Barış Çakır - Aesthetic Septorhinoplasty-Springer (2021) PDF

Barış
Çakır
Aesthetic
Septorhinoplasty
Second Edition
123
Aesthetic Septorhinoplasty
Barış Çakır
Aesthetic Septorhinoplasty
Second Edition
Barış Çakır
Visiting Staff
Nişantaşı American Hospital
Istanbul, Turkey
Editing and translation by Bülent Genç
ISBN 978-3-030-81860-9 ISBN 978-3-030-81861-6 (eBook)

https://doi.org/10.1007/978-3-030-81861-6
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and
retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter
developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed
to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty,
expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been
made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
To my dear wife, Çiğdem Çakır
Foreword
Dr. Baris Çakır has written a worthy successor to Jack Sheen’s monumental text Aesthetic
Rhinoplasty. As a resident, I remember reading Sheen’s textbook and suddenly seeing rhino-
plasty in a fundamentally new way. Sheen set specific aesthetic goals and achieved them with
a range of new techniques that he had developed.
For the next 30 years, I learned a great deal in the operating room and from lectures by my
colleagues. However, I had not had that feeling of excitement of witnessing a new era in rhino-
plasty surgery until I attended the Combined Rhinoplasty Meeting of the Turkish and American
Rhinoplasty Societies held in Istanbul in 2011. As usual, I was taking notes and trying to stay
awake late in the afternoon during the 5-min presentations. Suddenly, I became aware that
something dramatic was happening. A speaker was talking about new concepts for tip aesthet-
ics (polygons), bony vault remodeling (bony sculpting), and nostril sill excision. When the
session was over, I went up to Dr. Çakır and asked him if he would present the talk again for
me the next morning. He did, and I had him repeat it three times. I was totally amazed at his
concepts, but wondered if he could really do in the operating room what he was presenting.
Therefore, I asked him if he could do a case for me. The conversation went as follows: “I’d like
to see you do a case.” “When?” “Tomorrow.” “Okay.” The next day, Dr. Çakır did a rhinoplasty
employing a wide range of techniques that he had developed and achieved a superb result.
Later that day at lunch, my head was still reeling from trying to understand the nasal polygons,
his advanced tip suture techniques, and repair of numerous ligaments that I had routinely cut.
I reasoned that the only way I could understand his concepts was to help Dr. Çakır write up his
techniques that he had thus far been unable to publish. Subsequently, he came to me and said
he had more ideas for journal articles. I told him that he would always have too many ideas and
too little time. I advised him to go ahead and write a book as it would clarify his thinking and
allow others to build on his concepts. Naively, I thought he would be preoccupied for a couple
of years. Six months later, he sent me the manuscript, and 3 months after that, the Turkish
Edition was published to be followed by the English Edition.
In reading Dr. Çakır’s masterpiece, I am struck anew by how original and advanced his
concepts truly are. Something as mundane as nasal photography and analysis suddenly
becomes an art form and the use of preoperative “shadow photographs” a brilliant break
through. Some of his polygon concepts require multiple readings before one fully understands
them. For example, the concept of a “resting angle” between the lower lateral and upper lateral
crura is totally new. At first, one may think it is of little importance, but when linked to the long
lateral crus and herniation of the lateral crus into the vestibule, its relevance becomes obvious.
One suddenly has an answer for a previously inexplicable problem as well as a method of treat-
ment and more importantly a method of prevention. The discussion of multiple tip points and
definition of the soft tissue facets as well as their relation to specific tip sutures is crucial infor-
mation. In the surgical technique chapter, the importance of the continuous subperichondrial-
subperiosteal dissection plane becomes apparent. The novice surgeon should remember that
many of his techniques were perfected through the open approach before Dr. Çakır progressed
to the closed approach. There are certain ideas with which I disagree, including scoring of the
vii
viii Foreword
septum, leaving a 2-mm gap between the septal base and the anterior nasal spine, and resection
of the membranous septum. I also recognize that the book may prove daunting to some given
the plethora of new concepts and the quality of the English translation.
Yet, this is a book to be savored and read multiple times before returning to specific chapters
for greater insight into the challenges of rhinoplasty surgery. For a younger surgeon, the book
provides in-depth discussion of how to analyze and photograph the patient while formulating
an individualized patient-specific operative plan. The linkage of surface aesthetics to nasal
anatomy to surgical techniques is the foundation of this text. For the experienced surgeon, the
book will be a revelation of how to set and achieve higher aesthetic standards using the
described methods. For the master surgeon, Dr. Çakır challenges many of our accepted prin-
ciples and techniques ranging from the aesthetic dorsal lines to the need for lateral crural
transposition. Every surgeon performing nasal surgery should purchase a copy of Aesthetic
Septorhinoplasty as Dr. Çakır’s concepts, principles, and techniques represent the future of
rhinoplasty surgery.
Newport Beach, CA, USA Rollin K. Daniel

Preface to the Second Edition of the Aesthetic
Septorhinoplasty
I had known Dr. Barış Çakır long before, but it was the year 2010 when I first saw him in the
operating room. I was doing an open rhinoplasty in the other room and had a sneak peek at his
closed rhinoplasty. His meticulous dissection and closed approach drew my attention, but,
despite some negative feedbacks like a stiff nasal tip or occasional supratip swelling over the
years, I was satisfied with my technique and results by the time. In 2018, I was asked to trans-
late the Preservation Rhinoplasty book. I watched the surgery to orientate myself throughout
the book and read the Turkish version of the book several times word by word, not only to
translate it but also to learn it by heart, as I was changing sides theoretically even if not practi-
cally yet. Intrigued by his work, I found myself reading the first edition of Aesthetic
Septorhinoplasty. Then I started forcing myself out of my comfort zone. I was now executing
the steps that I knew like the back of my hand, and it was exciting. Since then, I have been
enjoying this less destructive and more anatomic surgery. This new concept of rhinoplasty is
becoming more and more popular among rhinoplasty surgeons throughout the world as dedi-
cated meetings are being held globally. Since its first edition in 2016, newer concepts of pres-
ervation rhinoplasty have ripened and found their way in this new edition of Aesthetic
Septorhinoplasty. We are witnessing a new visionary era in the history of rhinoplasty, and I am
glad and proud to be a part of it. The original language of the book is reader-friendly, and I
endeavored to keep the English fluent and understandable. I hope that the readers will benefit
immensely from this revised second edition of the Aesthetic Septorhinoplasty book.
Istanbul, Turkey Bülent Genç

Editor of The Second Edition
ix
What Kind of Book Is This?
This book describes closed rhinoplasty in which open rhinoplasty techniques are used. In order
to make the information presented here quickly and easily accessible, the writing style has
deliberately been kept simple, and more emphasis is put on the images, so that the book reads
like detailed surgery notes. No extensive explanation accompanies the photographs, but text,
photographs, and drawings complement each other, and the images illustrate the preceding
text. Photographs of those patients who gave permission of use are in standard format, while
the photographs of those who refused permission were cropped to make their faces unrecog-
nizable. Since I wanted to illustrate the effects of closed rhinoplasty, dissection, and ostectomy
techniques on healing rates, I have also included images with early results.
About the Second Edition
I have started performing dorsal preservation techniques in 2016 thanks to Dr Yves Saban. We
have been working on the Preservation Rhinoplasty concept since 2017 under the directorship
of Dr. Rollin K. Daniel. Although I still use the same techniques in tip surgery, new techniques
have been added to nasal dorsal surgery. Therefore, we have gathered so much new informa-
tion that a second edition of our Aesthetic Septorhinoplasty book has become mandatory. The
most important innovation in the second edition is the chapter about dorsal preservation.
Besides that, I have made some revisions in the entire book.
xi
Acknowledgments
Special thanks are due to Tayfun Aköz, MD, and Mithat Akan, MD, who taught me about nose
surgery; Ali Teoman Tellioğlu, MD, and Mithat Akan, MD, who undertook the scientific revi-
sion of the book; my wife Çiğdem Çakır; Metin Bahçivan for editing the Turkish text; Dr.
Bülent Genç, Dr. Erhan Coşkun, Nina Ergin, and Ali Rıza Öreroğlu for proofreading the
English translation; Art teacher Candan Canay and Yusuf Başoğlu for helping Polygon concept
surface analysis.
Barış Çakır
www.bariscakir.com
Inquiries, comments, and suggestions to the author can be sent to: drbariscakir@gmail.com
xiii
Contents
Part I Before Surgery
1 Photography �� 3

1.1 Patient Photographs�� 4
1.1.1 Reference Photographs �� 5
1.1.2 Photography Angles�� 9
1.2 The Photography System�� 14
1.2.1 Intraoperative Photographs �� 15
1.2.2 Light Illusions �� 15
1.2.3 Fish-Eye�� 20
1.3 Camera Settings�� 22
1.3.1 Focus Settings �� 22
1.3.2 ISO�� 23
1.3.3 Shutter Speed�� 23
1.3.4 F�� 23
1.3.5 Skin Color �� 23
1.3.6 Color Settings �� 23
1.3.7 Soft box Light Settings �� 23
1.3.8 Shooting with a Smartphone�� 26
1.3.9 Video Camera�� 27
1.4 Imaging �� 27
1.4.1 Shadowing the Images�� 36
1.5 The Importance of Photography and Imaging�� 43
1.6 Surgery Notes and Archiving�� 55
1.7 Photography Archive�� 56
1.7.1 Backup�� 57
2 How to Draw a Nose�� 59
2.1 Exercises �� 61
2.1.1 Sketch from the Front �� 62
2.1.2 Sketch from the Side�� 63
2.1.3 Sketch from Above and Below �� 66
2.2 Analysis of Patient Photographs �� 70
3 Nasal Polygons�� 75
3.1 Infratip Triangle�� 77
3.2 Tip Defining Point�� 78
3.3 What Is a Facet?�� 79
3.4 The Non-mobile Nose�� 79
3.5 The Mobile Tip Area�� 79
3.5.1 Mass Polygons�� 79
3.5.2 Space Polygons �� 79
xv
xvi Contents
3.6 Tip Breakpoints�� 79

3.7 Dome Triangles�� 80
3.8 Interdomal Triangle�� 86
3.8.1 Dome Divergence�� 88
3.9 Infralobular Polygon �� 89
3.10 Columellar Polygon�� 90
3.11 Footplate Polygons�� 91
3.12 Facet Polygons�� 92
3.12.1 Relation of the Facet and Dome Polygons�� 96
3.13 Lateral Crus Polygons�� 97
3.14 Resting Angle�� 97
3.14.1 Vertical Compression Test�� 99
3.14.2 Incorrect Resting Angle and Its Effect on the Ala�� 105
3.14.3 Wide Lateral Crura�� 106
3.14.4 Long Lateral Crura�� 106
3.14.5 Convex Lateral Crura�� 119
3.14.6 Cephalic Malpositioning�� 119
3.15 Scroll Facet �� 123
3.16 Scroll Line�� 126
3.17 Dorsal Cartilage Polygon�� 126
3.18 Dorsal Bone Polygon�� 128
3.19 Upper Lateral Cartilage Polygons�� 128
3.20 Lateral Bone Polygons�� 129
3.21 Dorsal Aesthetic Lines�� 129
3.21.1 Summary: Dorsal Aesthetic Lines�� 136
3.22 Lateral Aesthetic Lines �� 139
3.23 The Polygon Model�� 141
4 Instruments�� 143
4.1 The Rhinoplasty Instrument Set�� 143
4.2 Magnetic Instrument Mat�� 144
4.3 Nasal Speculum�� 144
4.4 Dorsum Retractor�� 145
4.5 Small Retractor (Crile)�� 145
4.6 Forceps�� 146
4.7 Needle Holder �� 146
4.8 Scissors �� 147
4.9 Bone Scissors�� 147
4.10 Rasp�� 148
4.11 Elevators�� 148
4.12 Hooks�� 149
4.13 Ninety-Degree Bone Raspatory�� 149
4.14 Rongeur�� 150
4.15 Chisels and Osteotomes�� 150
4.16 Hammer�� 151
4.17 Arkansas Stone�� 152
4.18 Sutures�� 152
4.19 Taştan-Çakır Saws�� 153
4.20 Forceps�� 153
4.21 Ayhan PPE Forceps�� 154
4.22 Headlamp�� 154
Contents xvii
Part II Surgery
5 Skin, Chin, Cheek, and Forehead�� 157
5.1 Skin Care and Rhinoplasty�� 158
5.2 Oral Isotretinoin Treatment�� 159
5.3 Menstruation �� 170
5.4 Forehead Fat Grafting �� 170
5.4.1 Why Is the Forehead Important in Rhinoplasty?�� 170
5.4.2 Technique�� 171
5.5 Jaw�� 187
5.6 Importance of Cheeks �� 192
5.7 Periorbital Fat Grafting �� 200
6 Surgical Preparation, General Anesthesia, and Local Anesthetic Infiltration �� 205
6.1 Patient Position and Tracheal Intubation�� 206
6.2 Cleaning�� 206
6.3 Local Anesthesia �� 208
6.3.1 For the Nose�� 208
6.3.2 For the Septum�� 208
6.4 Injection Points �� 208
6.5 Lighting in the Operating Room �� 210
6.6 Drawings �� 211
7 Turbinate Surgery�� 215
7.1 Turbinates�� 215
7.2 Turbinate SMR�� 215
7.2.1 Normal Anatomy�� 221
7.2.2 Inwardly Collapsed Maxillary Base�� 221
7.2.3 Segmental Out-Fracture�� 222
8 Incisions and Dissection in Rhinoplasty�� 225
8.1 Hemitransfixion and Transfixion Incisions �� 225
8.2 Entering the Nasal Dorsum from the Septal Angle�� 228
8.3 Infracartilaginous Incision and Auto-rim Flap�� 230
8.4 Markings �� 230
8.5 Lateral Crural Subperichondrial Dissection�� 233
8.6 How Is Lateral Crural Subperichondrial Dissection Performed? �� 233
8.7 Combining Tip and Dorsum Dissections�� 237
8.8 Periosteal Dissection�� 237
8.9 Subperichondrial Dissection in Secondary Rhinoplasty�� 241
8.10 Delivering the Domes �� 242
8.11 Supratip Break Point �� 248
8.12 Subperichondrial Dissection in Open Approach�� 253
8.13 Why Subperichondrial Dissection?�� 263
8.13.1 Subperichondrial Dissection and Healing�� 263
8.13.2 Subperichondrial Dissection and Muscle Function�� 263
8.13.3 Subperichondrial Dissection and the Camouflage Effect �� 264
8.13.4 Effect of Subperichondrial Dissection on Bleeding�� 264
8.13.5 Effect of Subperichondrial Dissection on Ligaments �� 264
9 Septoplasty�� 267
9.1 Dissection�� 268
9.2 Extracorporeal Septoplasty �� 273
xviii Contents
10 Classic Dorsal Resection�� 277

10.1 Dissection of the Upper Lateral Cartilage Mucosa�� 277
10.2 Dorsal Cartilage Resection �� 278
10.3 Dorsal Bone Resection�� 280
10.4 Radix �� 283
11 Osteotomy, Ostectomy, and Dorsal Reconstruction�� 285
11.1 Setting the Dorsal Height�� 285
11.2 Checking the Open Roof�� 285
11.3 Lateral Osteotomy�� 288
11.4 Transverse Osteotomy�� 290
11.5 Medial Oblique Osteotomy�� 291
11.6 Lateral Ostectomy�� 291
11.6.1 Ostectomy Technique�� 293
11.6.2 Instruments for Ostectomy�� 295
11.6.3 Why Ostectomy?�� 301
11.7 Out-Fracturing the Nose with Ostectomy �� 305
11.8 Bone Check�� 308
11.9 Bone Massage �� 309
11.10 Reconstruction of the Nasal Dorsum�� 309
11.11 Dorsal Aesthetic Lines�� 310
11.12 The Libra Graft �� 312
11.13 Nasal Dorsum Control�� 316
11.14 Bone Dust and Cartilage Paste�� 323
11.15 Short Nasal Bones�� 325
11.16 Dorsal Reconstruction in Men�� 330
12 My First 500 Dorsal Preservation (October 2019)�� 335
12.1 Dorsal Preservation and Classic Dorsal Resection �� 336
12.2 On Which Patients Should Dorsal Preservation Be Used? �� 336
12.3 Which Technique to Do First?�� 336
12.4 What Are the Types of DP?�� 336
12.5 When Do I Use Total Preservation and When Cartilage Only DP?�� 337
12.5.1 Cone Beam�� 337
12.6 Total Preservation Versus Cartilage Only Preservation�� 337
12.7 Low Septal Strip Versus High Septal Strip?�� 339
12.7.1 The Relationship of Septoplasty and Rhinoplasty with Skull Base�� 341
12.7.2 Removing the Septal Strip�� 341
12.7.3 The Resistance Points of DP�� 349
12.8 Dorsal Fixation�� 353
12.9 Dorsal Cartilage Fine-Tuning �� 355
12.10 No-Dissection DP �� 360
12.10.1 Case #1�� 360
12.10.2 Case #2�� 361
12.10.3 Case #3�� 362
12.10.4 Case #4�� 364
12.10.5 Case #5�� 365
12.10.6 Case #6�� 366
12.10.7 Case #7�� 367
12.10.8 Case #8�� 368
12.10.9 Case #9�� 369
12.10.10 Case #10�� 370
12.10.11 Case #11�� 372
12.10.12 Case #12–13�� 373
Contents xix
12.10.13 Complications: Case #1�� 374

