatomy of the alar base, deviated nose.
are seen in Bell’s palsy. In addition to innervation loss in all the
c. If the nose is non-deviated, then the release of
facial mimetic muscles on that side, the alar base goes down and
the alar base will be sufficient.
the nasolabial fold becomes flat. Nostril collapse and inspiration
problems also occur due to loss of function in the dilator naris 3. If the alar base retraction is accompanied by maxil-
muscle. However, total nostril collapse does not occur on the lary hypoplasia
paralyzed side because the cartilage and ligament systems and a. A maxillary augmentation should be made here
static components do not allow this. The piriform ligament, rising with either cartilage grafting or fat injection.
from the piriform aperture and lying on the lateral cartilage and
alar base, is the most important structure in this ligament system. 5.3.3 Releasing the Levator Alaeque Nasi Muscle
The treatment algorithm for alar base retraction is presented
5.3.3.1 Surgical Anatomy
in Figure 5.20. This algorithm was developed based on the
The levator alaeque nasi, transversalis nasalis, nasalis, and procerus
amount of alar base retraction, accompanying nose crooked-
muscles form a muscle triangle on the lateral wall of the nose [11].
ness, presence of maxillary hypoplasia, and the response to the
treatment, and was refined over large case series. • The LANM originates from the periosteum of the
frontal process of the maxillary bone at the level of
5.3.2 Algorithm the medial canthus and follows the nasal bone base
reaching to the alar base. The transversalis nasalis
1. If the alar base retraction is more than 2 mm:
muscle (TNM), on the other hand, goes down from
a. It is necessary to dissect the LANM. A rim graft the supratip toward the LANM and forms a modi-
can be placed on that side to prevent a possible olus on the alar base. This modiolus can be called
function problem. the “lateral modiolus”. The angle of this modiolus is
b. This procedure mostly corrects alar base retrac- approximately 90 degrees (Figure 5.21).
tion up to 5 mm, but if there is a more severe
case, then the LANM of the side without alar
base retraction should be plicated; in this way,
obtaining the intended results will be possible
even in most severe cases.
FIGURE 5.21 Muscle triangle on the lateral wall of the nose is shown
FIGURE 5.20 Treatment algorithm for alar base retraction. with its modioli.
• The nasalis and TNM form the second modiolus on

the supratip. This modiolus can be called the “cen-
tral modiolus”. The angle of this modiolus is approxi-
mately 60 degrees.
• The nasalis muscle rises from the central modiolus
and extends cephalically. The procerus muscle pro-
gresses caudally and meets the nasalis muscle at
the lateral keystone. Before this meeting point, both
muscles get thinner and ligament-like (Video 5.4).
• A closer look at this anatomy reveals that these four
muscles form a triangular shape. However, this mus-
cle triangle has two modioli, since there is no direct
relationship between the procerus muscle and the
LANM in the most cephalic corner of the triangle,
but there are some indirect fibrosis septas between
them. Thus, this corner can be called a “pseudo-
superior modiolus”. The angle of this indirect modio-
lus is approximately 30 degrees.
• The projection of the lateral modiolus corresponds
with the internal lateral osteotomy incision. So, to
reach the LANM, a dissection through the supra-
periosteal plane should be made approximately
2–3 mm cephalically after the internal lateral oste-
otomy incision. Otherwise, the lateral modiolus or
TNM will be exposed, and this has critical impor-
tance; dissection of the TNM rather than the LANM
can cause the alar base to shift laterally instead of
pulling down.
• When dissection is progressed further from the FIGURE 5.22 Levator labii superioris muscle is presented.
levator alaeque muscle, the levator labii superioris
muscle over the maxilla is reached (Figure 5.22).
It is nearly impossible to mistake this muscle for others, if

there is sufficient knowledge of anatomy. There are, however,
some tips that help to make the distinction:
1. Fibrils of the LANM vertically extend from the

cephalic to the caudal end; thus, if the dissected
muscle is parallel to the dissection line, then it is the
LANM. Fibrils of the TNM extend from the nasal
dorsum toward the lateral modiolus, so the verti-
cal fibrils on the incision line indicate the TNM
(Figure 5.23). If the direction of the muscle fibrils
cannot be distinct, then it means that surgical expo-
sure is on the lateral modiolus. When extended dis-
section is made on the nasal dorsum, the difference
between these two muscles is more clearly seen
(Video 5.5).
2. Stimulating the muscle using a monopolar electro-
cautery at a very low power setting (e.g., at 6 J, where
coagulation and cutting functions tend not to work)
enables contraction. If the muscle contracts up to the
FIGURE 5.23 The levator alaeque nasi muscle and transversalis nasa-
medial canthus (Video 5.6), then it is the LANM. If lis muscle were marked with a marker, and lateral modiolus was shown
it retracts toward the nasal dorsum, this indicates that endoscopically. Note the specific extension directions of the muscle
it is the TNM. fibers.
5.3.3.2 Surgical Technique made from the muscle, the alar base is pulled down by releas-
ing it from the subperiosteal plane with elevator (Figure 5.26,
Dissection of the LANM can be performed at the beginning Videos 5.7–5.9).
or end of the operation (Figure 5.24). After the LANM is If sufficient horizontal axis symmetry is not ensured
exposed through the internal lateral osteotomy incision, it is through the dissection of LANM, then the plication of
delivered out using mosquito or elevator forceps; however, if LANM should be made on the other side of the alar base
the surgeon has sufficient understanding of the orientation of (Figure 5.27).
the muscle, delivering can be omitted (Figure 5.25). The LANM is plicated and shortened by stitching a loop
To prevent bleeding due to the excision, a 0.5–1 cm muscle suture with 5/0 Polydioxanone. In this way, the alar base is
segment is coagulated using bipolar electrocautery before rotated upwards cephalically (Video 5.10).
excision. If no excision is made from the muscle, the stump A botulinum toxin-A injection can also be used to
ends of the muscle may stick to each other during the recov- treat alar base retraction without an operation. However,
ery period and retract the alar base again. After an excision is its effect is temporary, meaning the patient must be seen
more frequently. The result obtained with this treatment
provides 2–3 mm benefit and does not ensure definite
FIGURE 5.24 A patient with right alar base retraction and its correction
demonstrated schematically.
FIGURE 5.26 Before and five years after.
FIGURE 5.25 The parallel course of the levator alaeque nasi muscle FIGURE 5.27 Horizontal axis symmetry was achieved with the levator
fibers exposed through the internal lateral osteotomy incision indicates muscle dissection on the right alar base and levator plication on the left
that the muscle found is the levator alaeque nasi muscle. alar base.
treatment. If this injection is preferred, it must be applied

in the same way as surgery. The injection should be made
on the body of the LANM rather than that alar base, and
special care should be taken to avoid the angular artery.
As this artery is located on the surface of the LANM, if it
is damaged, the botulinum toxin will disperse, causing a
possible drop in the upper lip and flattening in the naso-
labial fold.
Playing with the LANM and alar base position can be lik-
ened to a puppet show, and it is possible to correct horizon-
tal axis symmetry with this pair of muscles that rise from the
medial canthal level and adhere to the alar base.
An ultrasonic study was conducted to reveal the relation-
ship between the LANM and alar base retraction. The fact
that there was alar base retraction as well as the shortness
of the muscle on the retracted side in this study endorses
focusing on this muscle for the correction of this deformity
(Figures 5.28–5.30).
FIGURE 5.28 Ultrasonographic study conducted by the author, reveal-

ing the high correlation between the amount of alar base retraction and
levator muscle shortness.
(a) (b)
(c) (d)
FIGURE 5.29 (a–d) Before and one year after.
(a) (b)
(c) (d)

FIGURE 5.32 The contribution of the rim graft to correcting the

deviation.
after making excisions from the ligament to prevent recurrence

in the recovery period (Video 5.11). Combining rim graft with the
technique will help to treat the deviations (Figures 5.32–5.34).
FIGURE 5.31 Release of the alar base after the dissection of the piri-
form ligament was demonstrated.
5.3.4 Releasing the Piriform Ligament

If the alar base retraction is 2 mm or less and if there is no
accompanying crooked nose deformity, then releasing the piri-
form ligament will be sufficient to correct the alar base retrac-
tion (Figure 5.31).

The surgeon enters from the internal lateral osteotomy incision,
but this time the direction of the dissection is toward the piri- FIGURE 5.33 A long rim graft prepared with septal cartilage can be
form rim instead of the maxilla. The piriform ligament is a solid placed on the pouch, made from three spaced punch incisions without
folium and the alar base is released from the subperiosteal plane making one long incision.
(a) (b)
(c) (d)
5.3.5 Maxillary Hypoplasia Treatment

Maxillary hypoplasia often accompanies asymmetries on the alar
base (Figure 5.35); its presence should be detected before the
operation and treatment should be planned. The method preferred
for maxillary augmentation changes based on the amount of defor-
mity and whether it is unilateral or bilateral (Figures 5.36–5.37).
1. If the hypoplasia is less than 2 mm, then deepening

the unaffected side of maxillary base with a power
burr may avoid grafting surgery [9]
2. If there is a 2–4 mm unilateral maxillary hypopla-
sia, maxillary augmentation can successfully be per-
formed by using a diced cartilage injection on the plane
above the periosteum over the maxillary at the level of
the apertura pyriformis through intranasal, intraoral,
or wing incisions (whichever one is available) [8]
3. If the unilateral maxillary hypoplasia is more than FIGURE 5.35 A patient with discordance between maxillary bones on
4 mm, then a wedge graft stitched together in layers either side.
FIGURE 5.36 Maxillary equalization and alar wing surgery were per-
FIGURE 5.38 The wedge graft that can be used for severe maxillary
formed on the patient and the deformity was corrected successfully.
augmentation.
FIGURE 5.39 In a case with severe bilateral maxillary hypoplasia, red

arrow, it is shown how the alar base is positively affected by fat injection
to the right cheek, green arrow.
FIGURE 5.37 Before and three years after.

5.4 Releasing the Depressor Septi Nasi Muscle
can be placed over the maxillary periosteum before The depressor septi nasi muscle is an active facial mimic mus-
the apertura pyriformis by entering from the intraoral cle and can cause the deformities occurring during laughing
incision, and fixing on the soft tissue (Figure 5.38, or speaking [15].
Video 5.12) [12–13] Smiling deformity: This is a condition where the nasal tip
4. If there is bilateral maxillary hypoplasia, then pre- droops significantly when the patient smiles and distorts the
maxillary hypoplasia is present and costal cartilage nose’s appearance, and the distance between the nasal tip and
will be necessary for its repair the upper lip decreases. If this deformity includes the appear-
5. If a maxillary augmentation including nasolabial sul- ance of gums while smiling, it is called the gummy smile.
cus is to be performed, then a fat injection is the most Speaking deformity: Nasal tip drop does not always pertain
logical approach (Figure 5.39, Video 5.13) [14] to smiling; it can also drop while speaking. In this condition,
FIGURE 5.41 Exposure of the depressor septi nasi muscle. This muscle
at the anterior end of the nasal spine extends caudally toward the orbicu-
laris oris muscle.
dissected. A segment can be removed to prevent recurrence.

Like every dynamic deformity, this deformity can also benefit
from a botulinum toxin application (Figures 5.42–5.43).
FIGURE 5.40 It was demonstrated in smiling deformity that depressor
septi nasi muscle pulls down the nasal tip, and that the levator alaeque
nasi muscle pulls up the alar base. VIDEOS
5.1 Alar excision.
5.2 Alar base narrowing suture.
the nasal tip droops, significantly affecting the nose’s appear- 5.3 Alar base pull down test.
ance, especially during words that contain the letter “M”
5.4 The muscle triangle.
which requires the patient to rub their lips together. It is some-
times accompanied by the smiling deformity. 5.5 LANM and TNM.
If only depressor muscle hyperactivity is involved in the 5.6 LANM stimulation.
deformity, then the dissection of the depressor septi nasi mus- 5.7 Alar base retraction in a non-deviated nose.
cle can be done through intranasal or intraoral incisions. If the 5.8 Dissecting LANM.
deformity is accompanied by levator muscle hypertrophy, then 5.9 Alar base retraction with a crooked nose deformity.
bilateral dissection of the LANMs is needed, which is very
5.10 Plication of LANM.
rare (Figure 5.40).
This muscle exists in the SMAS tissue over the periosteum 5.11 Alar base retraction in a non-deviated nose.
of the maxillary bone before the nasal spine (Figure 5.41). The 5.12 Maxillary hypoplasia: Wedge graft fixed on soft tissue.
muscle is cauterized with bipolar electrocautery before being 5.13 Maxillary hypoplasia: Fat injection.
(a) (b)
(c) (d)

(a) (b)
(c) (d)

REFERENCES 9. Taş S. The Alignment of the Nose in Rhinoplasty: Fix

1. Weir RF. On Restoring Sunken Noses without Scarring the Down Concept. Plast Reconstr Surg. 2020 Feb; 145(2):
Face. New York Med. J. 1892; 56: 443–52. 378–89. doi: 10.1097/PRS.0000000000006523. Epub 2019
2. Sheen JH, Sheen AP. Aesthetic Rhinoplasty. The C.V. Nov 19.
Mosby Co: Saint Louis, MO, 1978: 228–9. 10. Bruintjes TD, Olphen AF, Hillen B, Weijs WA.
3. Rohrich RJ, Adams WP, Ahmad J, Gunter JP (Eds.). Dallas Electromyography of the Human Nasal Muscles. Eur Arch
Rhinoplasty. 3rd Edition. QMP-CRC Press: Boca Raton, Otorhinolaryngol. 1996; 253(8): 464–9.
FL, 2014. 11. Taş S. Closed Atraumatic Rhinoplasty Course. Endorsed
4. Ilhan AE, Eser BC, Cengiz B. The Magic Finger by RSE (Rhinoplasty Society of Europe) and ISAPS
Technique”: A Simplified Approach for More Symmetric (International Society of Aesthetic Plastic Surgery).
Results in Alar Base Resection. Eur J Plast Surg. 2017; 40: Istanbul, Turkey, Nov 16–17, 2019. www.suleymantas.com.
137–42. tr/kapali-rinoplasti-kursu/ Accessed 11 Aug 2019
5. Rohrich RJ, Muzaffar AR, Gunter JP. Nasal Tip Blood 12. Taş S. The Approach to Horizontal/Vertical Axis Nasal
Supply: Confirming the Safety of the Transcolumellar Deformities with Dissection of Levator Alaeque Nasi
Incision in Rhinoplasty. Plast Reconstr Surg. 2000 Dec; Muscle. Contemporary Trends—Special Lectures on not-to-
106(7): 1640–1. be-Missed Topics. 7th Annual Meeting of the Rhinoplasty
6. Gruber RP, Freeman MB, Hsu C, Elyassnia D, Reddy V. Society of Europe, Mar 14, 2018, Bergamo, Italy.
Nasal Base Reduction: A Treatment Algorithm Including 13. Taş S. The Approach to Severely Asymmetrical Noses.
Alar Release with Medialization. Plast Reconstr Surg. Rhinoplasty Session. 12th International Caucasian
2009 Feb; 123(2): 716–25. Congress on Plastic Surgery and Dermatology, July 6–8,
7. Taş S. Correcting the Alar Base Retraction in Crooked 2018. Tbilisi, Georgia.
Nose by Dissection of Levator Alaeque Nasi Muscle. 14. Taş S. Nasal Base Retraction: A Treatment Algorithm. 5th
Ann Plast Surg. 2016 Oct; 77(4): 383–7. doi: 10.1097/ Bergamo Open Rhinoplasty Course, 2016, Bergamo, Italy.
SAP.0000000000000648. Epub 2015 Sep 10. 15. Benlier E, Balta S, Taş S. Depressor Septi Nasi Modifications
8. Taş S, Colakoglu S, Lee BT. Nasal Base Retraction: in Rhinoplasty: A Review of Anatomy and Surgical
A Treatment Algorithm. Aesthet Surg J. 2017 June 1; 37(6): Techniques. Facial Plast Surg. 2014 Aug; 30(4): 471–6. doi:
640–653. doi: 10.1093/asj/sjw203. 10.1055/s-0034-1383550. Epub 2014 July 30.
6
Revision Rhinoplasty Revision RhinoplastyRhinoplasty in Practice
Revision surgeries to be performed on patients who have pre-

viously undergone rhinoplasty are challenging because of
difficulties with the dissection of tissues and the reshaping of
non-anatomical structures to meet patient expectations. The
underlying bone-cartilage roof may have been destroyed, or it
may have been excessively/improperly grafted in these cases
(Figure 6.1). The surgeon must analyze and overcome these
difficulties using experience, knowledge, and capability.
Selection of these patients is critical and should be made
as described in Chapter 1, because most of these secondary
rhinoplasty patients are not well chosen. If a patient has a par-
ticular nose in mind before surgery, even if it is something they
may regret postoperation, it is the surgeon’s place to psycho-
analyze the patient to evaluate whether that patient will have
the same reaction to a more aesthetically pleasing nose.
Any surgery notes related to the previous operation and pre-
operative pictures are of great importance in revision surgery
in terms of providing insight to the surgeon. Decisions that
will affect the procedure to be performed can be made based
on these.
The closed technique is almost always advantageous in
revision surgery. The open rhinoplasty approach, on the other
hand, will be easier to do in cases where major nose recon-
struction is needed.
FIGURE 6.2 It can be seen that the dorsum skin adheres to the mucosa
in a secondary case. This finding indicates that dissection will be more
6.1 Dissection Plane in Revision Surgery difficult in this portion and it should be predicted that the elevated enve-
lope will have an asymmetrical thickness due to this defect.
It is known that re-dissection is quite difficult in secondary
and tertiary operations due to the scar tissue and adhesions
formed. Whether it is a revision of a surgery performed by previous operation was, the easier the current procedure will
another surgeon or your own revision, the more atraumatic the be (Figure 6.2).
6.1.1 If the Subperichondrial Plane Was

Preferred in the First Operation
Entrance and dissection can be made from the same plane
in the second operation. However, the perichondrium above
the cartilage will be attached to the mucoperichondrial plane
under the cartilage due to fibrosis related to the microperfora-
tions that each suture makes on the cartilage. At these points,
dissection will be interrupted.
It is important to note that almost half the nasal tip will be
affected by these points due to the suture techniques used in
the dome and columellar areas in tipplasty. Dissection will
be easier in the lateral area of the nasal tip—the body of the
lower lateral cartilage—because these suture techniques are
less common in these regions.
FIGURE 6.1 Noses severely deformed because of previous surgeries Similarly, nasal dorsum dissection for dorsum surgery will
need more attention and dedication. be interrupted at every suture point stitched in the previous
DOI: 10.1201/9781003174165-6 137

operation for the fixation of the spreader graft or flap. Because 6.1.3 If the SubSMAS Plane Was Preferred
no suture technique is used on the lateral surface of upper lat- in the First Operation
eral cartilage, dissection here will be easier.
It will be more difficult to open the nose a second time since
the perichondrium of the cartilage received more manipula-
6.1.2 W hat Should Be Done When
tion during the previous surgery. However, performing a subp-
Dissection Is Interrupted Due to erichondrial dissection in as many parts of the nose as possible
Fibrosis from Microperforations in these cases enables the surgeon to benefit from the advan-
Induced by the Sutures? tages of this plane in revision surgery (Videos 6.2 and 6.2).
Attempting to continue subperichondrially at these points will This approach needs time and energy but also valuable for the
only cause the cartilage, weakened due to the previous opera- result to be obtained. There will be less overall bleeding during
tion, to tear. Thus, it is necessary to move to the upper plane the surgery, and the surgery will be more predictable and defi-
without forcing the cartilage, that is the supra-perichondrial/ nite. Performing subperichondrial dissection in the first surgery
subSMAS. will ease dissection if revision is needed (Figure 6.3).
(a) (b)
(c) (d)

Revision Rhinoplasty 139
6.2 T he Closed Rhinoplasty Approach

for Challenging Cases
The concept of structural rhinoplasty has been developed
with open rhinoplasty techniques and descriptions of numer-
ous graft and flap methods, nasal anatomy is now clinically
understood better, and surgeons performing nasal surgeries
are better educated today. Yet, it is due to the surgeon that open
rhinoplasty is generally recommended rather than the limita-
tions of closed rhinoplasty.
Take this case study as an example: a 28-year-old female
patient with Binder syndrome has had two previous opera-
tions. An attempt at dorsal augmentation using a cartilage
graft taken from both ears had previously failed (Figure 6.4).
Problems encountered in this case include:
1. Short columella
2. Absence of nasal dorsum and all anatomical struc-
tures (nasal bone, upper lateral cartilages, radix, key-
stone, septal cartilage, etc.)
3. Absence of the nasal spine
FIGURE 6.5 The fact that the patient’s finger easily falls into the nasal
4. Severe small nose deformity containing not only cavity means that there is no anatomic structure left in the external nose
bone cartilage anatomy but also the skin and soft tis- or in the septum.
sue envelopes, which are also narrow
5. Total septal perforation—thus, when the patient
2. Abnormal positioning of nasal bones
was asked to press on their nose with a finger,
the finger collapsed inside the nose (Figure 6.5, 3. Intermaxillary hypoplasia and malocclusion
Video 6.3) 4. Absence of anterior nasal spine or hypoplasia
5. Nasal mucosa atrophy
It is a congenital disease of unknown etiology, with six 6. Absence of frontal sinus
characteristics:
Up to today, approximately 250 cases have been reported in
1. Arinoid face (facial appearance with almost no nose) the medical literature. Augmentation with costal cartilage or
alloplastic materials is recommended in its treatment.
In severe cases, the syndrome is accompanied by mandibular
prognathism; thus, the deformity looks more severe and orth-
odontic setback of the jaw should be planned in its treatment [1].
6.2.1 Discussion: Should the Open or Closed

Technique Be Used in This Case?
The immediate classic answer is the open technique as this
case requires severe augmentation, and stabilization using
rib cartilage would be easier using this technique. However,
the answer for this case should be the closed technique
because the columellar artery is the only source to feed the
columella in total septal perforation. If the open technique
were to be used, this artery would be cut at the beginning
of the operation. Additionally, this incision will be closed
under tension with the augmentation to be made in this
case. Necrosis, which can develop in the suture line, will
occur to full thickness in at least the septal perforation area
since there are only nonviable cartilage grafts underneath.
So, what is plan B in this situation? Columella reconstruc-
tion with forehead flap or nasolabial island flap? Often these
FIGURE 6.4 Binder syndrome was described by Dr. Binder in 1962. risks are unnecessary for easier stabilization. Sometimes
there is a need to operate the most difficult cases using the to provide the intended expansion on the skin envelope in this
closed technique, and at other times, simple cases can be particular case. Thus, the levator alaeque nasi muscles were
solved with the open technique. The surgeon should have dissected bilaterally, and so sufficient expansion was achieved
full knowledge of and be competent enough to deal with any (Video 6.5).
possible scenario and technique. Rhinology should therefore The sixth rib was taken by entering from the right inframa-
be a scientific branch that aids in answering the questions of mmary fold incision. Two flat pieces were achieved from this
what should be done and where, rather than creating distinc- rib to form a L strut (dorsum and anterior septum). K wires
tions about what is difficult or easier [2]. were used to fix one to the maxilla and the other to the frontal
In the surgery of the previously mentioned case, the rudi- bone. Next, these two pieces were fixed to each other, result-
mentary nasal dorsum was undermined with the closed tech- ing in a reconstructed nasal roof. The advantage in doing this
nique, and only the root of the nasal process of the frontal reconstruction with K wire was that the skin envelope of the
bone was observed. There were no other anatomical structures nose was forced to expand as much as it could be (Figure 6.6,
(Video 6.4). Video 6.6).
Because a severe augmentation was planned in the pre- The septum perforation was repaired using a rotation flap
sented case, and the patient had a very narrow skin envelope, on the right nasal mucosa and a skin graft obtained from the
extended dissection was made to expand the skin envelope. edges of the skin incision where costal cartilage was removed
Undermining of the dorsum was extended up to the infraor- for the left nasal mucosa. Next, a three-layered septal recon-
bital nerve at both sides. Even this wide dissection was unable struction was conducted with the thin layer prepared from
FIGURE 6.6 Upper left, the harvested rib. Upper right, two cartilage blocks which K wire can pass through were prepared to form an L strut. Lower,
the grafts fixed directly to the maxillary and frontal bones.
FIGURE 6.9 Endoscopic view indicates the huge septal perforation is

closed successfully.
cavity is a useful maneuver that prevents drying in the septal

cartilage layer graft and strengthens its viability (Video 6.7).
FIGURE 6.7 Peroperative result. No problem related to the skin circulation was encountered
in this case, and the aesthetic result on the table was satisfying
(Figure 6.7, Video 6.8). Two months after the operation, the K
the rib cartilage between both layers. Mucosal blood circu- wires were removed under local anesthesia (Video 6.9). The
lation was preserved by performing a unilateral instead of a result obtained one year after the operation was a natural and
bilateral flap surgery. Using a dermal graft in the left nasal functional nose appearance (Figures 6.8–6.9) [2].
(a) (b)
FIGURE 6.8 (a–b) Before and one year after.