12.10.14 Complications: Case #2�� 376
12.11 Conclusions�� 377
13 How Did the Nose Get Deformed?�� 379
13.1 Observation and Theory�� 379
13.1.1 Observations �� 379
13.1.2 Theory �� 387
13.2 Discussion �� 389
14 TIP Surgery�� 391
14.1 Auto-Rim Flap�� 391
14.1.1 When to Apply an Auto-Rim Flap�� 394
14.1.2 Is the Auto-Rim Flap Difficult to Perform?�� 397
14.1.3 What Is the Rationale for the Auto-Rim Flap? �� 397
14.1.4 How to Perform an Auto-Rim Flap�� 399
14.2 Marking and Lateral Crural Resection�� 413
14.3 Lateral Crura Preservation�� 415
14.3.1 Lateral Crural Steal �� 417
14.4 Cephalic Dome Suture�� 428
14.4.1 How I Started Using the Cephalic Dome Suture�� 428
14.5 Dome Equalization�� 432
14.6 Figure-of-Eight Suture�� 432
14.7 Columellar Strut Graft�� 433
14.7.1 Where Is the Best Graft Donor Area? �� 433
14.7.2 Strut Graft Placement�� 433
14.8 Loop Suture for Strut Graft Stabilization (Tie Suture) �� 434
14.9 C Suture�� 438
14.9.1 Columellar Breakpoint�� 438
14.9.2 Technique�� 439
14.10 Stabilization of the Columellar Polygon�� 440
14.11 Bow-Tie Suture (Figure-of-Eight, Horizontal Mattress Suture) �� 442
14.12 Medial Crura Overlap �� 443
14.12.1 What Is the Most Reliable Lower Lateral Cartilage Cutting Point? �� 444
14.12.2 Total Medial Crural Overlap �� 444
14.12.3 Partial Medial Crural (Caudal) Overlap�� 448
15 Tip Projection and Rotation�� 469
15.1 Projection�� 469
15.1.1 Nostril Apex Projection�� 470
15.1.2 Lobule Projection�� 471
15.2 Tip Rotation�� 473
16 Tip Asymmetry�� 475
17 Cephalic Malposition �� 487
17.1 Treatment�� 494
17.2 Summary �� 494
17.3 Transposition of the Lateral Crural Tail�� 496
18 Fine-Tuning�� 515
18.1 Narrowing of the Footplate Polygon�� 515
18.1.1 Asymmetrical Footplates�� 517
18.2 Dissection and Augmentation of the Origin of Depressor Nasi Muscle�� 519
18.3 Additional Transdomal Sutures�� 520
18.3.1 Increasing Dome Definition�� 520
xx Contents
18.3.2 Expanding the Interdomal and Infralobular Polygons�� 521

18.4 Resection of the Caudal Edge of the Dome�� 522
18.5 Infralobular Caudal Contour Grafts�� 523
18.6 Tip Grafts�� 531
18.6.1 Boomerang-Shaped Peck Graft�� 531
18.7 Deprojection of Nostril Apex Projection (NAP)�� 537
18.8 C′ Graft �� 539
18.9 Tip Camouflage�� 543
18.10 Extra Columellar Strut�� 543
18.11 Rim Grafts�� 544
19 Stabilization of the Nasal Tip�� 545
19.1 Vertical Scroll Reinsertion�� 549
19.2 Suturing the Pitanguy Ligament in the Open Technique�� 552
19.2.1 Repairing the Superficial SMAS�� 553
19.2.2 Membranous Tongue in Groove�� 554
20 Nostril Surgery �� 559
20.1 Problems and Solutions�� 560
20.2 Thick Alar Base: Simple Elliptic Resection�� 560
20.3 Big Nostrils: Nostril Sill Advancement Flap�� 568
20.4 Superior Repositioning of the Nostril Sill�� 576
20.5 Big Nostril and Thick Alar Base: Combination of Nostril Sill
Advancement Flap and Elliptic Resection�� 581
20.6 Common Mistakes�� 588
20.7 Hanging Alae�� 588
20.8 Alar Rim Excision�� 589
20.8.1 Marking�� 589
20.8.2 Incision�� 590
20.8.3 Resection�� 590
20.8.4 Suture�� 591
21 Deviated Nose �� 619
21.1 Problems with Left Axis Noses�� 620
21.2 Reference Points �� 621
21.3 Nasal Dorsal Resection �� 623
21.4 Septoplasty�� 625
21.5 Tip Surgery�� 628
21.6 Swinging Door Septoplasty�� 648
22 Secondary Rhinoplasty�� 649
22.1 Septal Cartilage�� 650
22.2 Rib Cartilage �� 650
22.3 Cartilage Chips�� 650
22.3.1 Surgery�� 652
22.4 Block Cartilage �� 655
22.5 Oblique Split Rib Grafts �� 656
22.6 Partial Oblique Split Rib Grafts�� 662
22.6.1 Surgery�� 662
22.7 Cartilage Paste�� 664
22.8 Turkish Delight �� 666
22.9 Rib Perichondrium�� 667
22.10 Nasal Dorsal Dissection in Secondary Rhinoplasty�� 667
Contents xxi
22.11 Hanging Columella �� 671

22.11.1 Preventing Alar Retraction�� 672
22.11.2 Surgery�� 675
22.12 Lateral Crural Cephalic Strut Graft�� 677
22.13 Pinched Nose Deformity�� 687
23 Taping and Splinting�� 695
23.1 Fixing the Silicone Splints:�� 696
23.2 Drains�� 696
23.3 Taping and Splinting �� 697
23.3.1 Prevent Fossa Formation Under Domes �� 699
23.4 Postoperative Care�� 700
23.4.1 Postoperative Order�� 704
23.5 Prescription After Rhinoplasty�� 704
23.6 Recommendations After rhinoplasty�� 704
24 Case Studies�� 705
References �� 787
Index�� 789
About the Author
Barış Çakır After graduating from the Electronics Department of the Çukurova Technical
High School, I studied at the Faculty of Medicine upon my parent’s wish, and during the fifth
year of my studies, I had to undergo rhinoplasty, followed by revision surgery 6 months later.
Within my own medical career in plastic surgery, I focused on microsurgery and performed
many such operations, but my strongest interest has been in nose surgery because it requires
both technical skill and aesthetic understanding. Even for someone like me who has both
undergone and then continually performed nose surgery, this specialization continues to pres-
ent interesting challenges because it is constantly developing. Several years of drawing and
sculpting courses have contributed to my own professional development, and in my own prac-
tice of 8 years—90% of which consists of rhinoplasty—I have made changes to almost half of
all the techniques I learned in medical school. For instance, I began nose remodeling surgery
with the open technique, but since 2008, turned to closed technique instead—a rather unusual
turn, as most surgeons move in the opposite direction. Today, I am performing approximately
200–300 closed-technique rhinoplasties per year.
In 2012, at the ASAPS Congress, Dr. Rollin Daniel encouraged me to write this book in the
format of an instruction manual, so as to allow others to benefit from my experiences with
rhinoplasty as well as visual documentation surrounding this type of surgery; hence, in the
framework of this book, I have defined proper standards for surgical photography and technical
drawings. It is my hope that readers will find the present work most useful for their own
practice.
xxiii
Part I
Before Surgery
Photography
1
Abstract
Documentation of patient information is very important

both medicolegally and scientifically. Photography occu-
pies an important place in this documentation, especially
in plastic surgery. On the other hand, evaluating patients’
pre- and postoperative photos is very important for per-
sonal surgical development. Results of surgical maneu-
vers and their long-term effects are only possible with an
objective evaluation. For this reason, a plastic surgeon
should pay utmost attention to photo shooting. This care
you show is actually the care you show to the patient. In
this section, you will find my photography system, cam-
era settings and making of the Photoshop projection of
the result in my own practice.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 3

B. Çakır, Aesthetic Septorhinoplasty, https://doi.org/10.1007/978-3-030-81861-6_1
4 1 Photography
1.1 Patient Photographs studio. Below you can see my photography studio. I have
been using a 100 mm macro lens and the soft boxes below
My patient consultation starts with taking photographs. I for 10 years now.
designed one of the rooms in my office as a photography
1.1 Patient Photographs 5
1.1.1 Reference Photographs take their photos. I collect the photographs that patients bring
to me as well. Sometimes I look at them. I would recommend
I have a “beautiful nose” folder on my computer. I take pho- the same to you. You can see a female and a male nose that I
tos of people with beautiful noses. I ask my patients’ com- consider beautiful below. You can return to these photos for
panions and my friends who have good-looking noses and the aesthetic details to be explained further.
6 1 Photography
Please pay attention to the light going from the tip to the
nasal ala of the beautiful nose below. The caudal edge of the
lateral crus and the facet polygon beneath can be clearly
visualized.
8 1 Photography
The parabolic dorsal aesthetic lines stand out in the case

below.
Please notice the relationship between the lateral supratip

break point that is the beginning of the right scroll line, the K
point, and the nasal radix.
You should employ a photographic standard. The more

importance you give to patient photography, the more you
will develop your own standards and make your patients feel
valued. Do not take photos just before surgery. Be done with
your photography and photo imaging work during the
consultation.
1.1.2 Photography Angles
Both ears should be equally visible in the frontal view. The

forehead and chin should be aligned, and the contralateral
eyebrow not visible in the lateral view.
10 1 Photography
Photos when smiling give an idea about muscle activity.

The patient can be asked to lift the nasal tip to show its
mobility.
Aligning the nasal tip with the cheek contour is an easy

way to standardize the oblique view. The nasal tip can be
located at the middle of the lip in the helicopter view.
Basal photos can be standardized by aligning the nasal tip The front view gives information about the dorsal aes-
with the eyebrows. thetic lines. It shows the shape of the nostrils. A contraction
of even 1–2 mm at the nostril apex will lead to an operated
look. This pose can be named as the “speaker pose.”
Deformed nostrils on television catch unwanted attention. A
standard front view gives an outline of tip bulbosity.
In the side view, facial profile is evaluated. The C point

and supratip break are best evaluated by this pose.
12 1 Photography
Photographs while smiling show nasal tip dynamics.
The nose should play along with facial gestures. Dorsal

aesthetic lines and lateral crural convexity are best shown in
the helicopter view.
I very much like the 3/4 view. The lateral crural caudal operated nose the most. This angle can be called the “artist
border light, facet, and lobule polygons are best examined in pose.” This becomes the most important angle in close-up
this view. Noses with inadequate definition look rounded in shots in movies. The 3/4 view never dismisses pinching.
this view. I believe that this is the pose that gives away an
The basal view is very important in meetings. This view views may reveal deformities in this view. Abnormal widen-
never hides deformities. A nose which is beautiful in all other ing in the columella may stand out in over-grafted noses.
14 1 Photography
My art teacher once asked me why some operated noses

were triangular and told me that it didn’t look natural. He
taught me that the transition from the alar wings to the tip of
the nose should be parabolic.
1.2 The Photography System
Obtain an intermediate-level SLR camera. A proper lens

(e.g., macro) is more important than the camera itself. I use a
100 mm macro lens. Standard shots cannot be taken with
zoom lenses. If you use a zoom lens, try to take photos
adjusting the zoom to 100 mm. I have tried using a 100 mm
macro lens with an anti-shake optical stabilization feature.
Such lenses are expensive and besides, I believe that portrait
shots are more difficult with these lenses. You should have a
standard background. It is better to select the correct back-
ground color in advance, because you cannot change it later.
The best choices in my opinion are black, gray, blue, and
dark blue. Black will appear more artistic, but blue is a better
choice for scientific purposes.
Shadows will not occur if you keep a distance of at least
1 m between the patient and the background. If you have a
studio with soft box lighting system, you should be able to
take good photos.
Take vertical (portrait) photos. Archiving and photo merg-
ing will be much easier. If you take horizontal (landscape)
photos, you will need extra work cropping them later on. The location and intensity of light reflections change as
Remember that you need to keep a distance with the the patient changes position for different angles. Because of
patient during the photo shoot to get good quality photos. If that, the positions of the lights and the patient must be steady.
you are using a macro lens, this distance should be at least In our photography studio, there is a circle on the floor, guid-
2 m distance in order to capture your patient’s face in the ing the patient’s position. You can use self-adhesive foot-
correct frame. Another important issue is the position of the prints for this purpose.
patient in relation to light sources.
1.2 The Photography System 15
1.2.1 Intraoperative Photographs
I have been taking photos of the structure of nasal cartilages

at the beginning and end of the surgery for many years.
Evaluating your 1-year post-op results with pre-op photo-
graphs will accelerate your development. In my practice, I
use a dSLR camera with 100 mm macro lens for photographs
in the operating room as well.
1.2.2 Light Illusions
The positions of the lights, the patient, and you should be

fixed. Occasionally I look at patients’ eyes in photographs
presented at meetings. Using a single flash preoperatively
and two light boxes postoperatively is a commonly used illu-
sion. A single flash exaggerates deformities. By only chang-
ing the light source, a substantial illusion of surgical change
can be obtained. For instance, both of the below photos are
preoperative, taken with a 10 s interval. The photograph on
the left was taken with a single top flash, and the photograph
on the right using two soft boxes.
16 1 Photography
This is another example where the only difference is the

lighting.
You can easily determine what kind of lighting has been at meetings to prevent the simulation of an enhanced surgical
used by simply looking at the patient’s eyes. Therefore, I outcome.
believe that patients’ eyes should be visible in presentations
18 1 Photography
Below you can see the preoperative and postoperative

photographs of the patient taken with two soft boxes.
20 1 Photography
1.2.3 Fish-Eye
If you get close to the patient and zoom out with the lens, the
photograph will be fish-eyed.
Such fish-eye photos taken from the front will make the lens. If a 100 mm macro lens is used without any zoom, these
nose look bigger and the ears smaller. On the contrary, fish- problems can be avoided.
eye profile photos make the ears look bigger and the nose The photos below were taken at the same time. I took the
smaller. In the front view, you should look at how much of photo on the left using a 35–85 lens set to 35′ and the photo
the ears is visible behind the cheeks. In fish-eye photos, a on the right using a 100 mm lens. There is no difference in
less amount of the ears is visible. The tip will also look bul- lighting either.
bous. Tip bulbosity can be corrected by just changing the
22 1 Photography
Ears should be seen equally over the cheeks in before and quality of photos instead of getting compliments for good
after photos. Otherwise, the effect of surgery on fixing bul- surgical results. If a dual soft box lighting system is used, an
bosity cannot be correctly verified. intermediate-level dSLR camera will be sufficient.
1.3 Camera Settings 1.3.1 Focus Settings
I am not a professional photographer, but I have acquired all Photographers usually choose the eyes in portrait photo-
the knowledge necessary for my purposes. Incredible photographs for focusing. In rhinoplasty photographs, it is better
graphs can be taken with just a few adjustments. As a sur- to choose the nose as the focus point. The focus point can be
geon, it is disappointing to receive criticism due to bad set to the nose.
1.3 Camera Settings 23
1.3.2 ISO 1.3.6 Color Settings
This is the camera sensitivity to light. 100 and 200 are appro- The photographs taken in photography studios with soft
priate. As ISO increases, the color quality of the photos dete- boxes may be blue, red, or green dominant. Fine-tuning may
riorates. Low ISO values need intense light. If you have soft be necessary in the white balance setting. I take my photo-
box lighting, you can easily take photos with an ISO setting graphs at a slightly blue setting, as I find my photographs to
of 100–200. be dominant in red. The aim here is to match real-life skin
color with the color in the photographs.
1.3.3 Shutter Speed
It shows how long the diaphragm stays open. If the shutter

speed is slower than 1/125, the photo can be affected due to
shaking. I generally use a setting of 1/160. If you choose a
shutter speed faster than 1/200, the maximum flash synchro-
nization speed of the camera may be exceeded which causes
photos to be half dark.
1.3.4 F
The f-number shows the aperture size and it affects the depth
of field, which is the distance between the nearest and fur-
thest points in focus. Artistic photos can be taken with low
f-numbers, blurring more of the front and back of the subject.
I prefer all of the face to be in focus, so I use a value of 10 or
above. 1.3.7 Soft box Light Settings
You can show aesthetic lines better in the front view if one of
1.3.5 Skin Color the soft box lights is more intense, but then you will have prob-
lems with profile photos. Since we make evaluations based on
The patient’s skin reflects light at different amounts. photos taken from all angles, it makes sense to adjust the soft
If the patient’s face appears dark in the photo, then box light intensity to the same level for all views.
decrease the “f” value. On the other hand, if the patient’s Taking photos in sunlight coming from curtains can give
face is bright in the photo, increase the “f” value. I take better reflections, but you cannot take the same photo at differ-
all of my photos by adjusting the “f” value between 10 ent times of day. Therefore a soft box lighting system is a must.
and 13. In order to take good photos in an “f” value of I lengthened the legs of the soft boxes to get more natural
11, you need to adjust the power of the soft box light reflections. In this way, the light comes from above the
lighting.? patient’s head level.
Here you can see a patient example with standard settings.
24 1 Photography
1.3 Camera Settings 25
26 1 Photography
are big in photos. You should know what a fish-eye problem

1.3.8 Shooting with a Smartphone is and be able to explain it to your patient. The below photo-
graphs were taken with an iPhone, the left side with a close
You cannot take patient photos with a smartphone. Even the photo shoot and the right side with a distant photo shoot and
best phone on the market takes fish-eye photos. Patients take zooming in. It is clearly visible from the ears that the left-
their own photos with smartphones and evaluate their noses hand side is fish-eye.
accordingly. Most of my patients complain that their noses
1.4 Imaging 27
1.3.9 Video Camera 1.4 Imaging
Since the light intensity of new video cameras is high, it is I am often asked about my photography techniques and
possible to have great details in the afternoon light from one imaging. Therefore, I will show step by step how to design a
angle. But it is difficult to archive videos and have a standard nose in Photoshop.
for all recordings.
28 1 Photography
Open the file.

1.4 Imaging 29
Choose the nose with Rectangular mask.

30 1 Photography
Open the Liquify filter.

1.4 Imaging 31
Design a nose that fits the face.

32 1 Photography
Practice it a few times and correct it over and over again.

1.4 Imaging 33
34 1 Photography
Work on tip details.

1.4 Imaging 35
You can use smaller masks for working in detail.

36 1 Photography
After making the design, you can add an “a” to the end of 1.4.1 Shadowing the Images
the filename and save. As you make different designs, you
can save the files with different endings, such as aa, aaa, aaaa Determine the work that fits the patient’s face. When you
and compare them easily. paste this photograph with 50% opacity onto the patient’s
original photograph, you can determine the differences
between the original nose and the nose you want to achieve
with surgery.
Example You should choose the whole picture at the beginning in
IMG_5643a, IMG_5643aa. When you sort the photos order to copy the work you like.
in the folder by name, your files will be aligned in Macintosh: cmd-A (Windows: CTRL-A): this will select
order. the entire picture.
1.4 Imaging 37
38 1 Photography
Macintosh: cmd-C (Windows: CTRL-C): this will copy With the paste command, the new nose will be pasted on
the picture. the older one as a new layer.
Go to the history and choose the original picture. Macintosh: cmd-V (Windows: CTRL-V).
1.4 Imaging 39
In the following photograph, two layers are formed. In

the upper layer you can see our work. The original photo
cannot be seen as it is underneath.
40 1 Photography
From the layer adjustment menu on the right, set the which is the original photo, partly visible. In this way you
opacity of the upper layer to 50% to make the lower layer, can see the differences between the two noses.
1.4 Imaging 41
If you save this document as a JPG file, you can store it Because of this, choose “merge down” under the layers
easily. The file that has more than one layer can only be menu.
saved as a PSD file and viewed by the Photoshop program. cmd-E: Pastes all layers.
Now the file can be saved as a JPG file and you can see
one layer on the right.
42 1 Photography
Add “plan” to the name filename and save.
Example
IMG_5643plan.
The shaded picture gives information to the surgeon You can use this picture in order to determine the new tip
about the rotation and the amount of the hump to be removed. point. We will use a shaded picture in surgery drawings.
1.5 The Importance of Photography and Imaging 43
1.5 he Importance of Photography

T Work with Photoshop to determine if either the radix is
and Imaging high or the glabella is low. I should admit that I have made
some mistakes with this in the past. In the profile view, if the
Make the design yourself. Do not undertake surgery without radix is high in comparison to the forehead and glabella in
a design. For instance, a nose may appear to have a hump spite of sufficiently lowering the radix to the level of the eye-
only because the tip projection is low. You can make changes lash tip, it is reasonable to fill the forehead with fat. If a cer-
to the forehead, chin, and cheek. The lowest point of the tain radix depth cannot be obtained, the nose can appear as if
radix should be a little in front of the eyelashes. In the profile it starts straight from the level of the forehead. Such a result
view, if the eyelashes of the other eye are visible, it is more tends to make patients unhappy.
rational to fill the radix. If your patient does not like your Photoshop design and
results, do not operate. Your work should meet your patients’
expectations.
Note
Here you can see the design and the patient’s result.
There are indeed no fixed rules when it comes to aes-
thetics. Every patient has a different situation. You can
choose to create a higher or lower nose ridge, but you
should not forget that, when you lower the dorsum, the
nasal body becomes indistinct in frontal view. Thus, a
low nasal bridge requires more in-fracture.
44 1 Photography
noses that you find beautiful by 90° and examine them.