6.3 Saddle Nose Deformity
A collapse in the nasal dorsum is called saddle nose deformity
because of its saddle-like appearance (Figure 6.10).
The etiology of this deformity includes:
• Trauma
• Iatrogenic surgeries
• Congenital syphilis
FIGURE 6.11 The type of hump excision that should be made to prevent
• Rheumatic diseases saddle formation is shown.
• Cocaine usage
• Leprosy TABLE 6.1
The most common causes are nasal traumas, followed by iatro- Classification of the Saddle Nose Deformity
genic surgeries (excessive excising or destructing the dorsum). Type Subtype Location Cause Treatment
As the number of rhinoplasty procedures increases, iatrogenic
1 A 1/3 upper Excessive Reconstruction/
reasons outnumber traumas.
B 1/3 middle resection Camouflage
The classic treatment of saddle nose deformity is augmen-
tation of the collapsed region. Diced cartilage (free, or in C Combined
Surgicel/fascia), rib cartilage, bone grafts, alloplastic materi- 2 1/3 middle Septum Rearrange/
als, and fillers can be used for this purpose [3]. dislocation/ Support
To eliminate iatrogenic reasons, excessive resection should Deviation,
be avoided. If the surgeon decides to excise the hump, making Loss of relation
in septum-spine/
the excision in a way to form a completely flat line may cause
Tip-dorsum
a minimal saddle because of the thickness of the soft tissue
3 1/3 middle Pseudo/ Deprojection/
envelope. Instead, it will be more logical to plan an excision
Exaggeration Camouflage
with a slight height in the keystone as re-excising is easier than
reconstructing (Figure 6.11).
Saddle nose deformity can be classified based on its cause, Type 1A: If it affects only the bone tissue, that is, 1/3 of
formation mechanism, clinical appearance, and surgical treat- the upper portion.
ment method, as follows (Table 6.1): Type 1B: If it affects only the cartilage tissue, that is, 1/3
of the middle portion.
Type 1: Forming due to over-resection induced by iatro-
genic surgery. Type 1C: Combined, if it affects both tissues.
Reconstruction or camouflage methods are preferred in its

treatment (Figures 6.12–6.14).
FIGURE 6.12 Left, the dorsal onlay graft will be wrapped in rectus
fascia. Right upper, a reconstructed L strut graft. Right lower, the premax-
FIGURE 6.10 Iatrogenic saddle nose deformity. illary graft has the sulcus in its center for an L strut graft.
142
Type 2: Type 2 saddle nose deformity appears in cases of nasal tip and nasal dorsum (Video 6.10). Although it
septum dislocation, septum deviation, loss of septum- generally occurs due to nasal traumas, it can also occur
spine relationship, and loss of relationship between the iatrogenically.
FIGURE 6.15 Saddle nose deformity is observed in the patient who has
no caudal septum due to the previous septoplasty. The nose was recon-
structed with a composite graft and deep SMAS suture obtained from the
hump instead of obtaining a graft from a distant donor area because the
patient needed reduction rhinoplasty.
FIGURE 6.17 If the supratip is iatrogenically exaggerated, a pseudo-
saddle nose appearance may occur.
6.4 U
sing Rib Cartilage in
Revision Rhinoplasty
Revision surgery requires massive preparation. The surgeon
should enter the operation with numerous techniques and plans to
overcome any possible difficult situation that can be encountered.
Silicone implants are widely used in rhinoplasty, especially
in Asia for augmentation rhinoplasty, but even these soft
implants may cause various problems such as infection, expo-
sure, and dislocation (Figure 6.18, Video 6.12).
FIGURE 6.16 The curved anatomy of the dorsum cartilage may cause
the appearance of saddle nose deformity.
Methods that employ reformation and support of the

r elationship are preferred in its treatment (Figure 6.15, Video
6.11a,b).
Type 3: Also known as pseudo-saddle, this may

present anatomically as the curved structure of the
dorsum cartilage (Figure 6.16), or iatrogenically
as over-exaggeration of the supratip
(Figure 6.17).
Camouflage or excisional techniques should be preferred

in its treatment if it is induced by the curved structure of the
cartilage, while deprojection methods should be preferred if
it is iatrogenically induced by the prominence of the supratip
incisura [4]. FIGURE 6.18 The exposed nasal silicone implant.
The use of synthetic implants such as porous polyethylene or
mesh implants in an organ with a relatively thin skin envelope
and with such aesthetic importance as the nose should not be
recommended (Video 6.13).
Due to the previously mentioned reasons, rib cartilage
provides an irreplaceable option, particularly in augmenta-
tion and secondary rhinoplasty. However, this technique can
also be over-used, especially in revision surgeries. If the sur-
geon increases their ability to use the materials at hand and
techniques for reconstruction, the need for rib cartilage will
decrease (Figures 6.19–6.20, Video 6.14).
FIGURE 6.19 Cartilage-bone complex composite graft obtained from

the hump and ethmoid graft which are prepared with drill for stabilization.
(a) (b)
(c) (d)
145
6.4.1 Harvesting the Rib Cartilage possible to extract the fifth or seventh rib located
right next to it from the same incision due to the
6.4.1.1 Thorax Anatomy intercostal connections; a wider sixth rib can also
• The fifth, sixth, and seventh ribs form cartilagi- be harvested due to the intercostal connections and
nous junctions between themselves, while there is extensions.
no intercostal junction between the first four ribs.
Thus, while the superior edge of the fifth rib is free,
6.4.1.2 Anatomic Landmarks
there is the junction made with the sixth rib in its
inferior edge. Beginning from the sixth rib, these 1. A vertical line drawn from the medial line of the
junctions are present in both superior and inferior nipple is generally the point where the cartilage por-
edges. tion of the rib ends and the bony portions begins.
• The eighth, ninth, and tenth ribs do not have a direct In incisions placed more laterally to this point,
relationship with the sternum. After the ninth and dissection should be made medially to reach the
tenth ribs are linked, they hold on to the eighth rib. cartilage portion of the rib, which is why it is not
The eighth rib ensures its stability by holding on to recommended.
the seventh rib. 2. The point that should not be crossed on the medial is
• The eleventh and twelfth ribs are known as floating determined by marking the parasternal area.
ribs because their edges are free (Figure 6.21). 3. Projection of the inframammary fold in women gen-
• The most suitable cartilages for rhinoplasty are the erally indicates the fifth intercostal gap.
fifth and sixth costal cartilages. Lower than seventh 4. The rectus abdominis muscle rises from the xiphoid
localized ribs are mostly used for ear reconstruction. eminentia—the lower surface of the fifth, sixth, and
• If the surgeon is not facing a very extreme case, the seventh ribs—and continues downward. Thus, the
fifth rib will provide a sufficient source of cartilage rectus muscle should be incised with a cautery while
and easier extraction than the sixth and seventh ribs taking all but the fifth rib.
because it does not have an intercostal junction in 5. While the intercostal artery-vein-nerve package is
the interior. present on the posterior-inferior surface of the rib, a
• However, if one rib will not be sufficient, then har- collateral artery-vein-nerve package is present on the
vesting of the sixth rib is more logical because it is superior surface of the rib (Figures 6.22–6.23).
FIGURE 6.22 Costal vein and nerve anatomy and localization are
FIGURE 6.21 The anatomy of the thorax. shown in detail.
FIGURE 6.23 Anatomic layers and the location of the vein-nerve pack-
age of the thorax wall are detailed. FIGURE 6.25 In a male patient, the planned incision (2 cm) for a costal
cartilage graft is seen. It is observed that the area became pale due to the
local solution injection with adrenaline.
6.4.1.3 Determining the Incision

The incision in women is 2–2.5 cm with a slight curve in
the medial part of the breast and is a few millimeters above
the inframammary fold. It is useful to locate this incision in
such a way as to provide the easiest access to the rib while
the surgeon is palpating (Figure 6.24). Placing the incision
a few millimeters above the inframammary fold rather than
at the same level allows the incision to be kept aesthetically
hidden. Otherwise, the scar may be visible, especially in
swimwear.
Other than the inframammary fold principle, everything is
the same for male patients. The surgeon can plan the incision
in a way to be directly over the rib to be taken considering the
anatomic landmarks (Figure 6.25, Video 6.15).

After the scalpel incision, the subcutaneous tissues and fas-
cia are incised with electrocautery. The surgeon continues to
go directly to the rib using finger palpitation. When the rib
FIGURE 6.24 The localizations of the incision to be preferred in man surface is located, the surgeon scratches the perichondrium
and woman to extract a rib graft are shown. with the cautery at the desired length and it is then elevated.
Getting under the perichondrium is critical to removing the rib

undamaged; the posterior of the rib is easily dissected due to
the subperichondrium plane, and the risks of severe complica-
tions such as pleura and pulmonary damage can be completely
eliminated. If a small amount of rib is needed, then the rib can
be partially removed without going through the posterior part
of the rib.
After the harvesting, the rib should be kept in an isotonic
solution so that possible crookedness can be seen before shap-
ing and so that it can be shaped accordingly.
Lastly, the donor area is filled with water after the extraction
of the rib and the anesthetist is asked to give positive pressure
to test whether there is pleural damage.
Important Note 1: If the rib is harvested subperichondrially, the
base surgery region is a clean and clearly white layer and there is
no need to give positive pressure to the patient as this may induce
pneumothorax in patients with emphysema or a bulla.
Important Note 2: If the base surgery region where the
rib was extracted does not look white, or if it is uncertain
whether the region is above the perichondrium, then the area
is filled with water and the anesthetist is asked to give posi-
tive pressure. If the region does not foam, then there is no
problem, but if it foams, then there is pleural damage and the
following should be done:
FIGURE 6.27 If the posterior surface of the rib is extracted subperi-
chondrially, the porous structure due to the perforator vessels can be seen.
• A loop suture should immediately be stitched to the
foaming area with a 2/0 atraumatic round needle
polyglactin. The tissue that the suture bites should not

be deep because it is the pleura that should be caught,
not the perichondrium. If there is the option to con-
sult with thoracic surgery, a perioperative consulta-
tion can be requested and the nose surgeon can return
to the nasal procedure immediately. The donor area
should not be covered until the end of the operation. If
saturation drops and the thoracic surgeon is not pres-
ent, then it means that atelectasis is forming. In this
case, a thorax tube is placed from the already open
donor area.
Although there is no literature regarding preference for right

or left side harvesting of rib cartilage, the right side is gener-
ally preferred as heart pulsations on the left can create the risk
of error during harvest.
If the rib is extracted from the subperichondrial plane,
it would be naked with no visible blood vessels. Also, the
anterior surface of the rib would have a flat central groove
filled by the perichondrium (Figure 6.26). If the rib is
extracted subperichondrially, the porous view induced by the
perforator vessels on the posterior of the rib would be seen
(Figure 6.27).
Costal cartilage can be shaped based on its intended use:
FIGURE 6.26 If the anterior surface of the rib is extracted subperi-
chondrially, it is seen that the anterior surface is not totally flat and has a • It can be reduced to diced or ultradiced cartilage
mild groove that the perichondrial tissue fills. to eliminate the risk of re-curvation during the
(a) (b)
(c) (d)
recovery period in cases where the aim is just to pro-

vide volume.
• It can be cut obliquely for structural grafts with
the aim of supporting the dorsal roof, nasal tip, or
side walls which will reduce the risk of curving
(Figure 6.28) [5].
6.5 C
ostal Reconstruction in Revision Cases
with Cleft Lip-Nose Deformity
Patients with cleft lip-nose have aesthetic expectations like
normal primary nose patients but are born with anatom-
ical deformations that become more deformed over time
with the surgeries they have undergone. If this patient
group is to be operated on, the surgeon must have expe-
rience on all cleft lip-palate surgeries, revision cleft lip-
palate surgeries, and revision rhinoplasty surgeries as FIGURE 6.29 Lower left, tertiary cleft lip-palate case with severe
each type has specific complicated techniques and the asymmetric cartilages. Lower right, lateral crural struts obtained from
surgeon’s experience will enable them to create the best the costal cartilage were overlapped. Upper, the tripod was formed with
reconstruction (Figures 6.29–6.30, Video 6.16). a strong strut.
(a) (b)
FIGURE 6.30 (a–b) Note the remarkable change in appearance.
There are often scar contractures that need to be opened method is the most effective treatment for them, and all the
in this patient group due to previous surgeries. The Z-plasty specifics must be known (Figures 6.31–6.32).
(a) (b)
(c) (d)
(a) (b)
(c) (d)
6.6 Using Auricular Cartilage

Graft in Revision Surgery 6.7 Diced Cartilage Flap Technique
Because of its squamous structure, limited cartilage reserve, The diced cartilage flap technique can have important contri-
and donor site morbidity that can lead to aesthetic problems, butions to the nose surgeon’s way of thinking and philosophy
auricular cartilage is the second option for revision surgeries in rhinoplasty operations [6].
as a source of distant cartilage. There are two flap surgery concepts—prelamination and
The advantages of auricular cartilage are its proximity to the prefabrication [7–8].
nasal surgery region; the fact it can be easily extracted compared Prefabrication: This consists of placing a vessel carrier tis-
with rib cartilage; and that it can provide a composite graft by sue under the donor area intended to be transferred to the body
leaving the postauricular skin adhered to the conchal cartilage. as a flap, waiting the required five to eight weeks for the area
Auricular composite graft application has an important place to be fed from here, and then transferring the donor area as a
in deformities that are difficult to correct such as alar wing vessel carrier-based axial patterned flap. Tissues that are not
reconstruction and severe rim retractions. The low survival rate suitable for transfer are turned into flaps.
of composite grafts in adults is another handicap of this. Prelamination: This consists of placing the tissue on
Auricular cartilage can be stitched to the middle vault like an another component, giving it a three-dimensional structure,
onlay graft due to its squamous structure in conditions like internal before transferring the tissue as a flap. In this way, component
valve collapse, and benefit can be provided by its flaring effect. tissues that are absent in the body can be formed.
FIGURE 6.33 Schematic drawing of the diced cartilage flap technique.
If a diced cartilage injection was made on the nasal dorsum The Soft Tissue Graft Can Be Obtained in Five Different Ways
in the previous operation, it is now a prelaminated tissue and
the following can be done with it: 1. If wing surgery will be conducted, then the excised
alar material can be de-epithelialized and used for
1. If the diced cartilage tissue was displaced, it can be this purpose.
dissected like a flap and aligned. 2. It can be obtained from the septal perichondrium. The
2. If there is absorption in one part of the diced c artilage perichondrium of previously dissected septum gets
tissue, then the undamaged part of this tissue can be thickened, so when an incision is made on the caudal
dissected and advanced as a flap and used to replace septum, the thickness of the perichondrium covering
the damaged area (Figure 6.33). the caudal septum can be seen. This perichondrial
tissue is extracted with sharp-ended scissors while
preserving the mucosa, stitched to the anterior septal
angle, and made to imitate the membranous septum.
6.8 R
estoring Tip Mobility in Revision
3. If perichondrio-SMASectomy will be performed,
Rhinoplasty Patients this material can be used for this purpose.
The nasal tip has a mobile structure due in part to the membra- 4. If the levator alaeque nasi muscle will be dissected,
nous septum between the tip and septal cartilage and also to its obtained muscle tissue can be placed here.
elastic lower lateral cartilages (Figure 6.34).
If the membranous septum is destroyed with aggressive sur-
gery, and if the lower lateral cartilages are fixed to the sep-
tum, or if numerous structural grafts with no elastic abilities
were made over and beside the lower lateral cartilages, then an
immobile nasal tip will form.
In this case, the patient will complain that it is not
p ossible to lie face down, kiss, or that there is pain in the
area. All these can affect the comfort and daily life of the
patient and lead to consultation for a secondary surgery.
Thus, surgeons must avoid creating an immobile or stiff
nose.
So, If the Patient Consulted with This Complaint,
What Should Be Done?
The item causing the limitation between the septum and medial
crura (such as a septo-columellar suture, septal extension graft,
ethmoid grafting, tongue-in-groove technique, etc.) should be
incised and a soft tissue graft imitating the membranous septum
should be inserted between the medial crus and caudal septum.
The patient’s nasal tip will not be as soft as before the opera-
tion, but the nasal tip regains a mobile character by sliding
over the caudal septum with the described maneuvers.
With the soft tissue pillow in place, pain is reduced as the
force of the trauma to the nose is not directly transmitted to the FIGURE 6.34 Left, seven years after the surgery. Right, a significantly
septum and spine. mobile, soft tip was achieved.
Whether done out of fear of postoperative nasal tip drop, or whether

the mechanisms keeping the nasal tip in place were not sufficiently
understood, no operation should ever end in such a result.
There are various studies showing that the nasal tip drops a
bit in time after surgery. However, if the amount of drop men-
tioned here is half a centimeter then there is something wrong
with the nature of this job.
Second, although lateral steal is a useful technique, if is overly
done, then the dome point will go back too much and there will be
no lower lateral cartilage to cover the soft triangle. This situation
will cause nostril show—the frontal exposure of nostrils—and
an over-rotated nasal tip from the sides. If a stiff strut is placed
between medial crura already prolonged due to the lateral steal,
then an over-projected image also occurs, and this causes the strut
to look like a sagging columella, creating the pig nose appearance.
The Reasons for an Over-Rotated Nasal Tip Appearance

(Pig Nose)
(a) 1. Over-lateral steal

2. Prolonged medial crus
3. Very powerful strut
To correct this difficult condition, deprojection and

derotation are performed. Lower lateral cartilages should be
prolonged again to pull down the nasal tip. For this, the lower
lateral cartilage is prolonged by releasing from the strut and
stealing from the long medial crus. This is regarded as a type
of nasal tip amputation and lateral crura should be given a
prolonged appearance with a cap and articulated rim grafts and
the footplate point should be set back (Figure 6.36).
The Following Are Used in the Treatment of an Over-

Rotated Tip:
1. Medial steal
2. Medial overlapping
3. Cap and articulated rim grafts
4. Footplate setback techniques (Figures 6.37–6.39,
(b) Videos 6.18 and 6.19)
5. If none of these options is available, then postauricular

fascia, deep temporal fascia, or a dermofat graft
obtained from another part of the body can be used
for this purpose (Figure 6.35, Video 6.17).
6.9 Treatment of Over-Rotated Noses

This condition, also known as pig nose, has damaged society’s
view of rhinoplasty. The surgeon must do everything possible
to avoid causing this deformity.
“Nose surgery is like dancing; you cannot force but only

direct your partner in harmony.” FIGURE 6.36 It can be seen how long the medial crura are in a patient
(E. Benlier) who was operated on due to pig nose appearance.
(a) (b)
(c) (d)
FIGURE 6.37 (a–d) Another case operated on due to pig nose appearance: her immediate result and the result seven days after the surgery indicate
an impressive change with fast recovery in a challenging secondary case.
(a) (b)
(c) (d)
(e)
FIGURE 6.38 (a–e) A patient with a severely deformed tip cartilage (before and three years after).
(a) (b)
(c) (d)

FIGURE 6.40 Schematic drawing of the fisherman suture.
6.10 Fisherman Suture (a)
The fisherman suture [9] is a very useful technique in diffi-

cult primary and secondary cases where the cartilage grafts
are weak. In this technique, crooked cartilage is corrected by
passing a continued suture with two loops on the convex sur-
face of the cartilage [10].

To correct C-shaped cartilage, the surgeon starts the suture
entering from one end of the convex surface of the cartilage,
and going to the other end by stitching continued horizontal
mattresses with 3 mm intervals which are designed to cre-
ate two loops in the convex side. This suture, stemming from
the other end of the cartilage, is passed through the loops and
brought back to where it started, and then the knot is settled
while holding the cartilage in a straight position with two for-
ceps (Figure 6.40).
Clinical Conditions Where the Fisherman Suture Can Be

Used
(b)
1. Dorsal septal curvatures
2. Over-bulbous or concave conditions of the lower lat- FIGURE 6.41 (a–b) Before and five years after.
eral cartilage
3. Crooked cartilage grafts
If there is a long cartilage curvature which may
Points to Be Considered When Using the Fisherman require leaving gaps longer than 3 mm, the number
Suture of loops should be increased.
3. Since establishment of the belief that dissolving
1. Intense suturing techniques can result in rupture for material should be used in today’s rhinoplasty, using
the cartilages which were naked due to subperichon- suture-based techniques in the correction of cur-
drial dissection. The surgeon should be aware of this vatures has remained in the background and using
and try to suture as atraumatically as possible. structural grafts has come to the forefront, but clini-
2. If the distance between the loops is too wide, the C cal trust in suture techniques using pds still continues
deformity in the cartilage turns into an S deformity. (Figure 6.41).
VIDEOS REFERENCES
6.1 Subperichondrial dissection in revision surgery 1. 1. Bhatt YC, Vyas KA, Tandale MS, Panse NS, Bakshi
HS, Srivastava RK. Maxillonasal Dysplasia (Binder’s
6.2 Subperichondrial dissection in revision surgery 2.
Syndrome) and its Treatment with Costal Cartilage Graft:
6.3 Binder syndrome with total septal loss. A Follow-up Study. Indian J Plast Surg. 2008 July; 41(2):
6.4 Surgery for Binder syndrome 1: Initial view. 151–9. doi: 10.4103/0970-0358.44925.
6.5 Surgery for Binder syndrome 2: Dissection of 2. Taş S. A Binder Syndrome Case. How I Did it? 8th Annual
LANM. Meeting of the Rhinoplasty Society of Europe, Apr 8, 2019.
Stuttgart, Germany.
6.6 Surgery for Binder syndrome 3: Creation of L
3. Cerkes N, Basaran K. Diced Cartilage Grafts Wrapped in
strut.
Rectus Abdominis Fascia for Nasal Dorsum Augmentation.
6.7 Surgery for Binder syndrome 4: Reconstruction of Plast Reconstr Surg. 2016 Jan; 137(1): 43–51.
the septum. 4. Taş S. Closed Atraumatic Rhinoplasty Course. Endorsed
6.8 Surgery for Binder syndrome 5: Preoperative and by RSE (Rhinoplasty Society of Europe) and ISAPS
postoperative. (International Society of Aesthetic Plastic Surgery).
6.9 Surgery for Binder syndrome 6: Before and two Istanbul, Turkey, Nov 16–17, 2019. https://drsuleymantas.
months after. com/course/ Accessed 11 Aug 2019.
5. Tastan E, Sozen T. Oblique Split Technique in Septal
6.10 Type 2 saddle nose deformity. Reconstruction. Facial Plast Surg. 2013 Dec; 29(6): 487–91.
6.11 Surgery for Type 2 saddle nose deformity: (a) The 6. Taş S. A New Technique to Correct Saddle Nose Deformity
strength of a deep SMAS suture; (b) the effect of a in Failure of Diced Cartilage Grafts: Diced Cartilage Flap.
deep SMAS suture. Aesthetic Plast Surg. 2015 Oct; 39(5): 764–70. doi: 10.1007/
6.12 Silicone implants. s00266-015-0530-8. Epub 2015 July 11.
7. Taş S. Microdissected Prefabricated Flap: An Evolution in
6.13 Synthetic implants.
Flap Prefabrication. Arch Plast Surg. 2016; 43(6): 599–603.
6.14 Revision rhinoplasty: Two years postoperative. doi.org/10.5999/aps.2016.43.6.599
6.15 Harvesting rib cartilage. 8. Taş S. A New Concept in Flap Prefabrication by
6.16 Costal reconstruction: Preoperative and postoperative. Supermicrosurgery: Microdissected Prefabricated Flap.
6.17 The effect of a soft tissue graft on the tip: before and Plast Reconstr Surg. 2015; 136(2): 437–8.
9. Çenetoğlu S. Personal Communication, Fisherman suture,
after.
Antalya, 2016.
6.18 Exposure of the tip cartilage in an over-rotated 10. Sibar S, Manav S, Cenetoglu S, Elmas C. A Novel Stitching
tip. Technique: Adjustable Closed-Loop Sewing Machine
6.19 Treatment of over-rotated tip: Three years Lock Stitching Technique to Bend or Unbend Cartilages. J
postoperative. Craniofac Surg. 2019 Nov–Dec; 30(8): e733–e7.
7
Advanced Rhinoplasty
4.
Jaw shape: Men have square jaws while women have
7.1 Male Nose more oval jaws.
5.
Adam’s apple: Men have a larynx bump called the
Differences between male and female noses have yet to be
Adam’s apple while women do not.
sufficiently studied. Before reviewing these differences of
the nose based on gender, the differences between male and • Rhinoplasty is also a part of sex reassignment sur-
female faces should first be understood (Figure 7.1) [1–2]. gery, so understanding the gender differences in
noses is essential. A cosmetic procedure known
as facial feminization surgery aims to form more
feminine features on men, so the previously men-
tioned differences are eliminated. During this
procedure, to cover the supraorbital ridge in male
patients, either fat can be injected in the con-
cave area or the forehead can be totally exposed
through a bi-coronal incision in a more aggressive
surgery where the ridge is either rasped or remod-
eled with osteotomies. The lips, jaw, and face gain
more oval lines through the fat injections. Then,
the Adam’s apple is incised, and surgery is per-
formed on the vocal cords. Surgeons need to be
quite careful in nasal operations for male patients;
otherwise, the surgery can transform these sec-
ondary sex characteristics in their patients.
6.
Nose: The transition between the forehead and
nose is Z-shaped in men and V-shaped in women
(Figure 7.2).
FIGURE 7.1 Male–female facial differences are shown.
1.
Supraorbital ridge: The supraorbital ridge created
by the frontal bone on the eyebrow line is clearer
among men. Women do not have such a ridge, so
their foreheads tend to be more oval while men’s are
more concave.
2.
Eyebrow thickness: Men have thicker flatter eyebrows
while women’s are thinner and bow-shaped.
3.
Lips: Men have thinner longer lips while women’s
are thicker and shorter. FIGURE 7.2 The forehead-nose transaction difference between genders.
DOI: 10.1201/9781003174165-7 161