Note Your brain can learn the appearance of a beautiful nose in a
During surgery, compared to our usual perception horizontal position.
when people are upright, we perceive the patient at a
rotation of 90° as the patient is lying down.
Important
Our perception of beauty develops through the observa- Aesthetic information feedback is very important. You
tion of other people. However, we decide on the tip position should avoid anything that may skew your perception.
and dorsal height during surgery with the patient lying For example, the head of the patient on the operating
down on the table. I think that this causes serious confu- table should be parallel to the floor. If you do not keep
sion. It takes time for our brain to adapt to this rotation of the position of the head at this angle in every operation,
the aesthetic perception by 90°. As for me, it took about your chances of making a mistake increase.
1 year. In order to accelerate this, rotate the pictures of
46 1 Photography
As I am left-handed, I stay on the left of the patient to

make my evaluation. Therefore, I set up the computer to
show the left view of the patient. Right-handed surgeons
should change position accordingly. You can rotate shad-
owed photographs by 90°.
The following unoperated natural nose looks over-rotated
when it is viewed at 90°, doesn’t it?
Do not start operating without imaging. I never operate

Note without my computer in the room. Front and lateral views
Do not enter the operating room without a photograph. and shadowed photos should be displayed on the computer.
48 1 Photography
The easiest way to put the patient’s photos and the design to see other photos, your assistant can do so by the left and
in one photograph is by opening all photos together and tak- right buttons.
ing a screenshot. On a Macintosh computer, a screenshot of
a specific part of the screen can be taken with Shift-
Command-4. On the other hand, shift-Command-3 will let Example
you take a screenshot of the full screen. During the surgery, Our patient’s photos were merged into one.
it will be easier to view the merged photos. In case you need
In the photo below you can see the pre-op lateral view, steps of the surgery. During the progress of the surgery, you
the computer design, and the 1-month result. The computer can make small changes if necessary.
design may not be perfect, but it is essential to plan the main
50 1 Photography
52 1 Photography
Same patient’s 3-year post-op photographs.

54 1 Photography
1.6 Surgery Notes and Archiving 55
grams. You can set up your own archive system with simple
1.6 Surgery Notes and Archiving programs by yourself.
I use the address book program on my computer. I have an
Even though operative notes may consist of drawings, I preoperative note template. After surgery, I copy and paste this
fer to write them so that I can search for a specific word for template and make necessary changes regarding that surgery.
scientific purposes. Then I e-mail it to the hospital secretary who copies it to the
You should be able to access your patient data and opera- discharge report to be given to the patient. So, even before
tive notes very easily and quickly, even after years. It is a the patient is awake, the operative note is written and
waste of time to ask for your patient’s file from the hospital e-mailed to the secretary.
archive. If you do not record the details of surgeries, your This system provides an advantage when preparing an
evolution as a surgeon will be slow. article for example about a new technique, e.g., the auto-rim
In rhinoplasty, certain results appear after about 1 year. flap technique. A search about the number of patients or in
Evaluate your first-year results with the help of your opera- which patients it was used is very easy. Writing “auto-rim
tive notes. In this way, you can find out what you did wrong flap” in the address book will give the patient names and
during the surgery and avoid these problems. Your recording total number in less than a second. Right at the time I am
program should be simple and easily accessed. I would sug- writing this section, I could easily find out that I have used
gest you not to spend a fortune on patient archiving pro- the technique in 1491 patients.
56 1 Photography
search box will take you to the folder. I suggest you not to
1.7 Photography Archive lose time making subfolders, such as primary or secondary
rhinoplasty. I keep all my patient folders in one folder. These
I create a new folder and name it with the patient’s name dur- details can be archived by adding a keyword in your opera-
ing the consultation and copy the patient’s photos in that tive note.
folder. In a follow-up, entering the patient’s name in the
1.7 Photography Archive 57
1.7.1 Backup
Make regular backups. The photo archive of a plastic sur-

geon is priceless. “Time Machine” is a quick and automated
backup application.
How to Draw a Nose
2
Abstract
You cannot perform a good surgery unless you draw the

organ precisely with the pen. I have been taking drawing
courses since 2006, and I think that it has improved my
surgery results. Design increases awareness. You cannot
solve a problem which you cannot see. Design allows you
to analyze a good nose and imitate it well.

60 2 How to Draw a Nose
You cannot perform good surgery unless you draw the organ a problem that you cannot visualize. Drawing allows you to
precisely with the pen. I have been taking drawing courses analyze a beautiful nose and imitate it well.
since 2006, and I am convinced that it has improved my sur- I strongly suggest you to draw noses with pencil, using
gery results. Drawing increases awareness. You cannot solve the methods mentioned in this section.
2.1 Exercises 61
2.1 Exercises During rhinoplasty courses in Turkey, we organize

sculpture classes. In these classes, basic design knowl-
1. Learn to draw a nose. edge is taught and nose drawing and modeling applied.
Buy a computer drawing tablet (electronic drawing note- Based on their drawings, participants sculpt noses from
book). There are various sizes on the market, but a 10 × 15 cm clay and apply them to noseless busts. We use polygons
tablet will be adequate for our purposes. Make drawings of as drawing and modeling method.
both beautiful and ugly noses. Draw the nose contours and
add the shading. Draw the edges of the cartilages.
2.1.1 Sketch from the Front
• The nose tip consists of three circles. The middle circle

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

the close relation between the nostril sill and footplate.
Investigate the endpoint of the nostril sill. If the scar of the
alar surgery aligns with the nostril sill anatomy, then the
human eye cannot recognize the scar.
• Investigate the fusiform structure that the nose dorsum

constitutes. In this way, you can understand the dorsal
aesthetic lines better.
• Shading is the next step. Investigate the relation between
dorsal aesthetic lines and shadows.
• Adding some highlights to the dorsal aesthetic lines will
make your drawing more realistic.
Note
Drawings below by Yusuf Başoğlu.
2.1 Exercises 63
2.1.2 Sketch from the Side
• Determine the length and height of the nose. Determine

the nasolabial angle.
• We will use the same circles again. The 3:2 ratio is the
same. The line which passes tangentially to the bottom
edge of the circles gives us the nasolabial angle.
• The lateral view of the nostrils is very important. Examine
the nostril peak point and the C point relation.
• Examine the columella and lobule ratio. You can copy
from beautiful noses in these drawings. It is easier to
make drawings from photos of beautiful noses.
2.1 Exercises 65
Important
The fundamental rule for closed surgery is to see the
topography of the cartilages by following the high-
lights in the skin.
2.1.3 Sketch from Above and Below
It is also important to draw the nose from top and bottom. If

you make drawings from all angles using the same cubic
forms, your brain will take stock of the cartilages and make
a three-dimensional model of it.
2.1 Exercises 67
Following page: A sculpture made from polygons.

Note how realistic a nose sculpture made of polygons
appears.
2.1 Exercises 69
Cartilage anatomy made from polygons.

form closed surgery, you should see the cartilage anatomy

through the skin. Below, you can see my computer and my
electronic drawing notebook. With this equipment, I created
the drawings for this book.
2.2 Analysis of Patient Photographs
There is no need to elevate the nasal skin in order to see the

nasal cartilage. Nose photos can provide more information.
As you perform nose drawing exercises, I suggest an addi-
tional exercise for you. Below, you can see a drawing made
on an electronic drawing tablet within 5 min. Try to see the
cartilage edges and draw the main lines. Use thin lines for
concave and convex forms. Thus, you can see the cartilage Study the examples below. I drew our patient’s cartilage
anatomy without elevating the skin. If you are going to per- anatomy from different views.
2.2 Analysis of Patient Photographs 71
2.2 Analysis of Patient Photographs 73
Let’s finish the nose design with detailed photos of a design will not encounter the question “Did you have your
patient who is in the fourth year of surgery. A rhinoplasty nose done?” Even alar reduction surgery will go unnoticed.
patient whose nose has been remodeled based on a suitable
Nasal Polygons
3
Abstract
You can draw noses and make nose sculpture with Cakır
polygons. On the other hand, you can use it for giving
shape to the cartilages in nose surgery. We developed
these polygons together with my sculpture instructor.
Since 2010, we have been organizing nose design classes
with my sculpture instructor in rhinoplasty congresses
and plastic surgery assistants study on nose drawings and
nose modeling. Polygons are one of the main parts of the
courses. The article in which this issue is detailed can be
found on the Aesthetic Surgery Journal Special Topic [1].

76 3 Nasal Polygons
You can draw noses and make nose sculptures with Çakır What is the difference between Çakır polygons and
polygons. Moreover, you can use this method for giving Sheen’s aesthetics?
shape to the cartilages in nose surgery. We developed these Jack Sheen [2] has described the ideal tip shape as “two equi-
polygons together with my sculpture teacher. Since 2010, lateral geodesic triangles with a common base formed by a
my sculpture instructor and I have been organizing rhinoscu- line connecting both domes. The highest projecting point of
lpture workshops at rhinoplasty congresses, and plastic sur- the tip should lie along the apogee of the curved line that
gery assistants study nose drawings and nose modeling. connects both domes.” We all know the infratip, supratip,
Polygons are one of the main topics of instruction. For an and soft triangles.
article discussing this method in detail, see:
3.1 Infratip Triangle 77
Shield grafts try to mimic the infratip triangle. However,

we see that this graft constantly changes over time. Using a
shield graft in a Y shape is an increasing trend, because the
short arms of the Y graft and the gap between them gives
more natural results. Placing a block cartilage to prevent the
shield graft from overturning is one of the least common dif-
ferences. The block graft both supports the shield graft and
forms a second tip breakpoint just 2–3 mm above the break-
point formed by the shield graft. Thus, it protects thin-
skinned patients from pointed tip deformity. The aesthetic
concepts described by Sheen cannot meet the needs of open
rhinoplasty technique. In this book, polygons, as they will be
examined in detail, can be considered as open rhinoplasty
update of Sheen’s aesthetic concept.
3.1 Infratip Triangle
We try to create this triangle with a shield graft. I use a shield

graft only for overly deformed noses. I think that it has no
place in primary rhinoplasty. We described this area with the
infralobule polygon and added more details to the nose tip.
78 3 Nasal Polygons
3.2 Tip Defining Point been used behind it. Toriumi mentions this graft repeatedly.
We have described the nasal tip area with two dome triangles
When the shield graft is used for increasing projection, the and an interdomal triangle.
tip becomes pointed. To prevent this, a block cartilage has
Note
I admire the approach based on an aesthetic conceptual
description from 30 years ago. Sheen counts as one of
the legendary surgeons for me. Topographic anatomy
is a more important concept for closed rhinoplasty sur-
geons; we have to follow the skin reflections created
by means of cartilage in the surgery.
3.6 Tip Breakpoints 79
3.3 What Is a Facet? 3.6 Tip Breakpoints
These are multi-edged flat areas which surround three- In profile, the nose tip makes two breaking points on the
dimensional objects. This is the easiest method for making a same vertical plane. We call the upper refraction Ts (tip
sculpture. You can imagine round organic forms consisting superior) and the lower one Ti (tip inferior) points. Peak
of several facets. Their sizes, angles, and the ratios between points of the dome triangles form the Ts point. Bottom inner
them are important. Analyzing organic forms with the help edges of the dome triangles form the Ti points.
of cubic forms is a basic drawing method.
3.4 The Non-mobile Nose
These polygons are mass polygons. They are created from

cartilage and bone.
• Glabellar Polygon
• Dorsal Bone Polygon
• Dorsal Cartilage Polygon
• Lateral Bone Polygons
• Upper Lateral Cartilage Polygons
3.5 The Mobile Tip Area
3.5.1 Mass Polygons
Dome Triangles
Lateral Crus Polygons
3.5.2 Space Polygons
• Interdomal Polygon
• Facet Polygon
• Columellar Polygon
• Footplate Polygon (we do not elevate the skin in this
Pay attention to the polygon drawings. If possible, draw
region)
them by yourself. It is easiest to begin the drawing with the
• Infralobular Polygon
interdomal polygon.
These polygons cannot be seen when the skin is raised.
80 3 Nasal Polygons
3.7 Dome Triangles In 2008, the right dome of one of my patients who had
beautiful right dome highlights had a triangular shape. In
These are the triangles formed by the Ti, Ts, and Rm points. order to give it a similar shape, I made the left dome triangu-
There are two dome triangles. Dome polygons should look lar. The dome triangle concept emerged with this photo.
exactly towards the front.
3.7 Dome Triangles 81
82 3 Nasal Polygons
Patient Example
Before surgery, let’s examine the cartilage anatomy of
a patient with well-articulated nose tip polygons. As
the patient’s skin is thin, it is easier to see the cartilage
anatomy underneath. You can clearly see the facet
polygon. As the resting angle of the lateral crus is ade-
quate, we can see the light formed by the lateral crus
caudal edge.
The dome is the meeting point of the lateral and medial

crus. Lateral and medial crura are not formed by the curve of
a plane rectangle cartilage from the middle with one angle. If
you force it to curve on one plane with stitches, the domes,
lateral and medial crura can be malpositioned. The infralob-
ule polygon expands, the apex of the facet polygon closes,
and the caudal edges of the lateral crura turn towards the
nostril.
The lateral and medial crura meet each other at a 15–20°
angle. This angled articulation makes the meeting point tri-
angular. In some patients, you can see this triangle clearly.
Generally there are more soft transitions between these
triangles.
84 3 Nasal Polygons
The patient’s right dome shows the triangle form more edges of the dome which will form the tip of the facet poly-
clearly. Examine how close the medial crus and lateral crus gon are far away from each other. Cephalic dome suture gen-
are to each other on the cephalic edge of the dome. We are erates a form similar to the right dome. Cephalic dome suture
trying to copy this form with tip sutures. does not generate a clear triangle, but this form can be
expressed with a triangle polygon. The triangle form can be
obtained with two different transdomal sutures that are posi-
tioned to each other at a 30–40° angle, but a clear aesthetic
achievement cannot be obtained. It lasts longer, is more dif-
ficult and harder to achieve symmetry.
Below, you can see the photograph of a patient who has
clear dome triangles.
However, the left dome of the patient does not show the
triangle form. The folding line near to the lateral crus is more
bent than the other one. Moreover, the folding line close to
the lateral crus is folded more at the cephalic edge of the
dome. The common characteristics of the left and right
domes are that the medial and lateral crura on the caudal
Below are the preoperative photos of one of my patients I have not used this method since 2008. Although the
who had an operation in 2007. I created dome triangles by cephalic dome suture cannot make the domes as triangular as
placing two different horizontal mattress sutures at a 30–40° above, it is a more useful technique.
angle. Clear triangle forms were given to the domes, but
planning and performing the surgery was not easy.
Important
While drawing, turn organic shapes into cubic forms.
This will make the analysis easier. The base length of
this triangle forming the dome is approximately 3 mm,
and this length constitutes the root of the facet
polygon.
Important
The horizontal mattress suture, named the dome span-
ning, transdomal, or dome-creating suture, is not a
suitable suture for dome anatomy. The stitch that cop-
ies the triangular dome anatomy best and at the same
time is the easiest one consists of the cephalic dome
suture. Cephalic dome suture forms the dome by nar-
rowing the top of the triangle. Do not put any stitches
from the caudal edge of the domes. Below you can see
an example of a patient where I used a dome spanning
or transdomal suture in 2008. I was trying not to col-
lapse the facet polygons by passing the stitches to the
cephalic edges of the dome. If you contract the stitch
too much, it can collapse; however, if you do not
tighten it enough, it does not work. Technically, this is
not an easy stitch. It cannot correct the lateral crus rest-
ing angle properly.
86 3 Nasal Polygons
3.8 Interdomal Triangle
The interdomal triangle is the space between the Ts point and

both Ti points. Like the dome polygon, it looks towards the
front.
For the purposes of aesthetics, you should not only see

mass, but also the spaces in between. The superior angle of
the interdomal triangle is 80° in men and 100° in women.
3.8 Interdomal Triangle 87
Try to see the borders of the light reflected through the tip
of the nose. You will see that it forms a triangle. Note
I discovered these angles through measurements that I
performed on beautiful noses in Photoshop. Angles
can vary between 5° and 10°. Based on my findings,
the peak angle of the interdomal polygon in men is
narrow.
Important
As the rotation of the nose tip increases, the caudal
edges of the domes drift apart. The angle difference
between women’s and men’s noses is due to the rota-
tion differences.
88 3 Nasal Polygons
Dome triangles only contact each other at the Ts points. 3.8.1 Dome Divergence
There should be space between the Ti points. If you close
this space with a suture, tip aesthetics substantially deterio- This is a controversial issue that has not yet been explained
rate. Facet polygons expand horizontally; hence you should clearly. It has been discussed in theory, but not yet performed
consider a rim graft. The incidence of a pinch nose increases in practice. Perhaps the inadequate explanation of interdomal
as the caudal edges of the lateral crura also become medial. space based on dome divergence has caused confusion. In
some drawings, dome divergence has been shown as space
between the cephalic edges of the domes. However, the
domes contact or stand close to each other even if there are
thin ligaments between them.
Important
Ti and Ts points should be on the same vertical plane.
In women, the Ti point could be 1–2 mm anterior of
the Ts point.
As a result, never close the interdomal polygon.