FIGURE 7.3 Nasofrontal angle difference between genders. FIGURE 7.5 Frontal angle differences between genders.
line. The angle between the lateral nasal area and midline is
For men, the ideal nasofrontal angle is 115 degrees and the
broader among men (Figure 7.5) [3].
ideal nasolabial angle is 90 degrees. In women, these angles
Intermediate forms should also be examined. A slightly
are 120 and 110, respectively (Figures 7.3–7.4).
humpy nose may reflect a more masculine and aesthetic
Men have a broader dorsum and flatter dorsal line while
look for men and some patients may make such demands.
women have a narrower dorsum and more concave dorsal
Some male patients do not have a supraorbital ridge; thus,
surgeons need to be careful while performing rhinoplasty
on these patients, since dorsum elimination and tip-
plasty may result in a feminine appearance, so this should
be discussed more than once with those male patients
(Figure 7.6).
FIGURE 7.4 Nasolabial angle difference between genders. (a)

Advanced Rhinoplasty 163
(b)
(a)
(c)
FIGURE 7.6 (a–c) Three types of male noses operated by the author are
shown. Types of noses that are different in terms of their angles and struc-
tures should be discussed based on the patients and their facial properties.
Before and two years after.
Rhinoplasty yields positive results when performed appro- (b)

priately among men. The purpose here is not to make patients
beautiful, but handsome (Figure 7.7). FIGURE 7.7 (a–b) Before and two years after.
(a) (a)
(b) (b)
FIGURE 7.8 (a–b) Before and four years after. FIGURE 7.9 (a–b) The male nose is a little bit wider than the line drawn
from both medial canthi.
Surgeons need to be more sensitive in terms of nasola- be made with them to reduce this angle for a more masculine
bial angle and tip rotation in male patients. Increase in these appearance (Figure 7.8).
angles within this patient group is often not well tolerated The male nasal floor is broader than the female. Moreover, it
among men, contrary to women. If patients with an already- slightly exceeds the vertical lines, extending down from both
high nasolabial angle desire rhinoplasty, discussions should medial canthi (Figure 7.9).
(a)
FIGURE 7.10 Repair of the hanging columella and long nose deformity
should be conservative on male patients; in particular, upper lip distance
should be preserved.
The distance between the nasal tip and upper lips should
be kept shorter in male patients. It is particularly challenging
to keep this distance short in patients with complaints of low
nasal tip. Nevertheless, attention and patience should be given
to adjusting this angle (Figure 7.10).
From the transverse perspective, the ideal male nose looks
geometrically like a major prism with two small circles on its
ground (Figure 7.11).
Dorsum lights are the aesthetic factors that reflect the dorsal
anatomy outwards and make the nose look pleasant from both
frontal and dorsal angles. An anatomic dorsum (or the dorsal
lights seen externally) is trapezoid-shaped; it narrows in the
radix and supratip while expanding in the keystone. This angle
(b)
FIGURE 7.11 (a–b) The ideal nose is geometrically similar to a right

prism with two small circles at its base.
FIGURE 7.12 Dorsum lights are near-flat trapezoid in the male patient. FIGURE 7.14 Postoperative seven-year image of the patient. A male
nose with the ideal ratio, angle, and sizes, according to the author, is
shown.
is flatter in men, whereas it is more concave among women

(Figure 7.12).
Male patients are more obsessive about nostril symmetry,
which should be observed by surgeons while selecting their
patients (Figure 7.13).
After reading these details relating to nose angle, ratios,
and other information, it might be simple to form a mental
concept of the ideal male nose (Figure 7.14). This, however,
can be challenging as the subjectivity of aesthetic surgery
limits these concepts. In practice, the generally accepted
pleasant-looking nose can be used to define the ideal.
Additionally, curating a collection of images of aesthetically
beautiful noses can be beneficial in helping a surgeon to form
a concept of the ideal nose by teaching criticism and training
observation. By doing so, patients can also be offered more
options to make their future noses closer resemble their ideals
(Figures 7.15–7.16).
FIGURE 7.13 Male patients can be more obsessive about nostril

symmetry.
(a) (a)
(b) (b)
FIGURE 7.15 Three male noses which are very popular and admired FIGURE 7.16 (a) Before and seven years after. (b) The patient’s preop-
by the patients and people are shown. (a) The leftmost nose was operated erative nose included a distorted prism and distorted and grown circles
on by the author; the other two were not operated on. (b) As can be seen, at its base. The shape given to the patient by surgery is considered to
the range of being admired is very wide, but the common feature of these be aesthetically successful by both the patient, people generally, and the
three noses is the form of the noses which forms a right prism with two author. In form it is seen that the preoperative distorted prisms and circles
circles at the base. were corrected.
(a)
FIGURE 7.18 On the left, there is a nose with lower dorsum, supratip
point, and a more upturned 110-degree nasolabial angle. On the right,
there is a nose with higher dorsum, indefinite supratip point, and more
flattened 100-degree nasolabial angle. This picture, which was shown to
the patient to understand the type of nose that the patient likes and thinks
they might be happier with before the operation, is a part of the preopera-
tive planning of the author.
already-difficult process more challenging, but there are cer-

tain ways to facilitate this challenge (Figure 7.17).
To start, the author shows Figure 7.18 to patients in the first
preoperative assessment and asks which nose is preferred. If
a patient likes a supratip break point nose with a lifted tip,
the one on the left is preferred. However, if patients prefer a
nose with flatter and more shaped lines and no lifted tips, they
choose the one on the right. This photograph test will t herefore
help you choose the correct shape during examination.
Female nose aesthetic operations constitute most nose sur-
geries. However, efforts should be made initially to understand
why people plan to have this surgery. The author explains the
reason for having a rhinoplasty as follows:
(b)
1. The humpy nose shape, where the tip gets lower and
FIGURE 7.17 A female nose with four separate structural features oper- lateral parts rise during a smile, has been associated
ated on by the author and aesthetically admired by everyone (the patient, with witches. Witches are characteristically por-
their relatives, the author). (a) profile angle; (b) frontal angle. trayed in stories with this facial form and with noses
that are too large for their faces. This characteristic
shape is also associated with other malevolent fig-
ures in society. Therefore, it is quite understandable
for those with similar nasal shapes to want aesthetic
surgery.
7.2 Female Nose
2. Noses with a non-prismatic form do not reflect
Generally, women prefer aesthetic rhinoplasty to achieve light because the external surface of this prism is
more gentle and smaller noses. This demand means changing convex and only the most convex spot reflects the
the volume of the entire nose. Knowing the nasal ratios and light. If a spot reflects the lights in place of a sur-
angles and examining the ratios between patients’ faces and face, a lesser amount of light will be reflected. The
noses will result in success. Personal perceptions make this nasal tip is also at a lower level, so the distance
(a) (b)
(c)
FIGURE 7.19 (a–c) Before and five years after of the patient with an arched nose and a droopy tip.
between the lights reflected from the most humpy impression on others; from a social perspective, the
location of the dorsum and from the nasal tip is concept of light includes many positive terms such
quite high, resulting in the appearance of a longer as illumination, benevolence, beauty, pureness,
nose. When a flat surface symmetrically reflect- or clarity. Therefore, people’s desire for this posi-
ing the light is achieved through rhinoplasty, more tive impact is totally normal and understandable
lights are reflected, helping patients make a positive (Figure 7.19a–c).
(a) (a)
(b) (b)
FIGURE 7.20 (a–b) Before and three years after. FIGURE 7.21 (a–b) Before and 4.5 years after reduction rhinoplasty
which was performed without making alar excision.
Reduction rhinoplasty of the radix and dorsum is also patients in the preoperative period. Correct diagnosis and
quite different than that of the tip area. As downsizing on explanation will help prevent postoperative dissatisfaction
the tip requires dealing with soft tissue, it is the most dif- (Figures 7.20–7.21).
ficult in this regard. Reducing the projection of the nose tip The distance of the upper lip is another subject to be con-
causes relative expansion of the nasal floor, requiring an sidered. As seen in Figure 7.22, if patients have a lip structure
alar excision p rocedure, which should be discussed with with long and thin upper lip distance, the nasal spine should
(a) (b)
FIGURE 7.22 (a–b) Before and four years after.
be supported during surgery so that the distance of the upper Patients whose radixes have been augmented may report that
lip does not increase when this procedure creates a longer nose they have not been able to adapt to their appearance, although
form. A high radix, on the other hand, should be downsized their radixes are where they should be and have not been
in women’s noses, thus creating a shorter and more feminine raised too much. Nevertheless, this procedure is necessary to
form. However, downsizing the radix too much causes the achieve a non-humpy appearance on a dorsum with low radix
expansion of the frontal nasal bridge and increases the dis- level and should be explained with patients very thoroughly.
tance between both eyes, as in hypertelorism. Additionally, raising the radix causes the narrowing of the
Radix augmentation can be more trouble than downsizing in nasal bridge from the frontal side and reduces the distance
women’s noses as it can create a more masculine appearance. between two eyes (Figure 7.23).
(a) (b)
FIGURE 7.23 (a–b) Before and two years after.

TABLE 7.1
Algorithmic Approach in Reduction Rhinoplasty Based on Skin Types
Moderate Skin
Thin Skin Thickness Thick Skin Loose Skin Scarred Skin
Subcutaneous
Oily Thickness Thick Dermis
Preoperative – – Oral isotretinoin/ Avit/dermaroller Laser Hifu/laser Nostril retainer

Preparation Local tretinoin
Diagnosis: Skin pores are Skin pores are Skin is shiny Skin pores are Skin pores are very There are lines Skin envelope is
1. Inspection invisible; there are invisible from the invisible large and big; on the skin; distorted due to
lines on the skin; excessive oil it Orange peel Langerhans scarring
Langerhans lines secretes appearance is lines are
are distinguishable apparent distinguishable
2. Palpation Skin thickness of the The difference The finger Soft skin, Rough skin; thick Loose skin; thin Non-expandable
supratip and between skin becomes oily subcutaneous skin that cannot skin that can skin
keystone is almost thickness of the after touching thickness that be pinched be pinched
equal supratip and the skin on the can be pinched between the between the
keystone is supratip between the fingers during fingers during
small fingers during palpation of the palpation of
palpation of the supratip the supratip
supratip
Surgical
Technique:
1. Dissection Submembranous DUAL plane DUAL plane Submembranous Submembranous DUAL plane Submembranous
Plane
2. Skeleton Perform suture-based Suture-based Structural grafts Structural grafts Limited Limited Structurally
Oriented rhinoplasty; prefer rhinoplasty and should be used should be used reduction and reduction and resistant grafts
relatively soft and medium-hard (cartilage grafts structurally structural grafts should be used
elastic cartilage cartilage grafts that can be resistant grafts should be used
grafts (e.g., that can be obtained from should be used
tailor-made strut) if obtained from the lower base,
needed the upper and and posterior
middle parts of parts of the
septum (e.g., septum such as
keystone septal keystone
anatomic strut) anatomic strut)
3. Soft Tissue Preservation of soft Perichondrectomy SMASectomy Perichondrio- Extended Alar excision and Preservation of
Oriented tissue envelope SMASectomy perichondrio- redraping soft tissue
SMASectomy and envelope
alar excision
7.3 Algorithmic Approach in Reduction

Rhinoplasty According to Skin Type
An algorithmic approach in reduction rhinoplasty based on
skin type is presented in Table 7.1, offering a holistic approach
by including diagnosis, preoperative preparation, and detailed
surgical treatment for all skin types.
7.4 Rhinoplasty in Thin-Skinned Patients