3.9 Infralobular Polygon 89
Does the interdomal triangle make a pit on the skin?

In naturally beautiful noses, the interdomal triangle always Important
exists. It is rare to see it on noses with thick skin, but more Do not resect too much because you may damage the
obvious on thin-skinned noses. The interdomal triangle can artery, vein, and nerve.
be seen from the outside as a facet or little groove. In the
cartilage anatomy this groove is more obvious. The superfi-
cial part of SMAS and the interdomal ligaments fill the
space in between. The superficial part of the SMAS should
3.9 Infralobular Polygon
be protected during the dissection. If you leave the superfi-
The infralobular polygon is the rectangle between the Ti and
cial part of the SMAS on the cartilages when you are ele-
C points, and it has been named by Rollin Daniel. The
vating the flap and make a resection while it gets between
infralobular polygon looks downwards at a 45° angle. It is a
the cartilages, that area will be empty when the flap is
space polygon. The superficial part of the SMAS fills this
closed again.
space and makes it a facet. The strut graft is also located in
The strut graft should be fixed to the cephalic edges of the
this polygon. If the strut graft is close to the caudal edge of
medial crus. Otherwise, we cannot protect the interdomal tri-
the medial crus, the infralobule polygon becomes round. The
angle. We should leave a place for the superficial part of the
infralobule polygon is constituted by the weakest part of the
SMAS between the medial crura. In thick-skinned noses,
lower lateral cartilage, named the middle crus. After dissec-
you can make this polygon obvious with small resections
tion this part weakens, and contour grafts will be needed in
from the perichondrium and SMAS.
order to strengthen it. We will describe this topic in the chap-
ter on surgery techniques.
90 3 Nasal Polygons
3.10 Columellar Polygon columellar polygon or make small flaps and turn them to the
space in the infralobular polygon. Below, the bulging on the
The columellar polygon is a space polygon, between the C C point was treated with a perichondrium flap.
points and the footplate polygon. The columellar polygon
looks downwards. The space between the caudal edges of the
medial crus should be protected. A commonly occurring
mistake is the extreme grafting of this region or making the
caudal edges too close to each other. Extreme grafting
expands the columellar polygon. Suturing the caudal edges
narrows the columellar polygon. However, in a normal and
beautiful nose, the columellar polygon can be seen clearly. A
little groove seems to be natural and will not disturb the
patient. The medial crura turn laterally and upwards in order
to form the footplates. If the columellar polygon is short,
then it is possible to lengthen the columellar polygon by
suturing the footplates to each other.
When the tip surgery is finished, the superficial SMAS

and perichondrium may cause bulging on the columellar
polygon. You can perform resections for the bulging on the
3.11 Footplate Polygons 91
3.11 Footplate Polygons The footplate polygon, columellar polygon, and lip may
not be separated from each other clearly. As in the examples
These are the planes formed by the footplates. They look at below, the lip, columella, or footplate can be dominant.
sideway and downwards.
92 3 Nasal Polygons
It can be plumper in women. In men, it is not uncommon In many of our patients, the footplate polygon projection
to see it form a sharp angle with the lip. In tension noses, the is excessive. This projection can be decreased via dissection.
excess of the caudal posterior part of the septum extends However, if the footplates are constricted too much, the foot-
between the footplates and expands this polygon. In patients plate polygon disappears and the columellar polygon elon-
with short columellar polygons, it is possible to make the gates too much. This creates an operated look.
columellar polygon longer by suturing the footplates. The
footplate polygon may be wide enough to obstruct breathing.
In surgery this region should usually be narrowed. 3.12 Facet Polygons
This is the polygon between the Ti, Rm, Rl, and C points. It
looks downward and lateral 45°. One of my essential objec-
tions is this region. This area is not a triangle. There is a
2–3 mm edge between the Ti and Rm points. The facet poly-
gon is not a space that has to be filled. This can be seen
clearly in beautiful noses. A thin-skinned nose without the
facet polygon significantly shows that it has been operated
on. It has an anatomy like a tent formed between the middle
and lateral crus.
3.12 Facet Polygons 93
4. The caudal edge of the lateral crus should be strong and

elevated like the rod of a tent. The lateral crus resting angle
is important. The caudal edge of the lateral crus should be
anterior to the cephalic edge. Thus, the caudal edge of the
lateral crus creates tension upwards and sideways and
stretches the facet polygon and as a result sets up the tent.
Otherwise a pinched nose occurs. In a pinched nose, the
caudal edge of the lateral crus is collapsed inwards to the
nostril. Noses with obvious facet polygons can breathe bet-
ter. Below you can see a nose with a clear facet polygon.
For a good facet polygon,
1. A strong middle crus is required. If it is weak, then I use Patient Example

contour grafts.
Below are the first-year photos of a patient with open
2. A right-sized infralobular polygon is needed. If the
surgery technique. The pinched nose deformity occurs
infralobular polygon is constricted with stitches, the facet
especially on the right side. The cartilage which can be
polygon expands. In order to compensate this mistake
seen from the nostril is the caudal edge of the lateral
you have to use big rim grafts.
crus. The lateral crus resting angle has been completely
3. The dome polygon which is at the top of the facet poly-
destroyed, and the caudal edge contacts the septum.
gon should be appropriate to the polygon concept. Non-
The patient’s dome plane and lateral crus polygons
anatomical sutures like the dome-spanning suture or the
have been deformed consecutively. This nose cannot
transdomal suture should not be used. Non-anatomical
support deep inhalation. Additionally, the caudal edge
sutures constrict the caudal part of the dome and thereby
of the lateral crus also creates breathing problems.
the top of the facet polygon.
94 3 Nasal Polygons
3.12 Facet Polygons 95
How can the facet polygon be destroyed?
1. The transdomal suture constricts the top of the facet poly-

gon. Because of that, the caudal edge of the middle crus
and the caudal edge of the lateral crus interfere with the
facet polygon.
2. If you use a lateral crus spanning suture, you will obvi-
ously destroy the facet polygon. This suture will impair
the resting angle.
Note
The lateral crus spanning suture is a suture technique
described by Tebbet. In order to correct tip width, the
suture passes through both lateral crura and helps them
to approach each other.
3. Extreme cephalic resection of the lateral crus weakens

the caudal edge of the lateral crus.
Below are photos of an operation I performed in 2007.

Although I had tightened the suture, constriction had
occurred at the top of the facet polygon in a patient on whom
I used a transdomal suture.
96 3 Nasal Polygons
3.12.1 Relation of the Facet and Dome narrow or are not evident, the aesthetic appearance deterio-
Polygons rates in the front view.
In the front view, the height of the dome triangle and the
height of the facet should be similar. If the facet polygons
3.14 Resting Angle 97
3.13 Lateral Crus Polygons 100°. The resting angle is an important topic on which I will
elaborate below. I have watched many surgeons’ operation
I do not want to cause confusion by assigning numbers to the videos, but few surgeons care about this angle. If this angle is
polygons’ corners. As it is very difficult to explain the nose regular, then the need for a rim graft dramatically decreases.
tip differently, I detail it in the following way: The lateral As the resting angle broadens, the nose starts to become
crus polygon is a mass polygon and made up from the body pinched. If the resting angle is 100°, the facet polygon appears
of the lateral crus. The caudal edge of the lateral crus is in well-formed. The section on techniques will discuss how the
front of the cephalic edge. This position produces a clear resting angle recovers with the effect of the cephalic dome
facet polygon and a scroll line in the skin. suture.
It is necessary to explain the surgical importance of the
lateral crus polygon.
Important
3.14 Resting Angle Tip aesthetics are relevant to each other. When a
15–20° angle is formed between the medial crus and
This is the angle between the surface of the lateral crus and the lateral crus planes, the resting angle will be correct.
the upper lateral cartilage surface. This angle should be 100°. As a result, the domes become triangular. Below there
Surgical techniques that ruin the nose tip also ruin the lateral is a simulation of the resting angle. Examine the shape
crus resting angle. This happens when the angle between the of the domes.
lateral crus and the upper lateral cartilage starts to exceed
98 3 Nasal Polygons
Below you can see how to correct the resting angle. 3.14.1 Vertical Compression Test
The nose tip cartilages are very thin. Cartilage thickness is

not the only parameter affecting the nose tip’s resistance to
breathing. The mass generated from the angles of the two
lateral crura on the horizontal axis also produces an addi-
tional resistance to respiration.
In order to produce horizontal resistance, the lateral crura

and transverse axis should be parallel to each other. The
angular relation between the lateral crus and the upper lateral
cartilages is very important for breathing. As this three-
dimensional anatomy is both complex and important, I
would like to emphasize this point particularly. By conduct-
ing this test with your patients, you can see how the lateral
crus affects breathing. Patients who state that they breathe
easily when they hold up their nose tips are actually correct-
ing the angle of the lateral crus while doing so. With the ver-
tical compression test, when the angle of the lateral crus is
corrected, the patients state that they can breathe easily. The
horizontal mass effect formed by the reclining of the lateral
crus in a 4–5 mm space between the septal angle and the
domes also stabilizes the internal valve. But the main effect
of the resting angle is on the external valve.
100 3 Nasal Polygons
Below you can see the nose in resting position. parallel. The nares do not close even when the patient takes
a deep breath. In order to make nares resistant to inspira-
tion, a rim graft and lateral crus strut grafts can be used.
However, graft application gives an unnatural rigor to the
nose.
The photo shows the transition of the lateral crus to the
horizontal plane during the vertical compression test.
Nares of the patient close in deep inspiration.
Note
A collapse is more obvious in the nostril through which
more air passes. As the right side of the nose is narrow
because of septum deviation, the collapse is obvious
on the left side.
Resistance that originates from the right lateral crus rest-
ing angle is the main reason for the resistance generated by
the nose tip against inspiration. Examine the shape of the
When the nose of the patient is compressed between lateral crus in the polygon model and the lateral crus shapes
three fingers, the horizontal axis of the lateral crus becomes after surgery.
Patient Example
An example of a disrupted resting angle, one of the
frequent rhinoplasty signs. Since the resting angle is
disturbed, the nose tip looks like a cephalic malposi-
tion deformity.
The cartilage anatomy of this patient has been drawn with

the help of an electronic drawing tablet.
When the long and convex lateral crus problem is added

to a wide lateral crus resting angle, an appearance of a
cephalic malposition occurs. Techniques that we use for tip
shaping should aim to correct this shape in the simplest way.
3.14.2 Incorrect Resting Angle and Its Effect

on the Ala
In noses with disturbed resting angle, the caudal edge of the

lateral crus cannot support the nares adequately. On the other
hand, the caudal edge of the lateral crus should be identified
from the nose skin. If the tip of the nose has a more rounded
look, the facet polygon is not clear. Patients with a correct
resting angle have a strong wing edge and a defined facet
polygon. In the following drawings, examine the differences
between lateral crus resting angle, facet polygon, and domes.
length, you should shorten the lateral crus length. Long lat-
eral crura are the most important obstacle in correct tip
surgery.
If you do not shorten a long lateral crus,
1. The long lateral crura will defeat you and the nose tip will
go back downwards. This is the main reason for a polly-
beak deformity and dropping of the nose tip.
2. It will be folded in some place. It folds most frequently
near the piriformis aperture and herniates on the interior,
causing breathing problems.
3. And if the herniation occurs from the middle of the lateral
crus outwards, you will increase bulbosity. If it is inwards,
then collapse or asymmetry occurs. I have even seen lat-
eral crus herniation of the right side inwards and the left
side outwards in the same patient.
4. And if you try to correct supra type fullness resulting
3.14.3 Wide Lateral Crura from a long lateral crus via sequent cephalic resections,
you will probably cause a pinch nose.
Most of the patients’ lateral crura are wider than normal.
This causes a lateral supratip fullness and narrow facet poly-
gon. Making all resections from the cephalic side is not cor- Important
rect. Do not forget that there is also width to the caudal side The length of the lateral crus should fit the nose
of lateral crus. In the section on the auto-rim flap, this topic planned.
will be discussed in detail.
3.14.4 Long Lateral Crura Below you can see a sample of patients in which the lat-
eral crus is kept long. The long lateral crus is folded and the
This is an ignored topic. If you are planning to increase rota- dome is deformed. The surgeon has tried to weaken it by
tion, lower the projection and make a reduction in nose performing a scoring to the lateral crus, but failed.
Patient Example
A closed technique rhinoplasty has been done in this
patient. Probably a rotation has been performed and
projection has been decreased. However, since the lat-
eral crus length was not changed, the lateral crus has
herniated through the airway. Possibly the patient’s lat-
eral crus was convex. Cephalic and caudal excess of
the lateral crus make convex deformity more resistant.
A convex lateral crus tends to herniate to the airway. Its
length and width should be treated. You can see the
herniation of the lateral crus below.
The caudal excess of the lateral crus was left on the skin The following image demonstrates a puff 4 mm medial to
as auto-rim flap. the herniated region in the airway. This puff recovers when
the lateral crus is stretched to the anterior with a forceps.
This means that the patient’s lateral crus was left long. Some
of the surplus in the length of the lateral crus has made supra-
tip bulging, and another part has herniated to the airway.
The lateral crus has been dissected subperichondrially.

Even the dissection alone has created some relaxation, but
this is not adequate.
Important
Subperichondrial dissection makes the lateral crus
softer and hence it is shaped easier. With the dissection
of the perichondrium, the cartilage may resist to the
desired shape. It can protect its convex shape even
though the length of the cartilage has been shortened.
The herniation is corrected after stretching with a forceps.

This mechanism deserves further discussion. In the open
technique, the airway is not constantly controlled. The sur-
geon should be able to observe the nose’s interior when the
nose is enforced for rotation before shortening the lateral
crura.
Stretching the lateral crus corrects the herniation of the

cartilage to the airway.
When tip surgery is completed, since the length and width

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

lateral crus herniates inwards from the weakest point again.
Compare the result with the herniation at the beginning of

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

noticed where the lateral crus herniates. This was improved
significantly after surgery.
The depression that occurred as a result of herniation of

the lateral crus inwards was also corrected.
Pay attention to the pit in the skin.

Patient Example
In the case of this patient who underwent surgery
10 years ago, the lateral crus has herniated inwards
into the nose.
In this photo the light sources was adjusted from below to

show herniation of the lateral crus inwards.
Post-op second-year view. In these photos, a single flash

was used on the left. As a result, the problem seems worse
Lateral crura were dissected from the skin and mucosa than it is.
and inserted again as grafts.
Patient Example
This patient underwent rhinoplasty four times, but in
none of the surgeries the lateral crura were shortened,
and hence the long lateral crura created a loss of rota-
tion. Shortening the lateral crura corrected the prob-
lem. Fat was also injected to the upper eyelids.
3.14.5 Convex Lateral Crura
The convex lateral crus problem is frequently seen. Convex

lateral crura can be found in both the vertical and horizontal
planes. The cephalic and caudal parts of the lateral crura
bend inwards, because the borders of the lateral crus are
shorter than the midline axis. These parts make the lateral
crus convex geometry resistant. Although the perichondrium
which is connected to the cartilage from both bottom and top
is very thin, it increases this resistance as well. This effect is
solely based on my observation. Cartilages on which I have
performed subperichondrial dissection shape easier with the
sutures.
Do not forget that, when the convex or concave plane
becomes flat, its length and width increases as well.
Adversely, when a plane becomes concave or convex its
length and width decreases. The main reason why the crura
become convex is the same as with the septum cartilage: not 3.14.6 Cephalic Malpositioning
fitting into the space and therefore folding. With the princi-
ples used for correcting the warp of the septum, we should Cephalic malpositioning has been described by Sheen as the
also correct the lateral crus. We should perform a wide dis- longitudinal axis of the lateral crus showing the medial can-
section in the subperichondrial plan and give shape with thus instead of the lateral canthus. Since the problem is
sutures after removing the surplus cartilage. Most of the con- described in this way, a lateral crus repositioning surgery is
vex lateral crus problems can be corrected with subperichon- suggested. The lateral crus is dissected totally, a pocket is
drial dissection, caudal and cephalic resections, lateral crura opened inferior to the lateral end, and the lateral crus is rein-
steal, and cephalic dome suture alone. serted. However, if you read this book you will not need to
After the surgery is completed, if you are still seeing a use that procedure, because I believe that the problem is
puff in the middle of the lateral crus, open 1–2 mucosa described in the incorrect way.
sutures of the cartilaginous incision. If possible, dissect the
mucosal side of the lateral crus on the subperichondrial
plane. This dissection also decreases the resistance of the lat-
eral crus. If you place 1.5 cm long and 1–2 mm wide carti- Important
lage grafts under the lateral crus, it can easily be adapted to If there is a long lateral crus, wrong resting angle, hori-
its new shape. zontal and vertical convex plane problems, and
cephalic and caudal surplus problems at the same time,
then the nose will look as if cephalically malpositioned
(parenthesis tip). The cephalic edge of the lateral crus
becomes more significant than the skin, so it shows the
medial canthus. As the caudal edge of the convex car-
tilage is folded into the nose, it cannot be seen through
the skin, and this creates the illusion of insufficient
cartilage in the alae.
This idea is supported in the new anatomical studies by

Daniel, revealing the formation of a ring by the lateral crura
and turning of the crus towards the nostril sill. Daniel argues
that the lateral crus ends at the same point in all people; all
changes take place in the body of the lateral crus.
I met Rollin Daniel in Istanbul in 2011, and he attended

Important one of our surgeries. I was operating on my own assistant on
You can solve most of the problems if you entirely that day.
mobilize the lateral crus by repositioning it inferiorly.
In my opinion, the main effect of the repositioning
technique is mobilizing the lateral crus with dissection,
rather than moving the cartilage inferiorly (once the
lateral crus is dissected from skin and mucosa, the con-
vex shape softens, hence solving the long lateral crus
problem as the cartilage spreads).
The photos show my assistant 2 years after the surgery. During the surgery, we talked about the effects of subperi-
Her left lateral crus was convex and her right lateral crus chondrial dissection. Subperichondrial dissection was
concave. The main difference between these lateral crura applied to the mucosal side of the left lateral crus, without
caused a cephalic malposition view on the left lateral crus. any repositioning.
The lateral crus topography has become more symmetri- obtained better results. I have been using the auto-rim flap
cal. If we had made a 2 mm auto-rim flap, we would have technique since early 2012.
3.15 Scroll Facet 123
Why am I against the repositioning technique?
1. It is very aggressive and causes long-lasting edema.

2. It can easily give an asymmetric result.
3.15 Scroll Facet
The scroll facet is the area near the cephalic side of the lat-
eral crus. The transition to the lateral crus polygon is usually
not clear. In some patients it is possible to see a clear edge. In
the patient below, for instance, the scroll facet can be clearly
seen. If the lateral crus resting angle cannot be achieved with
the cephalic dome suture, a 3–4 mm cut can be made in order
to form the scroll facet.
In the same patient, a 3 mm steal of the lateral crus is

planned. A new dome is formed with the cephalic dome suture.
The scroll facet is formed with a 4 mm cut on the lateral crus.
Patient Example dome is more on the cephalic and less on the caudal side.
Below you can see the shape of the cartilages of a patient Pay attention to the sharp edges on the cephalic edge of the
with a beautiful nose. The highlights of the dome on the dome. Moreover, there is a separate 2 mm area that can
skin look beautiful. However, the dome cartilages of the form the scroll facet. After using the cephalic dome suture,
patient do not form a clear triangular form; the fold in the we are going to copy the shape by scoring the cartilage.
3.15 Scroll Facet 125
A 3 mm lateral crus steal was applied. The tip was reshaped
with cephalic dome sutures in accordance with the original
anatomy. The scroll facet was rebuilt with a 4 mm incision.
In the following model, you can see the superficial cut for
the scroll facet.
You can see the creation of the scroll facet in a patient on

which I operated using the open technique. Making a 3–4 mm
cut for the scroll facet helps guarantee the correct lateral crus
resting angle. Compare the lateral crus resting angle in this
patient with the polygon model. In this photo, the infralobule
polygon had not been created yet. The photo is from 2007.
Transdomal sutures were used for domes.
Note
This maneuver prevents the lateral crus from overlap-
ping and slightly narrowing the tip.
Important
If the upper lateral cartilage and the lateral crus are
sutured with the scroll ligament, the internal valve is
repaired and the scroll line becomes distinct.
3.17 Dorsal Cartilage Polygon
The dorsal cartilage polygon is the area from the tip to the
keystone region. It can be clearly seen as a section looking
anterior in thin-skinned patients. In the cartilage anatomy,
there is a groove in the center of the cartilage; this groove is
deeper at the keystone. This groove is 1–2 mm deep and
filled by the dorsal perichondrium. The Pitanguy ligament is
on top of this perichondrium.
3.16 Scroll Line
The scroll line is the area where the upper lateral cartilage Note
and the lateral crus meet, forming a groove that is visible The Pitanguy ligament was described by Pitanguy in
through the skin. If we do not form this line, the nose 1960. It was initially named the dermocartilaginous
becomes round. If the lateral supratip skin does not fit com- ligament. Pitanguy stated that this ligament begins
pletely onto the cartilage skeleton after the rhinoplasty oper- from the supratip dermis, passes through the area
ation, the dead space fills with fibrosis and the scroll line between the dome and the septal angle, and is finally
becomes indistinct. For a beautiful scroll line, a correct rest- attached to the medial crura. In terms of surgical
ing angle is essential, since the scroll line is formed by the pit importance, he has stated: “Cut this ligament for nose
where the upper lateral cartilage and lateral crus connect. rotation, if the ligament is too much then resect.”
In order to form the scroll line, we should reconstruct the
scroll area. This is also functionally important.
3.17 Dorsal Cartilage Polygon 127
If you are making a subperichondrial dissection, forming

this groove wherein the tissues above fit will strengthen the
dorsum highlights. The drawing below illustrates a man’s
nose expressed with cubic forms. Therefore, the dorsum car-
tilage polygon is longer. As the dorsum cartilage approaches
the nose tip, the Pitanguy tissue thickness increases. The dor-
sum cartilage ends as it forms the septal angle after entering
between the lateral crura. Hence, I did not draw the dorsum
cartilage polygon adjacent with the nose tip.
The shape of the polygon that we are going to form with
spreader grafts or flaps should be as below.
Important
Dorsum bone and cartilage polygon become intercon-
nected in the keystone area. The bone lies on the dorsum
cartilage with a 2–3 mm bone shelf in the middle axis.
The dorsum cartilage, on the other hand, continues
upwards for 2–3 mm on both sides of the bone shelf.
Ismail Kuran has determined that the left nasal notch is
generally larger. Because of this, the dorsum aesthetic
lines are formed by cartilages which extend up to 3 mm
above the keystone region. Copying this anatomy will
cause better dorsum highlights. It will decrease our
responsibility in shaping the bone on the nasal dorsum.
We will examine the relation between the cartilage and
the bone in the keystone region on the polygon model.
3.18 Dorsal Bone Polygon
The dorsal bone polygon is the area between keystone and

nose radix.
3.19 Upper Lateral Cartilage Polygons
The upper lateral cartilage polygon is the area formed by the

upper lateral cartilage.
The dorsal bone polygon has more round lines compared

with the dorsal cartilage polygon. It does not give rigorous
light as much as the dorsal cartilage polygon. It is wider in
the keystone region and narrower in the radix. It is longer in
men and shorter in women. In other words, the keystone is
located higher in men when compared to women. If the roof
is completely closed with osteotomy, the dorsum bone poly-
gon becomes very narrow. When spreader graft or flaps are
used for dorsum highlights, we have a controlled open roof.
When this area is left in this way, you will see that the skin
shows the 1–2 mm opened framework. As the skin here is
very thin, you will experience collapses in the dorsum bone
polygon after a number of years. Therefore, I recommend
you to use camouflage techniques as standard. I most com-
monly use bone paste. Bone paste can be prepared from the
bone from the nasal dorsum within 1 min. I started using this
technique after I saw Fethi Orak using bone shavings from
They face lateral, downwards, and straight forward. As
rasping material, and I have been very pleased with the
upper lateral cartilages are very thin, they rarely have spe-
outcome.
3.21 Dorsal Aesthetic Lines 129
cific topographic problems. If the dorsal cartilage polygon is 3.20 Lateral Bone Polygons
shaped correctly, this section will not cause a problem. As
the height of the upper lateral cartilage is greater, we resect The lateral bone polygons are formed by bones. They face
from the upper lateral cartilage while removing the hump. lateral, upwards, and straight forward.
One problem not adequately discussed here is the case of a
long upper lateral cartilage polygon. In noses with a droopy
tip, we make the nose tip rotation by means of septum caudal
resection and cephalic lateral crura resections. However,
cephalic resection should be done to allow lateral cephalic
dome stitches. This is usually 1–4 mm. If this resection is not
enough for rotation, the resection should be made from the
caudal part of the upper lateral cartilages. In this way the
upper lateral cartilage polygon can be shortened.
They are generally convex and asymmetry can often be

observed. We can mobilize bones like flaps. However, topo-
graphic problems of the bone cause problems of asymmetry.
You can correct these asymmetries with a rasp after a wide
dissection.
To correct this problem, double-leveled osteotomy is well
advised, but I rarely use this method. The bone base is formed
by the maxilla and is convex-shaped from the medial canthus
to the piriformis aperture. This convexity cannot be changed
with osteotomy, and narrowing the lateral walls of the inter-
nal valves may impair breathing. Bone thickness in some
regions can reach 4–5 mm. In such patients, it is not accept-
able to collapse 5-mm-thick bone into the nasal cavity in
order to constrict the airway for aesthetic purposes. This
topic will be discussed in the section on surgery.
3.21 Dorsal Aesthetic Lines
This section will cover concepts that are very different

from those discussed in other relevant books. Discussions
and improvements are generally about techniques in nose
aesthetics. Concerning the nose aesthetic design issue, the

aesthetic concepts of well-known surgeons are accepted as Important
correct and generally not further discussed. Personally, I In the oblique view, if you see a depression in the key-
am entirely against the dorsum aesthetic line concept in stone area, but the front view of the dorsum appears
men and women, since it has no anatomical basis. This is perfect, then probably the studio lighting improves the
not a matter of preventing reverse-V deformity, but of the appearance. In the oblique view, a small hump at the
reconstruction of the nasal dorsum for correct anatomical keystone level can be natural. This hump is the result
highlight design. of the keystone region. It is more obvious and higher in
The colors of the sunlight and the skin are similar. It may men. Examine the natural noses at the beginning of
not be possible to make a complete assessment regarding the this section. Try to see this detail in noses that you like.
anatomy. During anatomical evaluation, since the light’s
intensity, arrival direction, and our viewing angle are very
variable, the ideal angle for the dorsum aesthetic lines is the
peak angle. In the front view, the paraflashlight shows the Patient Example
nasal dorsum better than it is. On the other hand, with a sin- Let’s examine the 2-year postoperative photograph of
gle light source it appears worse. As the lights wipe out shad- a patient whose nasal dorsum was reconstructed with
ows, it is difficult to assess the dorsum. The dorsal aesthetic the Libra graft technique. Natural rigorous light from
lines can be seen straight or concave, according to the assess- the front was used. There is no hump from the lateral
ment and environmental differences. From this point of view, view, but a 1–2 mm hump at 45°. In the peak view, the
it will be wrong to shape the nasal dorsum as straight or con- fusiform structure can be clearly seen. Libra grafts
cave. Under more careful observation, we will see the dorsal copy the fusiform anatomy in natural noses. This issue
aesthetic lines as fusiform due to the fusiform anatomy under will be described in the section on surgery techniques.
the skin.
Patient Example
Pay attention to the patient’s photos after 1.5 years; she
had a nasal dorsum reconstruction with a rib graft. In
the oblique view, fusiform dorsal aesthetic lines are
obtained.
The rib graft was prepared in a fusiform shape.

Patient Example prepared rib grafts accordingly. The rib grafts I use have
Second-year photo of a patient on whom a fusiform- concave bases in addition and fit the defect easily, show-
shaped rib graft was used. Gunter has determined the fusi- ing less visible edges.
form dimensions and defects for the nasal dorsum and
Important
We should develop a dorsal aesthetic line concept
compatible with the interior anatomy. Faulty concepts
will cause a wrong use of technique. We should cor-
rectly understand the nasal dorsal anatomy and use
more anatomical techniques accordingly.
3.21.1 Summary: Dorsal Aesthetic Lines
1. The dorsal aesthetic lines are not straight.

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

dorsal aesthetic lines at the top and my description at the bot-
tom. The drawings on the left show male dorsal aesthetic
lines and those on the right show female aesthetic lines.
I have selected the example below because the nose skin is

very thin. Examine the dorsal aesthetic lines from all angles.
3.22 Lateral Aesthetic Lines 139
3.22 Lateral Aesthetic Lines
Lateral aesthetic lines have also been defined by Daniel.

Since he was defining the base, he called it basal aesthetic
line, but published it as lateral aesthetic lines.
The lateral aesthetic line points to the groove in which the
maxilla turns to the nose. It generates the nose’s footprint.
This can be changed with osteotomy. When the hump is
removed, the base becomes wider and can be constricted
with osteotomy. We should operate on the bone only when
knowing the aesthetic rules of this region.
The narrowest part of the lateral aesthetic line is the level
of the medial canthus. It becomes wider while descending to
the alar base. Lateral aesthetic lines NEVER come down per-
pendicularly. There are both functional and aesthetic reasons
for protecting Webster’s bone triangle.
When we perform low-to-low osteotomy, the caudal edge
of the bone mobilizes more. I think that the bone rises some-
what after most osteotomies. After an osteotomy, if you in-
fracture the base by compressing it with plaster and if the
bone stays in that position, then the nose will look like a
pipe. You can see a sample of patients whose lateral aesthetic
lines narrow while descending.
Examine the same patient’s photos with single flash on

the left and without flash on the right. Abnormal lateral aes-
thetic lines reveal that the nose has undergone an operation.
3.23 The Polygon Model 141
If you do not change this approach you will keep hearing

complaints along the lines of “I was breathing better before.”
The bone base should be narrowed while protecting a form in
which it expands from top to bottom.
Polygons help to examine the topographic anatomy. Only
reading this book will not be enough to understand the
topographic analysis. Draw noses with the help of polygons
and aesthetic lines. If you do this, you can assess your
patients better before and after the operation. You will start
looking at areas you have never seen before.
3.23 The Polygon Model
Nose tip cartilages have a complex three-dimensional anat-

omy. Having a correct nose tip anatomy model can make the
surgery easier for surgeons who are just starting to perform
rhinoplasty. Actually, Gruber’s model for the rhinoplasty set
motivated me to make a model of the polygon model.
In Gruber’s model, the lateral crus resting angle has not
been shown clearly. Below you can see a nose model pre-
pared according to the polygon concept. This model describes
a surgery that is performed according to polygon rhinoplasty
logic. Bones were reduced with ostectomy. Lateral aesthetic
lines were protected. The nasal dorsum was reconstructed
with Libra graft technique. The nose tip was shaped with
cephalic dome sutures. The scroll facet was generated. The
facet polygon was relieved with an auto-rim flap. The
Pitanguy ligament was used as a cushion between the septal
angle and the dome.
Instruments
4
Abstract 4.1 The Rhinoplasty Instrument Set

Appropriate surgical tools play a key role in performing
what you actually go through your head in surgery. In
order to apply the surgical techniques described in this
book, there are some special surgical instruments that you
must include in your surgical set. Performing the surgery
with a closed technique, working in the subperichondrial
and subperiosteal plane, and having to perform surgical
maneuvers in tight areas require these instruments to be
suitable for this job. After experimenting with different
types of surgical instruments, I created a surgical set suit-
able for myself by specially designing some instruments
or selecting some other instruments specifically. This set
makes my job very easy. I explain these details about sur-
gical instruments that I think will be useful for you in this Because I had difficulties in preparing my rhinoplasty set
section. and needed to ask for help from many colleagues, I have
included a section on this topic. Obtain the right tools from
the beginning. Your practice is also important. This is why
you should have your own set. With approximately 25 surgi-
cal tools you can accomplish almost every type of nose sur-
gery. For closed rhinoplasty, you should have some special
tools. If your tools are not suitable for closed surgery, you
may have to turn to an open approach after starting a rhino-
plasty in a closed approach.
A bad workman always blames his tools. When you do
not have the right tool you cannot access the right plane. If
your tools are inappropriate, a successful closed surgery is
impossible to achieve. Since some of the instruments have a
thick body, they can obstruct the working area when you
insert them. Traditional elevators are not appropriate for sub-
perichondrial dissection, so I changed the shape of the eleva-
tors with a Dremel tool. I fashioned such an elevator for most
of my colleagues as well. With a gentle-tipped elevator dis-
section can be done easily. Following a surgery I undertook
with Rollin Daniel, his interest in the elevator I fashioned
resulted in his passing this instrument on to Medicon, which
then started serial production of this tool (Personal commu-
nication, June 24, 2011).
144 4 Instruments
4.2 Magnetic Instrument Mat 4.3 Nasal Speculum
A magnetic instrument mat acts as a second scrub nurse. If your speculum is not thin-legged, you cannot see anything
Time is saved by not handing over the instruments when the in closed surgery. Some speculums close the nostril com-
most frequently used instruments are placed in an order on pletely. A medium-sized speculum may be more appropriate.
this mat. I bought several of different lengths, but only used medium-
sized ones.
4.5 Small Retractor (Crile) 145
4.4 Dorsum Retractor 4.5 Small Retractor (Crile)
The retractor must be thin and concave. Without this retrac-

tor, closed surgery is difficult. Especially in subperichondrial
dissection, dissection is started by opening small pockets.
The retractor should be thin enough to fit into the pocket and
leave a working space.
The body of the dorsum retractor should be thin. You must

check the edge of the retractor with your finger, making sure
that they are not sharp. Sharp-edged retractors can damage
nostril margins.
146 4 Instruments
4.6 Forceps 4.7 Needle Holder
–– Toothless: For placing grafts into pockets and while A needle holder capable of managing a 6/0 suture is suffi-
stitching up cartilage, in order to hold cartilage. cient. A long needle holder may be used in repairing mucosal
–– Multiple Teeth: For stabilization while shaping grafts. lacerations.
–– Superfine-Tipped Toothed: For holding the
perichondrium.
–– Fine-Tipped Toothed: For holding the mucosa.
4.9 Bone Scissors 147
4.8 Scissors 4.9 Bone Scissors
–– Long Curved Sharp Tip: To access the subperichondrial I remove the hump with bone scissors. This is a very con-
plane. trolled maneuver.
–– Short Sharp Tip: For opening pockets for grafts.
–– Long Curved Ragged: For cutting cartilage and mucosa
parts.
–– Septum Scissors: For dorsal cartilage resection.
148 4 Instruments
4.10 Rasp 4.11 Elevators
I tried using many rasps. Despite the fact that tungsten car- –– Little Cottle: For septal dissection.
bide rasps are very hard, they can get blunted very easily –– Daniel Perichondrium: For dissection of the inner peri-
upon contact with other metal instruments. Rasps with cross chondrium of the upper lateral cartilage and medial crus
hatched pattern teeth leave marks on the bone. I am very sat- dissection.
isfied with hard steel rasps with horizontal pattern teeth. –– Çakır Periosteum: For periosteal dissection.
–– Çakır Perichondrium: For perichondrial dissection of the
dorsum, upper lateral cartilage, and lateral crus.
Left to right: Little Cottle, Daniel perichondrium, Çakır

periosteum, Çakır perichondrium.
4.13 Ninety-Degree Bone Raspatory 149
4.12 Hooks 4.13 Ninety-Degree Bone Raspatory
Dissecting the lateral crus requires fine hooks. You should try I designed this instrument at a dentist colleague’s office. We
to tuck the hook into the mucosa. If the hook gets into the worked on bone obtained from a butcher with an air motor,
cartilage, it can tear the cartilage. piezo, and rasp. We noticed that the sharp rasp performed a
very fine rasping when rubbed perpendicular to the bone. It is
very useful for rasping bone surface asymmetries. It thins the
bone, producing a very fine bone dust, and does not lead to
serration on the bone. This instrument is useful for radix
reduction without causing glabella swelling. I also use it in the
dorsal preservation technique to mobilize the bony dorsum, by
inserting it into the cut of the radix saw and rotating it.
150 4 Instruments
4.14 Rongeur 4.15 Chisels and Osteotomes
Rongeur is indispensable for let-down. It has to have a very –– 2 mm: Concha SMR, for internal and external
fine and long tip. This instrument needs to be used like a nail osteotomy.
clipper. It works quite effectively when 1 mm pieces of bone –– 1 mm: For external radix osteotomy. It can also be used to
are cut off. Breaking off bone by grabbing and twirling is not open a pocket for the rim graft at the end of the surgery.
safe. I am satisfied with the single-joint Storz brand rongeur –– 5 mm: For cutting the middle part of the hump.
pictured below.
Two and five millimeters chisels should be in your rhino-
plasty set. A strong straight lateral osteotome is very useful
for lateral osteotomy. I am very satisfied with the 3 mm
Fanous-Gubish lateral osteotome.
One millimeter chisels can achieve an osteotomy exter-

nally through a needle hole.
Five millimeter beveled cutting edge chisels (Cottle) do a

good job. Because of the beveled edge, the chisel cuts into
the bone. Internal transverse osteotomies are possible with
this chisel. By using chisels of high hardness steel, osteoto-
mies almost as good as piezo can be achieved.
4.16 Hammer 151
4.16 Hammer
It is the surgical nurse that usually uses the hammer. Prefer

flat surface and steel hammers. Lead hammers become
deformed easily, and besides, the metal falls off.
152 4 Instruments
4.17 Arkansas Stone 4.18 Sutures
Sharpening stones help you extract better use from your These three types of suture are sufficient for closed rhino-
chisels. Chisels become blunt after five to ten uses. A blunt plasty surgery.
chisel breaks the bone instead of cutting it. For osteotomy a
newly sharpened chisel is essential. Arkansas stones do not
create dust while sharpening the steel. You can moisten it
with saline while sharpening. You should wipe the tip of the
tool in case metal dust remains; it can cause permanent pig-
mentation on skin, especially during external osteotomies.
“Degussit” (Al2O3) serves as a good sharpening stone.