Noses with more distinctive lines have a thin skin cover,
while those with rounder and indistinct lines have thicker skin
(Figure 7.24).
Another subject to be discussed with the patient is that noses FIGURE 7.24 Left, a thin-skinned nose with a more definite supratip
break point. Right, a thick-skinned nose with a less definite supratip break
with thick skin rarely have a supratip break point, while those
point and more oval. Note that the patient on the right has large pores
with thin skin may occasionally have this characteristic to (orange peel) on the nose skin while the patient on the left has almost
excess. This consideration should be settled in the preopera- invisible pores. This gives us information about dermal thickness and on
tive period (Figure 7.25). shrinkage capacity.
(a) (b)
FIGURE 7.25 (3- A flatter nose is on the left while a more projected nose with supratip break point is on the right. The nose on the right has thin skin
while the nose on the left has relatively thick skin. (b) Before and two years after.
Patients with thin skin are quite fortunate in terms of rhi- skin swell less, meaning recover is faster. The reason for this
noplasty as their noses can be downsized easily. Thanks to can be explained using a sponge analogy. A thicker sponge
the high contraction capacity of this type of skin, the newly doused in water holds more water than a thin sponge, and thus
shaped cartilage form can adapt to the dorsum with no need requires more time to drain (Figure 7.27). The same holds
for alar excision (Figure 7.26). In addition, noses with thin true for the recovery of thick and thin skins.
(a) (b)
FIGURE 7.26 (a–b) Before and five years after.
(a) (b)
(c)
FIGURE 7.27 (a–c) Before and seven days after. As can be seen, the skin envelope was able to adapt without the need for performing alar wing
excision, although a severe reduction was made on the thin-skinned patient and swelling on the nose was minimal on the postoperative seventh day.
(a)
(a)
(b)
FIGURE 7.29 (a–b) Note how the structural grafting technique made
for nostril asymmetry was reflected on the outside and corrected thanks
(b) to a thin skin envelope. However, this is a more stiff nasal tip compared to
the old one. Before and three years after.
7.5 Rhinoplasty in Thick-Skinned Patients

One disadvantage for patients with thin skin is that contour In thick-skinned patients, wing excision is often required to
irregularities and the slightest asymmetries can easily be seen; readjust the skin envelope, which often results in scarring.
however, these can be eliminated through submembranous However, if suturing is done on the alar sulcus with subcu-
dissection (Figure 7.28). taneous sutures, skin sutures are properly removed, the area
Another problem is the low amount of subcutaneous soft is protected with sunscreen for at least one year and silicone
tissue, so noses of these patients can have a stiff form due to gel treatment is used for three months, scarring will be mini-
the structural grafting methods. Therefore, grafting methods, mal (Figure 7.30). It is best to inform the patient that hypertro-
graft amount, sizes, and volumes are critical in this particular phic and keloid scarring usually do not occur in the mid-face,
group (Figure 7.29). but protective measures should still be followed (Figure 7.31).
(a) (a)
(b) (b)
(c) (c)
FIGURE 7.30 (a–c) The scar of the patient on whom alar excision was FIGURE 7.31 (a–c) The fact that a thick-skinned patient in need of
duly made is invisible. Before and two years after. severe deprojection and reduction has deep nasolabial grooves may help to
hide the scars that have to be lifted above 3, 9 o’clock, but wing surgery
always involves the risks of scarring. Before and five years after.
(a)
(a)
(b)
(b)
FIGURE 7.32 (a–b) The skin thickness of the patient with oily skin
which was dried is thinner despite the reduction. Note that left levator
alaeque nasi muscle of the patient with left alar base retraction was dis-
sected. Before and two years after.
More sophisticated surgical procedures such as perichon-

drio-SMASectomy are also required in this patient group,
entailing a longer recovery time.
Oily skin is not the same as thick skin. The use of local
retinoic acid and intensive skin care will ensure that the skin is
covered in its original thickness and will help end the surgery
without alar surgery (Figure 7.32). (c)
Loose skin mimics thick skin as there is no shrinking effect
in this type of skin. This patient group should be informed that FIGURE 7.33 (a–c) Before and two years after views of the patient with
limited reduction is possible (Figure 7.33). In addition, even loose skin obtained with minimal reduction without performing wing
if no reduction is performed, the surgery may end with wing surgery.
surgery since the skin needs to be stretched. As this patient

group is generally over the age of 35, it is beneficial to plan
surgery after ensuring that there is skin tightness with modali-
ties such as HIFU (high-intensity focused ultrasound) before
the operation (Figure 7.34).
Skin with large pores and a thick dermis also does not have
the capacity to shrink. The debulking procedure performed in
this patient group is also not useful because of the thick dermis
layer like cardboard. Although the subcutaneous layer is thinned
as desired, the skin does not shrink. In this patient group, the
most effective preoperative preparation may be fractional car-
bon dioxide laser treatment. Wing surgery is almost always a
requirement to create a tighter sheath (Figure 7.35).
(a)
(b) (a)
(c)
FIGURE 7.34 (a–c) Wrinkles on the neck indicate the quality of dermis
of the patient with loose skin. Note that wing surgery was performed.
Before and three years after. (b)
(c) (d)
FIGURE 7.35 (a–d) Before and two years after views of a secondary rhinoplasty patient who had a thick dermis and received alar surgery.
In thick-skinned patients where augmentation rhino- skin type is a more important parameter in reduction
plasty is to be performed, there is no need to be worried rhinoplasty.
about the skin cover. These concerns are solely for redraping If there is a secondary cleft lip nasal deformity which has a
and shrinking effects. In augmentation rhinoplasty, as the scarred skin cover, then the skin requires expanding. For this
soft tissue envelope will be stretched, the skin looks thin- purpose, the patient may be asked to use a nostril retainer on
ner and more beautiful than before (Figure 7.36). Therefore, the cleft side for six months before the operation.
(a) (b)
FIGURE 7.36 (a–b) A secondary patient who needed dorsal augmentation and nasal tip reduction. Before and 2.5 years after.
In reduction rhinoplasty, the tissue needs to be folded and
7.6 DUAL Plane Dissection shrunk within itself so that it can adapt to the newly formed roof.
However, the non-homogeneous distribution of the soft tissue
In thin-skinned patients the submembranous dissection cover in submembranous and subSMAS dissection causes this
plane allows the use of the whole soft tissue cover as cam- shrinkage to occur insufficiently in places where the tissue is
ouflage for the skeleton, while in thick-skinned patients it thick. This mechanism is common after reduction rhinoplasty; it
allows for a clearer excision by holding it from the perichon- explains the reason for complications such as supratip deformity,
drium and removing more tissue with the perichondrium parrot nose (Pollybeak) deformity, the formation of pseudo-soft
while bulking. tissue hump, or the inability to eliminate tip bulbosity.
In rhinoplasty, it is imperative to remember that the soft tis- Therefore, in reduction rhinoplasty, in order to achieve max-
sue cover formed by the skin and subcutaneous tissue is asym- imum redraping effect and to eliminate this effect’s related
metrical, thick in the radix, thin in the keystone, and thicker complications, the DUAL plane dissection technique [2]
in the supratip. Neither the subSMAS nor the submembranous should be used as it provides an equal thickness of soft tissue
plane qualifies for a soft tissue cover of equal thickness. cover elevation (Figures 7.37–7.40, Videos 7.1 and 7.2).
FIGURE 7.37 Yellow line, the submembranous plane. Black line, the FIGURE 7.38 Spaced blue line, the areas where the surgeon should go
nose has a perfect profile. Blue line, the subSMAS plane. As can be seen, up to subSMAS plane from submembranous plane to obtain the DUAL
the submembranous (subperichondrial-subperiosteal) and subSMAS dis- plane [2]. A soft tissue envelope of equal thickness is obtained by the
section plane causes a non-homogeneously distributed soft tissue enve- DUAL dissection plane. This dissection plane can solve the redraping
lope thickness. problems in reduction rhinoplasty.
(b)
FIGURE 7.39 (a) The DUAL dissection plane which includes submem-
branous dissection over lower lateral cartilages and keystone area, and
subSMAS on upper lateral cartilages, radix, supratip, and scroll area.
(b) Although the patient had a thick soft tissue envelope on the supratip
area and underwent severe reduction, the supratip break point achieved
(a) in the operation shows the success of the DUAL plane in redraping issue.
180
(b)
FIGURE 7.40 (a) The DUAL plane which includes submembranous

dissection on upper lateral cartilages and subSMAS over the lower lat-
eral cartilages. Also, an articulated rim graft is seen in the frame. The
DUAL plane [2] means combining the both classical surgical planes (sub-
membranous and subSMAS) to get the best redraping option according
to the patient’s features. (b) Postoperative redraping is successful with the
(a) DUAL dissection plane, despite the thickness of the skin.
7.7 Asian Rhinoplasty

The characteristic Asian nose structure has a low dorsum
including the radix, a bulbous nose, wide base, and wide
pyramidal angle (Figure 7.41). While the ideal pyramidal
angle is 60 degrees [4], in the Asian population it is around
110 degrees, resulting in a nose that should both narrow and
rise. The septum is very short, so its cartilage reserve is too
low to meet the necessary augmentation. Because of this, the
routine approach in primary Asian rhinoplasty is rib cartilage,
implant, or filling materials.
Primary Asian rhinoplasty cases can be resolved without
taking grafts from elsewhere, as follows.
7.7.1 Nasal Tip Bulbosity

A bulbous appearance at the nasal tip is due to having thick
skin, a wide, short lower lateral cartilage, and a medial crus
shorter than the lower lateral cartilage.
FIGURE 7.41 Asian rhinoplasty patient.
To correct this bulbous appearance, projection and rotation
of the nasal tip are required. Looking at the Alexander tripod, it
can be seen that the movement of the nasal tip can be achieved rotation to the nasal tip, while lateral displacement projects
with the central leg and also the lateral legs. Thanks to the the nasal tip [5].
ST flap, the nasal tip can be lifted and projection achieved by This maneuver is important in Asian rhinoplasty. In a nose
using these lateral legs. Caudal shifting of the ST flap gives which already has cartilage deficiency, the ability to adjust
(a)
(d)
(b)
(e)
FIGURE 7.42 (a) Very short and wide lower lateral cartilages after
dissection are among the main features of this ethnic group. (b) Note
how the lower lateral cartilages are prolonged and thinned after ST flap
[6] application. (c) Preoperative profile image; (d) nasal tip projection
achieved with only ST flap application and appearance of the supratip
break point; (e) final version obtained after dorsal augmentation and alar
wing surgery.
(c)
for dorsum augmentation. The question remains then about

what should be done if there is curvature in the septum or if
nasal tip bulbosity, rotation, projection, external valve sup- the septal support requires increasing.
port, and internal valve angle with a flap without using a graft An ethmoid graft can be cut with bone scissors but not
enables the use of the entire cartilage reserve in the septum for removed and transferred as one large piece to the front
dorsal augmentation (Figure 7.42, Video 7.3) [6]. In Video 7.4, side of the caudal septum. Again, without removing it,
all steps of the application of an ST flap and alar excision in an holes are drilled and the piece is fixed to the septum using
Asian patient are shown. 4/0 pds with repeated stitches. In this way, the caudal
septum can be projected up, and if there is a saddle in
this area, it can be treated. In cases of axial deviation or
7.7.2 Septal Problems
crooked nose deformities, the septum can be kept in the
In this Asian population, since there is very little cartilage in midline again with an ethmoid graft (see Chapter 3 for
the septum, it becomes quite valuable and should be reserved septum deviations).
7.7.3 Dorsal Augmentation septum become level with spaced bone or cartilage
grafts to raise the dorsum, which is left above like a
If all the septal cartilage can be stored in the dorsum in this shield. If this technique is to be used solely for radix
way, then the required dorsal augmentation will be sufficient. augmentation, palpation will yield no gap on the
To eliminate irregularity problems due to coarse particles in side walls between the dorsal roof and the elevated
diced cartilage, the ultradiced cartilage technique developed area due to the thickness of the soft tissue cover in
for dorsum augmentation can be used (for details on the tech- this area. However, if it is to be applied to the whole
nique, see Chapter 3) (Figure 7.43) [7]. back, this space can be resolved by injection of diced
In this patient group, the dorsum is dissected just enough cartilage or by placing soft tissues removed from the
to make this injection. Here, it is important that the pouch to wings (Figure 7.44).
be opened on the dorsum is narrow. But more importantly,
• The fix-up technique can be used [5] if there is
the pouch to be opened to the dorsum should be opened
an external deviation in the nose as this tech-
through the subSMAS plane. If it is opened through the sub-
nique preserves the relationship of the dorsum
membranous plane, the skin cover will not be sufficiently
with the nasal bones and upper lateral cartilages
expanded, so the correct plane in dorsal augmentation is
and can be performed in augmentation by correct-
subSMAS.
ing the deviation (for details on the technique, see
If the dorsum requires not only augmentation but also rasp-
Chapter 3).
ing, then dorsum dissection should be performed through the
submembranous plane. In this case, the elevated periosteum
can be incised after rasping, especially at the radix level, so To use these techniques, bone and cartilage septum support
that the thick lifted skin can expand. must be adequate. If not, reconstruction with rib cartilage
If the nasal dorsum needs to be opened wide, diced cartilage should be done.
can be wrapped in Surgicel or facia to eliminate the disloca-
tion [8].
If there is not enough cartilage reserve in the septum for 7.7.4 Wide Pyramidal Angle and Wide Base
dorsum augmentation, then:
Medial transverse and lateral osteotomies are almost always
necessary and quite successful in this patient group to nar-
• The let-up would be the ideal dorsal roof technique [4, row the pyramidal angle and base. Alar excision is required to
9]. In this case, the dorsal roof can remain attached to achieve the lobule-to-tip ratio and to further narrow the base.
the skin flap and augmentation is provided by placing
any material (e.g., bone, cartilage, implant) providing
volume between the dorsal roof and the septum. The
creation of a sausage-like stuffing with no dead space
for augmentation is no longer required, making this
a positive benefit. The radix, keystone, and caudal
FIGURE 7.44 Left, a case with low radix is shown. Center, in the
dorsal roof (DR) technique, bone graft to be placed between radix and
DR will enable the uplifting of the radix, and DR is sutured to the sep-
tum again (radix-up procedure). Right, DR can be uplifted by bone/
cartilage grafts to be placed between DR and septum entirely (let-up
FIGURE 7.43 Before and two years after dorsal augmentation. procedure) [4].
Alar base narrowing suture is usually required to achieve the

purposed result.
With this approach described earlier, most Asian noses can
provide enough material for reconstruction in themselves, and
the frequency of rib graft use in this ethnic population can be
decreased to the level for the Caucasian group.
7.8 African Rhinoplasty

These types of noses are wide in baselines, resulting in the
tendency for patients to request narrowing and reduction.
A larger pyramidal angle is also a problem with this large
lobule structure requiring wing excision and often alar base
narrowing sutures. However, the use of wing excisions may
be pre-empted with RF (radiofrequency) application in mild
cases.
Medial, lateral, and transverse osteotomies are necessary
to narrow the nose. perichondrio-SMASectomy [2] are also
required due to the fat subcutaneous layer and provide good
results as this patient group does not generally have a thick der-
mis but does have thicker subcutaneous tissue (Figure 7.45). (a)
(b) (c)
FIGURE 7.45 (a–c) Pre- and post peroperative views of an African rhinoplasty case are shown. perichondrio-SMASectomy [2], anatomic strut, tip-
plasty, alar wing surgery, medial and lateral osteotomies, bone rasping, and radix augmentation were performed on the patient.
(a)
(a)
(b)
FIGURE 7.47 (a–b) A secondary case for Middle Eastern rhinoplasty.

Deep SMAS suture technique [10] was used to eliminate the supratip
deformity. Before and two years after.
Arabia, United Arab Emirates, Kuwait, Iran, Oman), Turkey,

and other surrounding countries (Lebanon, Syria, Armenia,
Afghanistan, Pakistan, India).
(b)
This patient group generally has a thick oily skin envelope
FIGURE 7.46 (a–b) A primary case for Middle Eastern rhinoplasty, with both thick dermis and subcutaneous. Therefore, sufficient
who had external deviation, breathing problems, hump and tip projec- contraction may not be seen despite performing a perichon-
tion, and droopiness accompanied by heavy skin structure. DR technique drio-SMASectomy [2].
was applied on the patient for the dorsum; note how the definition of Due to the conservative religious nature of this region, this
dorsum lights became apparent and note the positive effect the frontal patient group tends to request more natural noses. Therefore,
dorsum lights had on the nose. Perichondrio-SMASectomy, ST flap, and
anatomic strut were used for the nasal tip. Before and three years after.
increase of the nasolabial angle, tip projection, and rotation
should be considered carefully. In addition, this patient group
tends to be obsessive about nostril symmetry.
The depressor septi nasi muscle is generally hyperactive and
needs to be addressed in surgery. Also, supratip deformity is
common in the secondary patients of this group, which has
7.9 Middle Eastern Rhinoplasty
issues with redraping. Reduction should be limited as the skin
The Middle East covers a wide geography including North envelope has limited contraction capacity, and over-resection
Africa (Morocco, Algeria, Libya, Egypt), the Gulf (Saudi should be avoided altogether (Figures 7.46–7.48).
(a) (b)
(c)
FIGURE 7.48 (a–c) Another primary case for Middle Eastern rhinoplasty. Note the dark circles around the eyes because of a chronic breathing
problem. The bone roof was aligned with the fix down technique [5], the amount of reduction was kept minimal, and the alignment of the roof and
elimination of the hump were targeted. Submembranous dissection was performed. Perichondrio-SMASectomy, ST flap, and anatomic strut obtained
from the septal base were used. Before and three years after.
VIDEOS 3. Rohrich RJ, Mohan R. Male Rhinoplasty: Update. Plast

Reconstr Surg. 2020 Apr; 145(4): 744e–53e.
7.1 DUAL plane dissection technique: Preoperative and
4. Taş S. Dorsal Roof Technique for Dorsum Preservation in
postoperative 1.
Rhinoplasty. Aesthet Surg J. 2020 Feb 17; 40(3): 263–75.
7.2 DUAL plane dissection technique: Preoperative and doi: 10.1093/asj/sjz063. Epub 2019 Feb 25.
postoperative 2. 5. Taş S. The Alignment of the Nose in Rhinoplasty: Fix Down
7.3 Use of the entire cartilage reserve in the septum for Concept. Plast Reconstr Surg. 2020 Feb; 145(2): 378–89.
dorsal augmentation in an Asian patient: Preoperative doi: 10.1097/PRS.0000000000006523. Epub 2019 Nov 19
and postoperative. 6. Taş S. Superior-Based Transposition Flap: A Novel
7.4 ST flap and alar excision in an Asian patient. Technique in Rhinoplasty. Aesthet Surg J. 2019 June 21;
39(7): 720–32. doi: 10.1093/asj/sjy197. Epub 2018 Aug 10.
7. Taş S. Ultra Diced Cartilage Graft in Rhinoplasty: A Fine
Tool. Plast Reconstr Surg. 2021 Apr 1; 147(4): 600e606e.
REFERENCES doi: 10.1097/PRS.0000000000007794. Epub 2020 Sept 22.
1. Capitán L, Gutiérrez Santamaría J, Simon D, Coon D, 8. Erol OO. The Turkish Delight: A Pliable Graft for Rhinoplasty.
Bailón C, Bellinga RJ, Tenório T, Capitán-Cañadas F. Facial Plast Reconstr Surg. 2000 May; 105(6): 2229–41.
Gender Confirmation Surgery: A Protocol for Diagnosis, 9. Taş S. Response to Commentary on: Dorsal Roof Technique
Surgical Planning, and Postoperative Management. Plast for Dorsum Preservation in Rhinoplasty. Aesthetic Plast
Reconstr Surg. 2020 Apr; 145(4): 818e–28e. Surg. 2020 Mar 4. doi: 10.1007/s00266-020-01656-8.
2. Taş S. Closed Atraumatic Rhinoplasty Course. Endorsed [Epub ahead of print].
by RSE (Rhinoplasty Society of Europe) and ISAPS 10. Taş S. A New Way for Supporting Tip Projection in Closed
(International Society of Aesthetic Plastic Surgery). Rhinoplasty: Using the Medial Deep SMAS Layer. Plast
Istanbul, Turkey, Nov 16–17, 2019. https://drsuleymantas. Reconstr Surg. 2014 Jan; 133(1): 76e–7e. doi: 10.1097/01.
com/course/ Accessed 11 Aug 2019 prs.0000436809.88659.e0.
Index
Note: Page numbers in italics indicate a figure and page numbers in bold indicate a table on the corresponding page.
A excised during surgery, 66, 66

acoustic rhinometry, 1 flaps, 82 – 83, 82 – 83
Adam’s apple, 161 paste, 66, 66
advanced rhinoplasty; see also rhinoplasty portion of DR, 62
African rhinoplasty, 184 – 185 cartilage bone
algorithmic approach in reduction rhinoplasty according to skin type, complex composite graft, 145
172 junction, 59
Asian rhinoplasty, 181 – 183 septum, 39
DUAL plane dissection, 180 – 181 caudal malposition, 79
female nose, 168 – 171 caudal septal extension, 55
male nose, 161 – 168 cephalic dorsum stabilization suture, 44
Middle Eastern rhinoplasty, 185 – 186 cephalic trim, 82 – 83
thick-skinned patients, 175 cleft lip-nose deformity, 149
thin-skinned patients, 172 closed atraumatic rhinoplasty, 5 – 6
aesthetic nasal surgery, 1 before and after, 17 – 21
aesthetic rhinoplasty, 5, 37, 168 dissection plane, 8 – 14
African rhinoplasty, 184 – 185 evolution, 5
airways, functioning of, 1 incisions, 7, 7 – 8
alar base retraction, 122 – 124 local injection, 6 – 7
alar base surgery open and closed comparison, 22 – 23
alar base narrowing suture, 120 preservation, 14 – 15
alar excision, 115 – 117, 116 reconstruction, 16
depressor septi nasi muscle, release, 131 – 124 redraping and closure, 16 – 21
symmetry on vertical, horizontal, and sagittal planes, 120 – 131 reshaping, 15
algorithmic approach in reduction rhinoplasty according to skin type, 172 stages of, 6 – 21
anatomic columellar septal extension graft, 94 – 95 structure, 16
anatomic dorsum, 165 submembranous (subperichondrial-periosteal) and subSMAS planes,
anatomic strut application, 91 – 93 23
Anderson’s tripod concept, 73 closed rhinoplasty approach, 139 – 141
anterior based cartilage flaps, 83 columella, 6
anterior-caudal rotation of septum, 44, 53 – 54 columellar strut, 93 – 94
Asian rhinoplasty, 181 – 184 component hump removal, 29
asymmetric maxillary aperture, 43 composite hump removal, 28
atraumatic philosophy, 28 concha lateralization, 26
atraumatic rhinoplasty, 5 congenital bifid nasal tip deformity, 79
augmentation rhinoplasty, 105 conservative rhinoplasty, 39
auricular cartilage graft in revision surgery, 152 convexity deformity, 26
costal reconstruction in revision cases with cleft lip-nose deformity,
B 149 – 150
back-cut incision, 40, 54 costal vein and nerve anatomy, 146
banana-fashion excision, 116, 116 Cottle’s technique, 38
bi-coronal incision, 161 crooked nose deformity, 53
bifid nose deformity, 79 – 80
Binder syndrome, 139 D
blinking nose deformity and its treatment, 109 debulking, 178
surgical anatomy, 109 decortication, 6
surgical technique, 110 deep SMAS suture, 98 – 100, 98
bone depressor muscle hyperactivity, 132
excision from ethmoid, 42 diced cartilage flap technique, 152 – 153
scissors, 42 dissection plane, 8 – 9
bone-cartilage-ligament complex, 59 DUAL, 10, 180 – 181
bone dust technique, 66 Room Concept, 10 – 14
before and after, 35 – 36 submembranous, 15
demonstration, 34 sub-skin, 13
botulinum toxin, 110 subSMAS, 11, 180 – 181
botulinum toxin-A injection, 126 dissection plane in revision surgery, 137
bowling pin deformity, 120 fibrosis from microperforations, 138
subperichondrial plane, 137
C SubSMAS Plane, 138
camouflage or excisional techniques, 144 dorsal roof technique, 58 – 66
canthal ligament, 26 patient selection, 60 – 61
cartilage surgical anatomy, 59 – 60
189
190 Index
surgical technique, 61 – 66 fix down technique, 40, 55, 65