4.20 Forceps 153
4.19 Taştan-Çakır Saws 4.20 Forceps
I saw this instrument at Dr. Eren Taştan’s live surgery Two millimeters, through cut, straight Weil-Blakesley
(Personal communication June 2017). Also similar trans- Forceps is useful to remove inferior turbinate SMR.
verse handsaw was published by Howard Gottschalk [3]. The
steel and saw teeth have been extensively studied. A convex
handsaw is used to perform transverse osteotomy, a concave
handsaw to cut the radix. These handsaws make cuts as clean
as piezoelectric or micromotor instruments and even faster.
Besides, they do not produce heat and are cheap.
154 4 Instruments
4.21 Ayhan PPE Forceps 4.22 Headlamp
Ankara Medisoft Company made this tool. It is possible to

make resections from PPE and vomer without any rotational I prefer to use a light headlamp. Is it important to place the
movement. headlamp on your eye level to see deep areas as the vomer
and radix. It is difficult to see the inside of pits with the head-
lamp at the level of the forehead.
Part II
Surgery
Skin, Chin, Cheek, and Forehead
5
Abstract look bigger than it actually is. Therefore, augmentation of

these structures is important in achieving a nose in har-
The quality of skin is an important constituent of the rhi-
mony with the face. When needed, forehead fat grafting,
noplasty result. Oral isotretinoin treatment will help
which I no longer perform because of the potential to
shrink the sebaceous glands and thin the skin so that the
cause blindness, fat injection to the cheeks, and Medpor
changes made in the osseocartilaginous framework are
implant to the chin improve the results of a rhinoplasty.
reflected onto the skin.
Fat injection to the upper eyelid, on the other hand, will be
The three-dimensional structure of the nose is very
a good adjunct by correcting the aged and tired appear-
much affected with that of the forehead, the cheeks, and
ance of the eyes.
the chin. Retrusion in these structures makes the nose
158 5 Skin, Chin, Cheek, and Forehead
5.1 Skin Care and Rhinoplasty office, I have an aesthetician who performs skin care on nasal
skin before and after surgery. In the picture below, you can
Changes made in the osseocartilaginous structures of the see a patient’s photo before surgery on the left, 1-month
nose are reflected on the skin. Therefore, we have to help the post-op in the middle, and after skin care on the right. The
skin to adapt to it. Blackheads worsen the quality of skin and patient’s skin became more oily after surgery. In my opinion,
make re-draping difficult. You should have an aesthetician an increase in the skin’s oil production negatively affects
who performs skin care without bruising the skin. In my skin re-drape.
5.2 Oral Isotretinoin Treatment 159
5.2 Oral Isotretinoin Treatment these patients after they have used oral vitamin A for some
time. The following patient who had an open technique rhi-
Inflammation is common in oily skin due to sebaceous noplasty elsewhere demanded a revision surgery, and we
glands. In such patients re-draping will not be the same as in offered her to use isotretinoin treatment before her revision
thin-skinned patients. It is advisable to perform surgery on surgery. You can see the effects of the treatment on the skin.
Some examples for oral isotretinoin treatments:

I do not operate on patients with a skin type as below. worse after surgery. Patients with this condition can com-
Areas of red inflammation around sebaceous glands get plain of ending up with a bigger nose after surgery.
The inflammation becomes more evident with a closer

inspection.
The following patient used oral vitamin A treatment,

30 mg/day, for 6 months, starting 2 months after surgery.
One-year post-op results can be seen.
5.3 Menstruation 5.4.1 W

hy Is the Forehead Important
in Rhinoplasty?
Do not operate on your patients during their menstrual
period. Bleeding and edema can be more significant during My patients often say: “I don’t want a nose that starts from
surgery, and you may lose your control over the surgery. the forehead, I see it elsewhere, and it is very unappealing.”
Swelling and bruising can be more intensive. The same prob- It is not easy to lower the radix; dissection is difficult, bone
lem can be seen in patients who use oral contraceptives. density is high and adapting the skin in this area is not easy.
An important issue concerns the following: when the height
of the radix at its lowest point is lowered more than 1.5 cm,
5.4 Forehead Fat Grafting the three-dimensional structure of the nose becomes obscure.
It is not wise to lower the radix more than ideal just so that a
The cheeks, chin, and forehead are important reference transition from the forehead to the nose is achieved. It is
points in rhinoplasty. When planning a rhinoplasty, these ref- more appropriate to correct the area where the actual prob-
erence points should be taken into account and altered if nec- lem lies.
essary. Small chins can be corrected with chin prostheses. In I learned fat injection to the forehead from Oscar Ramirez.
addition, the cheek and forehead reference points can be We performed rhinoplasties together for 3 days in Istanbul. It
changed. If the malar and zygomatic areas are not prominent was then when I participated in forehead fat injection for the
enough, the nose can appear bigger than it is. Changing the first time.
forehead reference point is not a well-known procedure, but
it is possible. Selçuk Işık [4] has published a most useful
paper on this issue. Işık uses intracath for fat injection [2]. I,
however, think that fat grafting using a cannula is safer.
5.4 Forehead Fat Grafting 171
5.4.2 Technique
In the two drawings below only the foreheads are differ-
Before starting rhinoplasty, fat is harvested with a 2.1 mm ent. The noses are identical. I recommend fat injection for
cannula and 10 cc locked injector. It is homogenized and the 10–20 % of my patients.
injector is held upright during rhinoplasty so that the fat set-
tles. After taping the nose, the fat is injected into the fore-
head. I use a 1.2 mm blunt cannula for injection. It is possible
to fill the glabella and forehead by means of three stab inci-
sions with a blood transfusion needle. The incisions are
placed at the eyebrow edges and hairline. Aqueous fat is
injected without centrifuging so that the fat is distributed
more homogeneously.
Important
The 2 cc liquid collected under the fat layer in the per-
pendicularly placed injectors is used to infiltrate the
area where the fat will be injected. This will hydro-
dissect the tissue and make room for the fat. I also
achieve hemostasis with the adrenaline in it. This can
increase the safety of fat injection. I give a total of
8–10 cc of this liquid for the forehead.
The navel, waist, and medial part of the knee are ideal
sites for harvesting fat. I usually prefer to take fat from the
waist area.
Patient Example
I injected fat into the forehead and chin of this patient who
had rhinoplasty. Note the effect of fat injection into the fore-
head and chin on the appearance of the nose. In the first two
photos you can see the result of her rhinoplasty surgery. In
the subsequent photos you can see the effect of fat injection
into the forehead and chin. The 1-year postoperative results
of rhinoplasty and 1-month results of the fat injection can be
seen in the photographs.
Patient Example deepening the radix. As this patient’s skin is very thin, the
Below you can see the 13-month results of a patient who has supratip breakpoint became more obvious than normal. A
had fat injection into her forehead. Note the relationship revision is planned. Please also note the reduction in the
between the patient’s tip of the eyebrow and radix. The tran- appearance of exophthalmos.
sition between the forehead and nose was corrected without
Patient Example
The nose looks smaller with fat injection into the forehead.
Seven-month postoperative results.
Patient Example
One-year postoperative photographs of rhinoplasty and fore-
head fat injection.
Patient Example the dorsal aesthetic lines and the tip shadows in the 1-year
Photographs of a patient with rhinoplasty and forehead fat photographs. Tip and dorsum surgery is discussed in detail in
injection. The skin is thin and the infratip lobule short. Note the chapter in Part II.
Patient Example changed. This patient also had sagging alae which was cor-
This patient has a blunt radix. This is why I reduced the dor- rected with alar rim resection. This topic is discussed in the
sum a lot. I did not think that fat injection into the forehead chapter in Part II. This is the 1-year postoperative photo after
would be efficient. This is a good example showing the effect fat injection into the forehead. There is no over-reduction.
of fat injection into the forehead. Note how the relationships This result confirmed my belief in the efficacy of fat injec-
between the forehead and the radix, eyes and eyelashes have tions. Six-year post-op results.
Patient Example removed. Note the relationship between the tip of the eye-
As the patient’s forehead is retruded in relation to the cheek brow and radix. In the shadowed photos below you can see
and chin, the forehead was filled with fat and the radix with the surgical plan. These are the patient’s 1-year postoperative
cartilage. With this plan a lesser amount of hump was photographs.
5.5 Jaw 187
result. Whereas fat injection is usually sufficient for a chin

Note augmentation of 2–3 mm, chin implants are necessary for
At the Versailles meeting in 2016, an Italian surgeon smaller chins. I prefer Medpor implants. The two-piece
reported unilateral blindness after glabellar fat injec- implant designed by Yaremchuk fits the chin better [5]. It is
tion. I stopped forehead fat injection from then on. difficult to insert the implant intraorally. Besides, this
increases the risk of infection and it is difficult to close the
mucosa. The implant can be placed through an external
approach with a 2–2.5 cm incision in the mental line. If the
5.5 Jaw pocket for the implant is opened at the mandibular edge,
there is no need for fixing the implant with a screw. I usually
In a patient with a small chin, the nose, the cheeks, and the need to shorten the tip of the implant. It is possible to increase
lower lip appear relatively prominent and catch unwanted projection by placing pieces of the implant under it. When
attention. In such patients, I try to provide awareness to this the two pieces of the implant are joined, I suture them to
problem, and show them before and after photos so that they each other using a big-needled Monocryl stitch. If a drain is
can see the benefit of chin augmentation on the rhinoplasty needed, a 16G intravenous cannula can be used.
5.5 Jaw 189
5.5 Jaw 191
5.6 Importance of Cheeks
I learned about the illusion effect of the cheeks on the nose

from Michael Esson in 2009. Esson gave drawing lessons to
20 plastic surgeons at the Istanbul Memorial Hospital.
Bringing forward the cheeks makes the nose appear
smaller. On the other hand, flat cheeks make the nose appear
bigger than it actually is. With only a midface lift or fat injec-
tions to the cheeks and the lower orbital rims, you can make
the nose seem smaller than before.
5.6 Importance of Cheeks 193
Patient Example
Note the effect of fat injection into the forehead and lower
orbital rim on the nose. The photos show the patient 10 days
after surgery.
Patient Example jaw. Note the effect of chin implant and fat injection into the
This revision case had been operated on elsewhere. I advised forehead. The forehead fat injection was repeated 6 months
that the problem was not the nose, but the forehead and the later.
This patient regularly comes to my clinic for botulinum Patient Example

toxin injection. In her case, I need to stick the needle deeper For her big nose to appear smaller, fat injections have been
than usual. made in the forehead and the cheeks of this patient. Her nose
will be discussed in the chapter in Part II. These are the
patient’s 1-year post-op results.
5.7 Periorbital Fat Grafting Then I inject to the contralateral side to save time. The
fluid causes vasoconstriction as it contains adrenaline. The
Periorbital fat atrophy results in an aged appearance. head is then elevated. Attention is paid to keep the blood
Periorbital fat grafting can be an adjunctive treatment in pressure low. Fat is easily injected to the area between the
rhinoplasty. supratarsal fold and eyebrow because it was first infiltrated
After centrifuging fat, take the fluid right below the fat with fluid.
and inject it between the supratarsal fold and the eyebrow to Keep in mind that the upper eyelid fold is concave medi-
lower the supratarsal fold. I inject at least 2–3 cc of this fluid ally, straight in the middle, and convex laterally. Pay atten-
on each side. tion to this fact when grafting. An abnormal appearance
forms by over-injecting the medial part. One to three cubic
centimeters of fat is injected through two points at the lateral
end of the brow. Sunken cheeks and hollow eyes make the
nose look bigger and the patient older.
Patient Example
Pre-op and post-op 1.5 years result of rhinoplasty and fat
injection to supraorbital region and cheeks.
5.7 Periorbital Fat Grafting 201
Patient Example Pay attention to the rejuvenation effect of the fat

This patient had four previous rhinoplasties. Rotation was injection.
achieved by shortening the lateral crus. What impressed the
patient was actually the fat injection. One-year post-op
results.
5.7 Periorbital Fat Grafting 203
Patient Example main point of the change seems to be the fat injection, not the
Two-year post-op photos of a patient after rhinoplasty and rhinoplasty.
fat injection beneath the eyebrows and to the cheeks. The
Surgical Preparation, General
Anesthesia, and Local Anesthetic 6
Infiltration
Abstract In this section I will describe my routine before starting the

surgery. Each description is accompanied by numerous pho-
A subject that is as important as the techniques, maneu-
tographs corresponding to that specific step. So, once you
vers and procedures you use in the surgery is the patient’s
read each section, the photos will be sufficient for
preparation for the surgery. It is important for the surgeon
clarification.
to have a comfortable operation process, as well as for the
For a long time, I have been discharging the patient the
patient to feel good after surgery. The tricks that I will
same day. After admittance to the hospital patients are taken
explain in this section are based on my experiences over
to the operating room and they go back home 6–8 h after
the years. I will share details about the position of the
surgery. Xylometazoline nasal spray is used for septal muco-
patient, intubation, the position of the surgeon, and the
sal vasoconstriction. The spray is given to the patient who is
application of local anesthetic, which is a very important
asked to take a deep breath while squeezing the pump into
subject.
each nostril and clean the nose afterwards. In this way the
spray acts homogeneously on the mucosa. Using the spray
30 min prior to surgery ensures a bloodless septoplasty and
decreases the systemic absorption of septal injections. It also
eliminates the need for intraoperative use of nasal packings
with adrenaline.
206 6 Surgical Preparation, General Anesthesia, and Local Anesthetic Infiltration
6.1 atient Position and Tracheal

P
Intubation
The patient’s chin should be visible and the tube is posi-

tioned away from the surgeon at a 45° angle. Be sure that the
intubation tube does not pull on the lips. If the tube is posi-
tioned in the midline as a reference point, it can slip and mis-
lead you. The chin kept in the visual field will provide more
substantial control.
The pressure of the intubation tube is measured through-
out the surgery. This decreases sore throat after surgery.
6.2 Cleaning
Remove nose hair with a blade. Applying povidone-iodine The patient is positioned in a reverse Trendelenburg posi-
will ease gliding the blade on the mucosa. Do not struggle tion, with the head extended 20–30° so that it is parallel to
with applying ointments or using scissors. the floor. This position allows the hip to be in the lowest posi-
6.2 Cleaning 207
tion and decreases blood pressure in the head. Keeping the fromAlan Landecker increases the surgeon’s field of view
head parallel to the floor decreases the likelihood of making (Personal communication, November 12, 2015).
rotation errors.
After working with the anesthesiologist Mustafa Özgön

Make sure you have a foot controlled hydraulic stool. You at the American hospital, we made very positive changes in
should evaluate the nose from different angles by adjusting our surgery protocol (Personal communication, June 2017).
the height as needed throughout the surgery. Besides, the We wrote a rhinoplasty anesthesia protocol for the Operative
cartilages can be sutured more precisely while sitting. Plastic Surgery book. Mustafa says that the cause of bleed-
ing in surgery is the surgeon, not the anesthetist (Personal
communication, June 2017). He taught me the parameters
that the surgeon should pay attention to. Let me share them
with you. Implementing these parameters will add another
10–15 min to the overall surgery time, but thanks to blood-
less surgery, it will save you 30 min back in surgery. The
nose will swell less and it will be a more enjoyable
surgery.
The adrenaline solution injected to the nose provides
vasoconstriction and the surgery can be performed by seeing
the details. However, the increase in the blood pressure and
pulse rate due to the systemic effect of adrenaline counter-
acts the local vasoconstriction. Therefore, it is necessary to
control the pulse rate as well as the blood pressure.
The best parameter that shows both pulse and blood pres-
sure instantly is the end-tidal CO2 pressure (EtCO2). When
injecting the local solution, make sure that EtCO2 remains
To check the tip and the dorsum symmetry, one must look between 30 and 34 mmHg. If EtCO2 rises, take a break from
at the nose from the top of the head. This approach I learned injecting until the pressure drops.
Injections to the septum can act like an IV injection.

Therefore, we prefer low concentrations of adrenaline and a
small volume of injection.
Dr. Gubisch says that the best local anesthetic agent for
the nose is ropivacaine. Unfortunately we don’t have it in
Turkey (Personal communication, June 6, 2015).
6.4 Injection Points
I start the injections with the incision points.
1. Both sides of the caudal septum.
Before doing anything on the patient, I wait until the sys-

tolic blood pressure drops below 90 mmHg and the pulse rate
below 80 min−1. I use 4–5 cc of 1/80,000 adrenaline contain-
ing solution for the nose and 2 cc 1/400,000 adrenaline con-
taining solution for the septum. Injections to the septum
cause systemic side effects at most. I apply the solution very
slowly. Add 25 mg of tranexamic acid per 10 cc of local
anesthetic solution. I infiltrate one area with the solution,
wait and sip my coffee in the meanwhile, and move to the
next area to be injected. The injections usually take 10 min. I
follow the pulse rate and EtCO2 pressure while injecting the
solution. There is no need to give extra injection during the
surgery. A bloodless surgical field for 2 h can be obtained 2. Into the planned incision sites for tip surgery and over the
with the injections. We have not needed using a beta blocker lateral crura.
or a calcium channel blocker like nidilate for a long time. We
watch out for ECG findings as QT interval prolongation and
absence of the P wave, which may spark off arrhythmias.
6.3 Local Anesthesia
6.3.1 For the Nose
9 cc Isotonic saline

10 cc Mepivacaine HCl
1 cc ¼ Adrenaline
With this composition, this solution contains 1/80,000
adrenaline.
6.3.2 For the Septum
The solution prepared for the nose is used at a 1:5 dilution

for the septum so that it contains 1/400,000 adrenaline.
6.4 Injection Points 209
3. Internal valve. 6. Over and under the pyriform aperture.
4. Dorsum of the nose. Injecting below the perichondrium 7. Mucosa of perpendicular plate of ethmoid bone.
starting from the septal angle eases subperichondrial 8. Anterior maxillary spine and nasal base. Injection around
dissection. the branches of the palatine artery reduces mucosal
bleeding.
5. An artery passes through the apex of the radix mucosa.