dorsum fix up technique, 54
algorithm in reduction rhinoplasty, 65 – 66 flap surgery, 5
anatomic, 165 forehead-nose transaction, 161
curvature deformity, 53 free tissue transfers, 5
dissection, 42 – 43 frontal angle, 162
integrity, 59 – 61
lights, 165 G
nasal, 15 grafting, 5, 27, 40, 108
osteotomy, 62 cartilage, 124
reconstruction, 30 – 31, 66 double layer, 40
repair, 30 ethmoid, 153
skin, 38 structural, 175, 175
sutures, 43
with wide pyramidal angle, 62 H
dorsum augmentation, 66, 139, 181 – 184 hemitransfixion incision, 41
surgical technique, 66 – 69 hump
ultradiced cartilage method, 66 – 69 elimination technique, 37
dorsum excision, 28 excision, 142
bone dust technique, 33 – 35 removal surgery, 28
component hump removal, 29 humpy nose shape, 168
composite hump removal, 28 – 29 hypertelorism, 40
dorsum reconstruction, 30
history of, 28 I
dorsum preservation techniques, 28 iatrogenic saddle nose deformity, 142
dorsal roof technique, 58 – 66 incisions, 7, 7 – 8, 41
down techniques, 40 – 58 intracartilaginous, 7, 7
history, 36 – 40 marginal, 8
dorsum surgery, 25, 27 – 66 rhinoplasty, 8
categorization of, 27, 27 trans-columellar, 8
dorsum augmentation, 66 – 70 inferior based cartilage flaps, 83
hump removal technique, 27 – 28, 28 inferior chondrotomy, 41
maxilloplasty, 27
open roof, 27 J
osteoplasty, 26 – 27 jaw shape, 161
osteotomy, 25 – 26 Joseph’s technique, 38
techniques for, 27
double layer graft, 77 K
down techniques, 40 keystone anatomic strut, 92, 94
bone excision from ethmoid, 42
dorsum dissection, 42 – 43 L
ethmoid incision, 42 lacrimal bone, 25
fixation, 43 – 44 lacrimal sac, 25
incision, 41 lateral crural flap technique, 83
M suture, 44 lateral modiolus, 124 – 125
osteotomies, 43 let down technique, 39, 47 – 48
principles, 41 – 44 levator alaeque nasi muscle (LANM), 123, 124
radix osteotomy, 42 parallel course, 126
residual hump, 44 surgical anatomy, 124 – 127
selection, 41 levator labii alaque nasi muscle (LLANM), 123
septum, 41 – 42 ligaments of nose, 13
step-by-step let down, 47 – 48 lips, 161
step-by-step push, 44 – 45 local injection, 6 – 7
wedge excision, 43 loose skin, 177
DUAL plane dissection, 180 – 181 lower lateral cartilage (LLC), 73, 73, 84 – 110
lower septal anatomic strut, 92 – 93
E
electrocautery in rhinoplasty, 108 – 109 M
ethmoid incision, 42 male–female facial differences, 161
eyebrow thickness, 161 male nasal floor, 164
male nose, rhinoplasty in, 161 – 166
F marginal incision, 8
facial feminization surgery, 161 maxilla, 26
fat injection, 124 maxillary bone, 25
female nose, rhinoplasty in, 168 – 171 maxillary hypoplasia, 27, 27, 124, 130 – 131
finesse rhinoplasty, 105 maxilloplasty, 27
fisherman suture, 158 medial crus malposition, 78 – 79
fixation, 43 – 44 medialization of the nostrils, 115
Index 191
medial overlapping, 74 redraping and closure, 16 – 17

Middle Eastern rhinoplasty, 185 tissue reconstruction, 5
M suture, 44 poliglecaprone, 117
mucosal tunnels under the upper lateral cartilages, 62 polydioxanone, 44, 55, 120, 126
polyethylene, 145
N posterior based cartilage flaps, 83
nasal asymmetries, 121 posterior chondrotomy, 41
nasal bones, 15, 59 post-lacrimal sac, 25
nasal cosmetic surgery, 5 postoperative supratip deformity, 109
nasal dorsum, 15 preservation, 14 – 15
nasal framework, rooms, 13 pseudo-soft tissue hump, 180
Nasal Obstruction Symptom Evaluation psychological evaluation form, 3
(NOSE), 1 push down technique, 37 – 39, 44 – 45, 45
nasal tip pyramidal angle, 43, 60, 60
bulbosity, 181 – 182 pyriform (pyramidal) ligament, 10
cartilage anatomy of, 74
surgery, 73 – 110 R
nasofrontal angle, 162, 162 radix augmentation, 171
nasolabial angle, 162, 162 radix osteotomy, 42, 62, 62
nasolacrimal duct, 25 – 26, 26 reconstruction, 16
necrosis, 139 closed atraumatic technique, 16
nose columella reconstruction, 139
blood supply of, 8 costal, 149 – 150
external vascular anatomy, 6 dorsum, 30 – 31
framework, 8 ear, 146
internal vascular anatomy, 6 operations, 5
soft tissue envelope, 8 plastic surgery tissue, 5
treatment algorithm, 41 surgery, 35
nostril redraping
collapse, 124 and closure, 16 – 21
deformities, 76, 76 for rhinoplasty, 106
image, 75 – 77 reduction rhinoplasty, 105, 170
possible treatment options, 76 based on skin types, algorithmic approach in, 172
shape and classification, 75 of radix and dorsum, 170
reshaping, 15
O residual hump, 44
oblique cut for radix osteotomy, 42 restoring tip mobility in revision rhinoplasty patients, 153 – 154
oily skin, 177 reverse ST flap, 90 – 91
onlay graft, 73 revision rhinoplasty, 137
open atraumatic rhinoplasty, 6 auricular cartilage graft in revision surgery, 152
osteoplasty, 15, 26 – 27, 26 closed rhinoplasty approach, 139 – 141
osteotomies, 25 – 26, 33, 43 costal reconstruction in revision cases with cleft lip-nose deformity,
airway problems, 26 149 – 150
line, 26 diced cartilage flap technique, 152 – 153
nasolacrimal duct damage, 25 – 26 dissection plane, 137 – 138
rocker deformity, 25, 25 fisherman suture, 158
over-rotated noses, 154 – 158 over-rotated noses, 154 – 158
restoring tip mobility in revision rhinoplasty patients, 153 – 154
P rib cartilage in revision rhinoplasty, 144 – 149
parrot nose (Pollybeak) deformity, 180 saddle nose deformity, 142 – 144
patient selection, 1 rhinomanometry, 1
aesthetic evaluation, 2 rhinoplasty, 26, 80; see also advanced rhinoplasty
functional evaluation, 1 comparison of surgical approaches, 22
patient identification, 1 comparison of surgical planes, 23
physical examination, 1 incisions, 7 – 8
psychological evaluation, 1 rib cartilage in revision rhinoplasty, 144 – 149
revisit, 2 rib graft, 147
simulation study, 2 rocker deformity, 25, 25
perichondrio-SMASectomy, 102 – 103, 177 Room Concept, 7, 10 – 11, 11, 13, 17, 87
perichondrium, 9, 147 – 148
photographic and video documentation, 1 S
pig nose, 154 saddle nose deformity, 142 – 144, 144
pinch test, 102 scroll-based cartilage island flap, 88
piriform ligament, 129 scroll ligament, 10
pitanguy ligament, 6, 11, 95 – 96, 96 septum, 41 – 42
plastic surgery, 1, 16, 28 anterior caudal direction, fixing, 55
principles of, 117 and Kiesselbach plexus, 6
reconstruction in, 16 problems, 182
192 Index
pyramidal adjustment and repositioning (SPAR) technique, 40 vein-nerve package of, 147
surgery, 53 tip bulbosity, 180
sex reassignment surgery, 161 tipplasty, 80 – 82
silicone anatomic columellar septal extension graft, 94 – 95
implants, 144 anatomic strut concept, 91 – 93
tube intubation, 26 bifid nose deformity, 79 – 80
SMASectomy, 17, 102 – 103 columellar strut concept, algorithm of, 93 – 94
smiling deformity, 130 – 132, 131 – 134 deep SMAS suture, 98 – 100
soft tissue history, 73
anatomy, 123 lateral crural flap, 83 – 84
graft, 153 lateral crus malposition, 78
redraping, 105 – 106 lower lateral cartilage flaps, 82 – 83
speaking deformity, 131 – 132 medial crus malposition, 78 – 79
spiderweb network suture, 54, 55 mystery of pitanguy ligament, 95 – 96
spreader graft, 30 – 31, 30 nostril image, 75 – 77
stabilization of spreader flaps, 63 perichondrio-SMASectomy, 102 – 103
step-by-step fix down technique, 51 – 58 reverse ST flap, 90 – 91
before and after, 46 – 47, 49 – 50 soft tissue redraping, 105 – 108
push, 44 – 45, 45 ST flap (superior based transposition flap), 84 – 88
structural rhinoplasty, 139 supratip break point, 75
structure, 16 surgical anatomy and deformities, 73 – 80
submembranous (subperichondrial-periosteal) and subSMAS planes, 23 techniques, 81
submucoperichondrial tunnel, 33 techniques on tripod, 74
submucosal tunnel, 33 tripod concept, 74
subperichondrial dissection on septal cartilage, 14 trans-cartilaginous incision, 7
subperichondrial plane, 9 trans-columellar incision, 8
sub-skin dissection plane, 13 transnasal bone fixation, 43
subSMAS dissection plane, 11, 10 – 12, 14 transversalis nasalis muscle (TNM), 124
superior based cartilage flaps, 86 triangular cartilage, 59
superior based transposition flap (ST flap), 84, 85 trigeminal nerve, divisions, 7
advantages and disadvantages, 90 tripod, 74, 74
indications and contraindications, 85 Turkish Delight, 28
supraorbital ridge, 161
supratip U
break point, 75, 75 ultradiced cartilage, 66 – 68
deformity, 109, 180 upper lateral cartilage (ULC), 83
suture rhinoplasty, 73
swing door technique, 41 V
valve of Halser, 26
T VAS (Visual Analog Scale), 1
tachycardia, 7
tailor-made anatomic strut, 93, 93 W
TAŞ3®, 27, 33, 33 Webster triangle, 26, 26
thick-skinned patients, rhinoplasty in, 175, 179 wedge excision, 43
thin-angled concha, 42 wedge resection/let down technique, 39
thin-skinned patients, rhinoplasty in, 172
thorax Z
anatomy of, 146 Z plasty for radix osteotomy, 42

Suleyman Tas - Rhinoplasty in Practice - An Algorithmic Approach To Modern Surgical Techniques-CRC Press (2022)

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Rhinoplasty in Practice

Videos are available on the Companion Website: www.routledge.com/cw/tas

1.4 Functional Evaluation

second observation provides numerous advantages; the patient

Name and Surname:

2. How often do you visit a hairdresser?

Although many incisions have been presented in the litera-

• The incision can be repaired by primary suturing

Therefore, before choosing the open technique, the irrevers-

2.2 Stages of the Closed Atraumatic Technique

2.2.1 Local Injection

FIGURE 2.4 Divisions of trigeminal nerve.

Due to the septum’s rich blood supply, tachycardia and

Fundamental Closed Atraumatic Rhinoplasty Incisions

1. Inferior intracartilaginous incision

FIGURE 2.7 Classic rhinoplasty incisions.

FIGURE 2.9 The framework of the nose.

Classic Rhinoplasty Incisions (Figure 2.7)

2.2.3 Dissection Plane

FIGURE 2.13 The bloodless surgical plane created by the subperichon-

plane is the most bloodless surgical plane that can be achieved

FIGURE 2.15 The DUAL dissection plane described by the author is

2.2.3.1 Room Concept

(b) • For the submembranous dissection plane:

• For subSMAS dissection plane:

FIGURE 2.16 The transition zone described by the author is schema-

The upper room is separated from the middle room by the

FIGURE 2.29 SubSMAS dissection meets with the subperiosteal dis-

bones, the dissection switches itself under the periosteum of

FIGURE 2.28 In this histological study of the author, it is clearly

Important Note: When dissecting the dorsum completely in

• With respect to the thickness of the nasal bones, they

FIGURE 2.37a Exposure of the lower lateral cartilages, while com-

FIGURE 2.35 As a result of component excision from cartilage dor-

2.2.8 Redraping and Closure

FIGURE 2.39 (a, b) In a patient who underwent rhinoplasty with

FIGURE 2.42 (Continued)

TABLE 2.2 Rhinoplasty Society), ISAPS (International Society of

FIGURE 3.1 The correction of a severely crooked nose with asymmet-

closed with the lower concha lateralization, the tear drainage

The Following Should Be Done in These Cases

1. The eye should immediately be covered with a strip

If the nasolacrimal duct is damaged, or if there was already

3.1.1.3 Airway Problems

If power instruments are not available, TAŞ3® can be used

FIGURE 3.6 (a) The historical categorization of dorsum surgery.

and proposed closed roof techniques, popularizing the push

3.4.1.2 Composite Hump Removal

FIGURE 3.9 Component excision material.

3.4.1.3 Component Hump Removal

3.4.1.4 Dorsum Reconstruction

• Reconstruction should be eased by minimizing the

region that cannot be covered with an osteotomy, the

3.4.1.5 Bone Dust Technique

1. Thickness of spreader flaps: the thickness of the upper

3.4.1.5.1 Surgical Technique

FIGURE 3.18 The cartilaginous roof is covered with spreader flaps.

FIGURE 3.20 (a, b) Schematic demonstration of the bone dust technique.

completely flattened (Figure 3.17), the excess of the upper lat-

of the surgical technique are shown in detail in Video 3.10

FIGURE 3.21 The ultrasonographic study: blue arrow, glabella; yellow

FIGURE 3.22 (a–d) Before and five years after.

FIGURE 3.23 (a–d) Before and 3.5 years after.

3. C-shape deviation in the anterior-posterior direction Type 3:

4.2 Surgical Anatomy and Related