Injecting there will decrease bleeding from the bone.
Stick a transparent tape over the mouth to keep your

Important little finger and the sutures from contacting the inside of
If you only use lidocaine, the analgesic effect begins to the mouth. This is one of the many suggestions of Dr. Ali
decrease after 2 h. This causes an increase in blood Teoman Tellioğlu (Personal communication, February
pressure, as the patient starts to feel pain. If you use 2014).
mepivacaine, you will not experience pain-related rise
in blood pressure. It also comforts the patient during
the first few hours after surgery. After taping and
splinting the nose at the end of the surgery, an infraor-
bital block with 1 cc solution also increases post-op
comfort of the patient. When I visited Dr. Daniel, he
was making an infraorbital block before awakening
every patient (Personal communication, December 17,
2014).
Important
Do not inject too much. This can result in a loss of
surface details. You should be aware of the side effects
of local anesthetics. A total of 5–7 cc solution should
be sufficient.
6.5 Lighting in the Operating Room
Important Perform surgery in a brightly lit environment. If the lights

During the dissection of the nasal dorsum, there can be in the room are not adequate, turn the surgical lights to the
bleeding from bone which is usually venous and diffi- ceiling to illuminate the room. Do not point the surgical
cult to control. Injection into the mucosa underlying lights directly on the nose; otherwise you will not see the
the bone can decrease bleeding. details. I have learned this information from Micheal
Esson, an Australian artist who attends plastic surgery
operations and arranges workshops for plastic surgeons
Now take a break as your nurse prepares the patient. (Personal communication, April 2009). He organized a
Adjust your head lamp and scrub. course in Istanbul in 2009. As Esson said: “Surgical lights
Before starting the surgery, wash the inside of the nose prevent you from seeing the form” (Personal communica-
with 10 cc isotonic saline. tion, April 2009).
6.6 Drawings 211
A photo from Esson’s course in Istanbul in 2009.
Another option is to illuminate the operative field with the case, it will be useful to keep the focus of the surgical lamps
surgical lights at a very low setting (laparoscopy mode). wide so that the lamps illuminate a large area, not a single
point.
6.6 Drawings
For years I have been marking lines on the cheek that show
my new tip point, and this effectively facilitates my job.
Performing surgery without planning makes me nervous as
I want to control every step. Operating in the light of the
drawings in Photoshop is safe. I look at shadowed photos. I
mark my planned tip on the current nose. I draw two to
three arrows on the cheek that are aimed at this point. These
lines guide me while adjusting tip position. I determine the
amount of steal from the lateral crus according to these
lines. I decide on the correct dome positions performing the
lateral crural steal until the tip rotates to my previously
marked points.
It is very difficult to shoot videos when using a headlamp.
In order to get good quality recording, you need to turn on 1. Sit on your stool. Lower your stool enough to see the full
the surgical light at the intensity of the head lamp. In this profile.
2. In the shaded photo, locate the tip. Find out where the
new tip rests on the existing nose.
3. Mark the tip you plan on the patient’s nose. Draw three
lines showing this point. Do this before starting surgery,
because the shape of the nose will change with dissection
and resections. If you have a tip reference point, you can
decide more easily in surgery.
This line is usually at the level of the tragus or malar

prominence in females. Leaving the ears uncovered during
surgery will increase orientation.
6.6 Drawings 213
A photoshop analysis and simulation of lateral crural

steal, footplate deprojection, and medial crural overlap. Real
life can make surprises but nevertheless mathematics is
important to understand the logic of tip surgery.
Turbinate Surgery
7
Abstract I ask my patients about breathing problems. I make a

physical and endoscopic examination and decide whether
Turbinate surgery may be needed in patients with breath-
or not to make an intervention on the turbinates. With the
ing problems. Preoperative endoscopic examination will
suggestion of Dr. Sercan Göde, I started making interven-
reveal the need for a turbinate intervention. I apply turbi-
tion on the head of the turbinate more frequently
nate submucosal resection in 20% of my patients. After
(Personal communication, February, 2008). If the tail of
infiltrating the turbinate, a small incision is made and the
the turbinate is large in endoscopy, I also intervene in that
submucosal cavernous tissue removed. Bony intervention
area.
includes lateralization of the turbinate and partial bone
If it shrinks with Otrivin spray, I cauterize the subcutane-
excision, which can be made by removing small pieces of
ous tissue with monopolar radiofrequency or electrocautery.
bone with a thru-cut forceps. Internal silicone nasal splints
Otherwise, I make bony reduction in the turbinate and bleed-
are placed after the intervention and they are removed on
ing control with cautery.
the fourth post-op day.
7.2 Turbinate SMR
1. Apply a small amount of local anesthetic solution with

epinephrine to the enlarged concha and wait for a few
minutes.
2. Expand the concha with 10 cc saline solution. Inject
slowly not to tear the mucosa.
7.1 Turbinates
I have to admit that I don’t have a full knowledge of the tur-

binates like an ENT surgeon. I will write my own practice
and experience.
216 7 Turbinate Surgery
3. Using a surgical blade, make a 4 mm C-shaped incision

on the head of the turbinate (the concavity of the C should
be facing laterally). You can also start turbinate surgery
by making elliptic resections starting from the turbinate
head.
4. Cut out the cavernous tissue in between the mucosa and
the bone. This procedure is useful even when applied to a
depth of 3–4 cm only.
7.2 Turbinate SMR 217
5. With a 2 mm chisel or Cottle elevator, dissect both sides

of the bone. Turn the chisel 90°, go over the bone and try
to fracture the bone with controlled back and forth move-
ments. Turn the chisel 90°. Break off small pieces of bone
by moving the chisel on the bone. Aspirate the free pieces.
6. Take out the pieces of bone with a thin punch.
The best tool I have used for this is Medicon’s 2 mm

straight Weil-Blakesley thru-cut forceps.
The inside of the turbinate.

The procedure is finished without tearing the turbinate 8. Push on the turbinate with a blunt elevator and make
mucosa. medial and lateral fractures consecutively to open the
nasal airway passage. Close the wound with 6/0 Monocryl
suture and place the silicone splints.
7. Control bleeding with electrocautery. Once again be care-

ful not to tear the mucosa.
Here you can see the airway after the turbinate SMR pro-
cedure has been completed.
I perform turbinate SMR in about 20% of my patients.

Even if there is only mild deviation at the septal base, I Note
always remove a cartilage segment of 1–3 mm width from In the following photograph, turbinate bone removed
this area. Otherwise, osteotomies in asymptomatic septal in one piece can be seen. It is impossible to take out
deviation cases with a low resistance septal cartilage can such a large piece of bone without tearing the mucosa.
cause total axis deviation even 1–6 months after the surgery. Therefore, I prefer not to remove the turbinate bone in
I make resections from the septal cartilage in about 90% of one piece. It is more logical to remove it in pieces. I
my patients. In septal surgery, I leave a 1–2 mm space included this photo in order to illustrate how big the
between the septum and maxillary spine. I want the perios- turbinate bone can be. You can imagine how this bone
teum and perichondrium segments at the bony cartilaginous can obstruct the airway. Radiofrequency and laser can-
junction of the septal base to fill this space. I prefer to keep not reduce the size of the bone because they are effec-
the silicone nasal splint for 4 days in cases with turbinate and tive on cavernous tissue only. Turbinates with a big
septum surgery. If a procedure has been done at the septal bony part also have a thicker mucosal lining. The tur-
base, I prefer to cut out parts of the silicone splint as shown binate mucosa contracts after bone reduction and
in the following photo. This increases patient comfort. bleeding control by means of electrocautery. I have
previously used Tebbetts’ technique for excising turbi-
nate bone and mucosa, repairing with 6/0 Monocryl
continuous sutures [6]. This is a time-consuming and
difficult technique. The turbinate SMR technique
serves the purpose.
In secondary patients and sometimes in primary patients,

the bone to which the concha is attached is either in-fractured
or naturally narrow. If you out-fracture a 3–4 mm long seg-
ment of this part with a lateral osteotome or a 4 mm chisel,
your patient will remember you with gratitude (Webster tri-
angle out-fracture).
7.2.1 Normal Anatomy
Below you can see the turbinate bone removed in pieces.
7.2.2 Inwardly Collapsed Maxillary Base
My experience as a patient for my allergic turbinate

hypertrophies included electrocautery, radiofrequency
(twice), steroid injections into the turbinates, acupuncture,
and turbinate SMR. I wasted so much time until the turbi-
nate SMR. Shaver is not a controlled way of bone removal.
It is easier to take out pieces of bone under visual control.
Finally, I had bony reduction and out-fracture of the
Webster triangle. As a result, I can now breathe much
better.
7.2.3 Segmental Out-Fracture

Note
Dr. Peter Palhazi invited us to a cadaver lab in Budapest
(Personal communication, July 2016). All together we
were four surgeons, including Dr. Yves Saban. Yves is
a very good anatomist. When he explained the anat-
omy of the pyriform aperture, I took a picture.
Caucasian race is the unluckiest group as for the anat-
omy of the aperture. The protrusions of maxilla antero-
medially in the aperture can narrow it to an extent to
cause breathing problems. Dr. Yves expands the
entrance of the aperture by removing bone from this
area, where the head of the concha is also attached. I
think it is a neglected surgery for correcting
breathing.
widest
Lepto Meso Platy

(Caucasian) (Asian) (Black)
Hypmlepto
stero rhinia
B1mA1 A2mB2
Incisions and Dissection in Rhinoplasty
8
Abstract 8.1 Hemitransfixion and Transfixion

Incisions
Subperichondrial and subperiosteal dissection is a key
element in proper healing after rhinoplasty. Less fibrosis
is observed in this plane of dissection. The perichondrium
Note
or periosteum left on the skin side of the dissection serves
I use the transfixion incision in long noses and the
as a strong cover on the changes made in the osseocarti-
hemitransfixion incision in the rest. The incision made
laginous framework. The placement of the incisions and
from the membranous septum enters the “Pitanguy”
the dissection technique are important for an easy dissec-
midline ligament and disrupts the integrity of the liga-
tion in this plane. This chapter focuses on the tips and
ment. I make the incision directly above the caudal
tricks about the incisions and dissection.
septum and leave a 0.5 mm wide part of the caudal sep-
tum attached to the Pitanguy ligament. Leaving a wider
part of the caudal septum makes it more difficult to
suture it back at the end of the surgery. As for the trans-
fixion incision to the internal valve region, I make a
3–4 mm back-cut along the edge of the upper lateral
cartilage. I have not been making intercartilaginous
incisions for years. My field of vision has decreased
slightly, but reducing incisions has improved mucosal
healing. I have also begun to repair the scroll ligament
more anatomically. My transfixion incisions, which
continued with an intercartilaginous incision, caused
contraction of the internal valve in some of my patients.
I am happy to have abandoned the intercartilaginous
incision. If I compare it with open rhinoplasty, the
marginal incision is the same; there is no columellar
incision; there is an extra transfixion incision.
Note
In the first edition, I noted that I usually dissected the
periosteum of the anterior maxillary spine to facilitate
septal angle dissection. This process deprojects the tip
and now I do it only when necessary. This rate does not
exceed 20–30%.
226 8 Incisions and Dissection in Rhinoplasty
Cut the most caudal 0.5 mm of the caudal septum with a

#15 scalpel so that it adheres to the perichondrium of the
opposite side.
At this stage, dissect the septum on both sides in a subp-

erichondrial plane. After irrigating with saline, you can wash
the pouches with the local solution.
This cartilage which is left attached to the Pitanguy liga-

ment passing through the membranous septum can be called
the “posterior strut.”
8.1 Hemitransfixion and Transfixion Incisions 227
Note
In the first edition, I mentioned that I was making a full
thickness cut at the caudal septum with a #11 scalpel
leaving a 2 mm strip of the septum caudally. At the end
of the surgery when suturing this strip back to the sep-
tum, it can drop on either side of the septum rather than
being end-to-end. Leaving this posterior strut attached
to the opposite perichondrium makes it easier to suture.
Thanks to the posterior strut technique, natural elastic
support structures between the tip and septum are pre-
served. We can freely continue caudal septum resec-
tion. When the surgery is finished, the “posterior strut”
will be sutured back to the septum.
Note
Benlier (2006) describes leaving the caudal part of the
septum attached to the Pitanguy ligament and suturing
it back to the septum [5].
If nasal tip deprojection is not sufficient in the later stages,

the posterior strut can be removed. This gives deprojection of
0.5–1 mm.
8.2 ntering the Nasal Dorsum

E Endoscopic photos showing the entry into the subperi-
from the Septal Angle chondrial plane from the anterior septal angle.
Using sharp tipped scissors, separate the posterior strut com-

pletely from the septal angle. After a 3–4 mm of separation
of the cartilage, head towards the nasal dorsum from the sep-
tal angle. Dissect up to the upper lateral cartilages. At this
point you will see the caudal edge of the nasal dorsal peri-
chondrium. This is the most appropriate area for getting
under the perichondrium. If the scissors are not sharp enough,
you will have difficulty getting under the perichondrium.
My favorite tool for this job is Marina Medical®’s Çerkeş

scissors.
Important
There can be a second plane of perichondrium that
goes under the bony cap 1 cm ahead of the anterior
septal angle (ASA). Find it too with your pointed scis-
sors and go under it. If you are going to use dorsal
preservation techniques, the second layer should
remain above the dorsal cartilage.
8.2 Entering the Nasal Dorsum from the Septal Angle 229
By moving the elevator sideways, dissect the perichon-

drium of the upper lateral cartilages and stop at the scroll
ligament.
Proceed to dissection of the nasal tip cartilage and join the
scroll region last.
Important
It is difficult to get under the dorsal perichondrium
from the intercartilaginous or infracartilaginous inci-
sions. It is easier to access the subperichondrial plane
from the anterior septal angle. Once at the right plane,
dissection will be faster than the sub-SMAS plan.
When you master it, it is likely that you will find it an
indispensable technique.
8.3 I nfracartilaginous Incision and Auto- The direction of the scalpel is changed. Maintain the
rim Flap direction of the first incision and proceed to the caudal part
of the dome.
If the lateral crus does not have caudal excess, it will be cut
from where the cartilage ends (infracartilaginous incision). If
there is caudal excess, an auto-rim flap will be planned.
8.4 Markings
1. Place the double hooks and evert the nostril tip with your
middle finger. The lateral crural edge can be seen where
an incision of 6–7 mm length and 1 mm depth will be
made. When you get close to the domes, it will be diffi-
cult to visualize the edges of the cartilage. Do not cut here
based on chance.
Note
In the dome region, it is absolutely necessary to stay
infracartilaginous. The auto-rim flap incision must be
completed at a 2–3 mm distance to the dome. Let’s
take a look at these cadaver photos to better show
which part of the lateral crus is used as a rim flap.
8.4 Markings 231
Please note that the auto-rim flap ends 3–4 mm before the
dome. After lateral crural steal, the auto-rim flap supports the Important
facet polygon better. Make sure that the auto-rim flap is completely sepa-
rated from the lateral crus. Otherwise, the domes may
be damaged during dissection.
The other option is to make the medial and lateral crural

Continue the incision along the caudal edge of the medial
incisions and connect the two.
crus.
1. Make an intracartilaginous incision over the lateral
crus.
2. Evert the columella with your finger and cut the mucosa
along the edge of the medial crus.
The incision is completed 3–4 mm before the

“footplates.”
8.6 How Is Lateral Crural Subperichondrial Dissection Performed? 233
3. Place the double hook to the apex of thse nostril and evert 8.5 ateral Crural Subperichondrial
L
it. Now join the two incisions. This way you are less Dissection
likely to make mistakes.
Lateral crural subperichondrial dissection may sound fan-
tastic, but one can say that it is already being done in that
plane (see, for example, Gruber’s comment on Cakir et al.
[8, 9]). Subperichondrial dissection can make use of the
auto-spreader flap technique easier for the dorsum; how-
ever, all surgeons say that their dissection is in the subperi-
chondrial plane at the lateral crus. If you make a true
subperichondrial dissection, you can clearly write on the
cartilage with a surgical marking pen, like writing on a
paper with a pen. When you dissect subperichondrially at
the lateral crus, as in the subperichondrial dissection of the
septum, you can clearly see the perichondrium on the flap.
Since muscle and perichondrium stay on the cartilage when
subperichondrial dissection is not used, the ink of the mark-
ing pen disperses. Subperichondrial dissection is extremely
easy with the correct surgical tools and appropriate tech-
nique. It takes 10–15 s to get into the correct plane and dis-
section is much quicker.
8.6 ow Is Lateral Crural

H
Subperichondrial Dissection
Performed?
1. The key point for lateral crural dissection is the lateral

crural turning point.
Important
If the hook plunges into the cartilage, it can break it.
Because of this, you should use a hook penetrating no
more than 1 mm.
2. The nurse should pull the hook down gently.

3. Retract the skin to see the cartilage edge using a sharp
tipped forceps.
4. Cut with the blade until you reach the cartilage.
5. When you reach the cartilage, hold the knife reversely
and incise the perichondrium of the cartilage.
Blue arrow: Lateral crus; Green arrow: Perichondrium
of the lateral crus; Yellow arrow: Auto-rim flap.
Note
Using one leg of pointed scissors is also successful in
finding the plane.
6. Hold the perichondrium and its overlying tissues tightly

using the forceps.
7. Try to get into the bloodless subperichondrial plane with
sharp tipped scissors through the long axis of cartilage
for a length of 2–3 mm.
Important
You may not succeed going under the subperichondrial
plane at first. But remember being upset while suturing
your first vein. It is similar to scraping the adventitia
with your fingertips. You will get used to it, so do not
give up. By using the subperichondrial plane, you can
protect the nasal muscles and nerves.
8. After entering 2–3 mm into the subperichondrial plane,

place in the small retractor, hold and compress the ala
between the retractor and your middle finger, and
stretch it.
8.6 How Is Lateral Crural Subperichondrial Dissection Performed? 235
10. Place the hook closer to the dome and, while protecting
Important the perichondrium, approach the dome using subperi-
The perichondrium of cartilage can tear with sharp dis- chondrial dissection.
section. Use a blunt perichondrial elevator. 11. Attach the hook to the mucosa of the dome, create trac-
tion, and move forward by cutting the tight junctions of
the perichondrium to the caudal side of the lower lateral
9. While stretching the perichondrium with one hand, cartilage.
advance the elevator in the subperichondrial plane. The
perichondrium can be dissected easily through the dome.
12. After passing the dome, medial crural subperichondrial

dissection becomes easier. Dissect this region with the
Be careful about lateral dissection. The perichondrium
Daniel elevator stretching the ala with a retractor.
can tear easily in this region. You can perform lateral dissec-
tion after delivering the domes.
Important
Important It is necessary to stretch the dome downward while
If you have done everything correctly to this point, you dissecting the lateral crura and upward while dissect-
will see the sesamoid cartilages attached to the scroll ing the medial crura.
ligament on the undersurface of the flap. These carti-
lages will be used for internal bandaging while
closing.
Note the capillaries in the medial crural perichondrium.
13. Apply the same procedure to the other side.

8.8 Periosteal Dissection 237
When you come to the scroll region, you can reach the
nasal dorsum dissection plane by pressing the elevator gently
on lateral crura. Connect the two planes, and the lateral crus
will be totally freed from the skin.
8.8 Periosteal Dissection
Do not try to enter the subperiosteal plane at the keystone

area. This will damage the periosteum. Using the Çakır peri-
osteum elevator, dissect the periosteum starting laterally.
Attention
The subperichondrial plane continues beneath the
bone. While advancing in the subperichondrial plane,
8.7 Combining Tip and Dorsum stop when you feel the bone. Otherwise you will sepa-
Dissections rate the upper lateral cartilages from the bone
laterally.
The dissection of the dorsal cartilage was completed. The
dissection of the tip is also finished. Now these two dissec-
tion planes will be united at the scroll region.
In this way, the periosteum is cut with the elevator and the
subperiosteal plane is entered. Insert the small retractor
under the periosteum, squeeze the skin flap with the perios-
teum underneath it with your finger, and stretch it
downwards.
With the tunnel formed, dissection under direct vision can

be achieved until the radix. Make deeper dissections with the
Aufricht retractor.
With the periosteal elevator, scratch the perichondrium

and periosteum at the inferior edge of the bone.
8.8 Periosteal Dissection 239
In this endoscopic view, the cut at the left maxillary peri-

osteum can be seen. I try to dissect the periosteum very delicately.
Dissection of the right nasal bone. The periosteum is cut

with the Daniel-Çakır periosteal elevator.
At the sides of the keystone region there is usually no
bone. In this region, the cartilage merges into the bone like a
wedge. Carefully protect the perichondrium in this region.
This is one of the regions in which dorsal irregularities can
form.
The transition between the perichondrium and periosteum

can be seen.
Cut the periosteum of the dorsal bony cap in the midline

with the Daniel-Cakir elevator. Raise the dorsal periosteum.
In this way, the planes will be combined.
8.9 Subperichondrial Dissection in Secondary Rhinoplasty 241
Important
It can be difficult to dissect the domes in secondary
rhinoplasty. In such cases you can approach from the
medial crus and join both dissection planes at the
dome. Below you can see secondary dissection in a
previous open rhinoplasty patient.
Although the periosteum of the nasal bone is slightly

injured, the dorsal periosteum is intact.
8.9 Subperichondrial Dissection

in Secondary Rhinoplasty
It is possible to perform subperichondrial dissection in revi-

sion rhinoplasty. This is because surgeries are generally
made in the sub-SMAS level, that is, over the perichondrium.
This means you can perform your surgery in an untouched
plane.
Important
In secondary rhinoplasty, if you use the subperichon-
drial dissection, you will not see the grafts used in the
previous surgery. In order to reach the tip grafts, you
should cut the perichondrium and reach the sub-SMAS
plane.
8.10 Delivering the Domes
1. Grab the domal mucosa bilaterally using hooks while

your nurse pulls them equally.
2. Insert the retractor to allow you to see the medial peri-
chondrium of the dome.
Dr. Arslan has introduced a flap from the Pitanguy mid-

line ligament, using it to control the supratip skin. Keeping
the integrity of the ligament makes it easier to control supra-
tip skin [10].
Below is an endoscopic view of the dissected Pitanguy
midline ligament and the superficial SMAS. The left medial
crus can be seen at 8 o’clock position, the left medial crus
3. With a sharp tipped scissors, dissect towards the other perichondrium and superficial SMAS at 10 o’clock, and the
dome from the end point of the perichondrium trans- Pitanguy midline ligament at 4 o’clock.
versely. Do not cut more than 2–3 mm.
Note the vascular structures passing through the Pitanguy

midline ligament.
4. Separate the superficial SMAS and the Pitanguy liga-
ments on the columellar and infralobule polygons. The
superficial SMAS should stay on the columellar skin.
8.10 Delivering the Domes 243
In the photograph below, you can see the left lateral crus
at 4–7 o’clock, the short sesamoid cartilage at 11, the long
sesamoid cartilage at 12, and the septum at 9 o’clock. The
perichondrium of the lateral crus can be seen near the long
sesamoid cartilage and the perichondrium of the upper lat-
eral on the far side.
The Pitanguy midline ligament attaches to the right and

left scroll ligaments. In the middle you can see the left scroll
ligament. There are generally two sesamoid cartilages on the
scroll ligament, one shorter and one longer.
Note that the Pitanguy midline ligament is a thick struc-

ture similar to the palmaris longus tendon.
Start splitting the Pitanguy ligament from the middle

while the domes are being held firmly on both sides. Splitting
the ligament for a distance of 2–5 mm will mobilize the
domes which can now be pulled out of the nostrils. With this
procedure, the Pitanguy midline ligament can be seen clearly.
Do not disturb the integrity of this system. After having per-
formed 100 rhinoplasties, you will no longer need to cut the
Pitanguy ligament to access tip cartilages and suture it back
afterwards. Don’t forget that cutting the Pitanguy ligament
creates 1–3 mm projection loss.
Important
One of the advantages of the closed technique is to be
able to perform surgery without cutting the Pitanguy
ligament. In the open approach you can suture the liga-
ment back. This will have a similar effect, but you
should be careful about a symmetric alignment.
Dr. Tellioğlu has stated that, after repairing the
Pitanguy ligament, the droopy nose rises when smil-
ing. Repairing the Pitanguy ligament allows nasal
muscles to exert their elevating effect (Personal
Communication, April 2016).
Important
With appropriate dissection, the lower lateral cartilages Cartilage is softer after subperichondrial dissection
have been delivered from the nostrils. compared to sub-SMAS dissection. 6/0 PDS is enough
for shaping the cartilage.
Important
In thick-skinned patients with long interdomal dis-
tance and bulbous noses, removing only the cartilage
will not be enough. Soft tissue should be removed as
well. Do not assume this procedure as a skin reduction.
If you want to narrow the nasal tip in such cases, leave
2–3 mm of perichondrium on the Pitanguy ligament
while entering between the Pitanguy and superficial
SMAS with scissors. Then resect the perichondrium
and soft tissue that you leave on the Pitanguy ligament.
Take care not to disrupt the Pitanguy ligament during
this procedure. In the patient below, soft tissue removal
from the interdomal space is planned.
This dissection provides enough exposure for tip surgery.
The area between the superficial and deep SMAS was The perichondrium left below the cut was then resected.
entered such that on both sides 3 mm of domal perichon-
drium was left below.
Photos of our patient 1-month post-operatively.

If you have projection problems, the perichondrium left In the example below, the perichondrium below the mark
on the Pitanguy ligament can be sutured under the domes was added to the soft tissue pillow between the domes and
instead of being removed. In this way, a 2 × 2 mm tissue will the septal angle.
be added to the soft tissue pillow.
8.11 Supratip Break Point
The supratip break point is the transition point from the dor-
sum to the tip. It is the most difficult region to control in
rhinoplasty surgery. If the skin is completely freed from the
skeleton, it is very difficult to create a breakpoint in medium
or thick-skinned noses.
The most commonly used techniques to highlight this

breakpoint are resection from the anterior septal angle and
sutures between the supratip skin to the septal angle.
Preserving the Pitanguy ligament is the easiest way to create
the supratip break point. The end point of the dissection
between the superficial and deep SMAS (Pitanguy deep liga-
ment) forms the supratip break point.
8.11 Supratip Break Point 249
The point where the dissection of the Pitanguy ligament

ends can be clearly identified on the skin. This point will
form the break point.
Important
At the end of tip surgery, dissection of the ligament can
be extended if the supratip break point is too promi-
nent. The supratip break point can be far too deep in
thin-skinned patients requiring a revision surgery. Less
dissection is made in thick-skinned noses because it is
very difficult to create a supratip break in such noses.
In patients where it is necessary to lengthen the lobule, the

lobule compartment needs to be enlarged. This is accom-
plished with dissection between the superficial and deep
(Pitanguy ligament) SMASs. Otherwise, the supratip break
turns out to be very prominent and over-defined.
Whereas dorsal surgery is performed under the Pitanguy In one of my patients with very thin skin, the supratip
ligament, tip surgery takes place over it. break point became very prominent after surgery. I injected
0.2 cc filler in the Pitanguy ligament entering from the septal
angle. I do not like filling the nose and besides, I am actually
intimidated with it. I couldn’t obtain sufficient deprojection
in this patient. I know that I had made a good dissection in
front of the maxilla, but the strut graft was probably unneces-
sarily strong.
8.11 Supratip Break Point 251
The last option is to cut the Pitanguy ligament and inten- my patients. I used to cut the Pitanguy ligament in 10% of
tionally create a supratip deformity. In this way, the concav- patients but lost my control over definition. I now weaken the
ity is filled and projection decreases. I cut the Pitanguy Pitanguy ligament by dissection in patients with over-
ligament in thin skin patients whose supratip break points are definition. If still not enough, I place finely crushed cartilage
already very prominent. But this does not exceed 1–2% of grafts on top and bottom of the Pitanguy ligament.
Important
On the contrary, the Pitanguy ligament dissection is
kept more limited in patients with thick skin.
Note the supratip control.
Pitanguy dissection was completed at the level of the cau-

dal point. I do the dissection up to the cephalic point in noses
with medium thickness skin.
8.12 Subperichondrial Dissection in Open Approach 253
Supratip break point and better definition were obtained.
Continue with the subperichondrial dissection on the lat-

eral crus.
You can begin the dissection from the lateral crus and cut
8.12 S
ubperichondrial Dissection in Open the columella later. Some surgeons find dissection from the
Approach lateral crus towards the dome more practical.
After columellar incision, enter between the medial crura

without cutting the cartilages. Cut the superficial SMAS.
Open a perichondrial window on the medial crus and start to
scrape upward.
In order to repair it more easily later on, put two mark-

ing sutures and cut in between them to reach the septal
angle. Find the perichondrium at the level of the septal
angle and enter beneath it, using the Çakır perichondrium
elevator.
The Pitanguy midline ligament can be visualized easily in

the middle when the tip cartilages are dissected
subperichondrially.
Dissect the perichondrium of the upper lateral cartilages

by making right and left swiping movements similar to the
closed approach.
Dissect the bone starting laterally with the Çakır perios-

teum elevator.
The scroll and Pitanguy ligaments as seen in an open

approach subperichondrial dissection.
When you reach the bone, cut the periosteum and peri-
chondrium with a blade. There is a sharp bone corner at the
lateral to the paramedian groove. You can scrape that corner
with the Çakır periosteum elevator and start to elevate the
periosteum easily.
Important
Do not perform periosteal dissection without clear
visualization. Otherwise, the periosteum will be dam-
aged. Using a little retractor and head lamp, it is pos-
sible to see and dissect easily up to the radix.
There should be no soft tissue in the material extracted

from the nasal dorsum. If you do not perform a good dis-
section, after cutting the bony hump, you will have to pull
out the bone with a clamp instead of a bayonet forceps.
This is because of the incomplete dissection of the perios-
teum. Skin ecchymosis usually occurs at this stage. A good
dissection, however, rarely results in ecchymosis of the Below you can see the photos of five consecutive patients
skin. after surgery. In all of them, an intervention to the bone was
Below you can see the limits of the periosteal dissection. made and the average surgery time was 3 h. Note that dissec-
tion, resection, and intervention to the bone have had no sig- sensitive due to oral Vitamin A use. Note the rash on the
nificant effect on the skin. The last patient’s nasal skin was nasal dorsum.
8.13 Why Subperichondrial Dissection? 263
sible for me to see, protect, and reconstruct the ligaments

that we only see in anatomy papers [9].
8.13.1 Subperichondrial Dissection

and Healing
As a rule, septal surgery takes place in the subperichondrial

plane, resulting in less inflammation and fibrosis. The same
principle is valid for nasal surgery. If muscle and fatty tissue
are damaged during dissection, progressive thinning occurs
in nasal tissue, the main reason being soft tissue injury. The
simplest indicator is shining of the skin in the first months. If
the skin shines, this shows soft tissue injury with a possibil-
ity of changes in the nose in the long term.
Important Important
If you are performing a wide dissection for all nasal 1. Whereas entering the subperichondrial dissection is
bones, use lateral osteotomy cautiously. The bone can difficult, dissection is easy.
collapse into the nasal cavity since the periosteum is 2. Dissection is easier when a previous subperichondrial
completely separated from the bone. Instead, you can dissection was applied on the nose. Similarly, once
perform osteotomy with a 2 mm chisel or ostectomy dissected, the septum can be dissected more easily.
with a Çakır 90 chisel. 3. Yet, in a sub-SMAS surgery patient, the subperi-
chondrial dissection plane has been kept intact. You
can perform subperichondrial dissection under the
previous sub-SMAS dissection plane without any
Attention fibrosis.
In surgery with a proper dissection, ecchymosis of the
skin is not common. If it occurs, you may have dam-
aged the periosteum or even the SMAS, or you may
have compromised a vessel during local anesthetic 8.13.2 Subperichondrial Dissection
injection. If the SMAS and subcutaneous fat tissue are and Muscle Function
damaged, nasal skin will look shiny for months. This
may be due to the inflammation related to soft tissue A person with facial palsy breathes with difficulty on the
injury. If you perform a delicate subperiosteal and sub- paralytic side. The nasal muscle helps keep the internal and
perichondrial dissection, you will not see any shining external valves open [13].
of the skin. If the skin shines, this is a sign that the nose Nerves of the facial muscles enter the muscles from
will go on changing. below. A sub-SMAS dissection plane hence is adjacent to the
nerves. Therefore, a possible nerve injury may lead to
decrease in muscle function. Another reason for impaired
Ahmet Karacalar has used laterally based perichondrial muscle function is an injury to the muscle tissue itself. If fat
flaps to cover dorsal irregularities [11]. is encountered during dissection, you are probably progress-
Dr. Çerkeş has also elevated the perichondrium of the ing inside the muscles. In addition to the direct damage by
nasal dorsum as a flap and repaired it at the end of the sur- sub-SMAS dissection, retractors also cause muscle injury
gery [12]. during surgery.
Seyhan Çenetoğlu calls the muscle function impairment
due to rhinoplasty a “paralytic nose,” which is an excellent
8.13 Why Subperichondrial Dissection? expression (Personal communication, June 2013). Muscle
function is impaired due to subsequent dissections. In
One of the new approaches in this book is the subperichon- patients who have had three or four surgeries, examine the
drial dissection of nasal tip cartilages and the nasal dorsum. valves and look for their resistance against inspirium. You
I have used this dissection plane since 2006. This dissection will see that functions of the nose have been decreased iatro-
accelerates healing of the nose. In addition, it has been pos- genically. Structural rhinoplasty aims to treat this side effect
by solidifying the nose. If you protect the nasal muscles, the

need for structural grafts decreases. Important
If you dissect the nasal cartilages entirely in the subperi- Cartilages are surrounded with perichondrium. When
chondrial plane, you will never see fat and muscle tissue. you make a sub-SMAS dissection, you resect the carti-
lage together with the perichondrium on it. Especially
at the nasal dorsum, the septum and the internal valve
8.13.3 Subperichondrial Dissection mucosa will be in direct contact with the overlying soft
and the Camouflage Effect tissue without the perichondrial barrier.
If you are in need of placing acellular dermis or fascia onto

the dorsum in primary rhinoplasty, scrutinize your dissec- 8.13.4 Effect of Subperichondrial Dissection
tion. The perichondrium of the nasal dorsum is a 1-mm-thick on Bleeding
great covering and healing tissue. Do not look for extra cam-
ouflage materials. With a little attention paid to dissection This book includes many perioperative patient photos.
and the correct tools, you can benefit from the advantages of Examine the dorsal skin surfaces. You will see very little
subperichondrial dissection. In the photo below, a dorsal edema and ecchymosis. Likewise, pay attention to how the
reconstruction was performed. Examine the covering tissue surgery causes very little bleeding. If you perform a subperi-
of the perichondrium above. chondrial dissection, there will be bleeding only from the
mucosal incisions, the Pitanguy ligament dissection, and the
veins emerging from bones. I rarely use cautery.
8.13.5 Effect of Subperichondrial Dissection

on Ligaments
The Pitanguy and scroll ligaments are in fact thickenings of

the SMAS. These ligaments can tear if you pass the suture
through them. The perichondrium and sesamoid cartilages
on the other hand are tough enough tissues for holding the
suture. If you perform a subperichondrial dissection, you can
see the sesamoid cartilages attached to the scroll ligament. In
sub-SMAS dissection, however, the scroll ligament and
attached sesamoid cartilages stay on the cartilage and are cut
off with lateral crural cephalic resection. The perichondrium
I took the next photo in a cadaver lab. Two plastic sur- is a strong tissue for repairing the Pitanguy ligament in the
geons asked me to show the perichondrium in the nose they open approach. In the closed approach, however, surgery is
dissected in the sub-SMAS plane. I dissected the perichon- done without cutting the Pitanguy ligament. I use the sesa-
drium and we were able to photograph the perichondrial moid cartilages while repairing the scroll ligament.
thickness. As a result, subperichondrial dissection allows you to pro-
tect ligaments and reconstruct them effectively.
Dr. Vincent Patron’s work on nasal perichondrium (used
with permission from Dr. Vincent Patron and Septum Publisher).
The perichondrium is a connective tissue, mainly com-
posed of collagen 1. It is innervated and vascularized, and it
is responsible for nourishing the cartilage and its healing. It
is therefore of paramount importance when performing a
subperichondrial dissection. It is composed of two layers: an
outer one and an inner one.
The outer one is called the “stratum fibrosum.” It is a
fibrous, vascularized, and innervated connective tissue layer
that nourishes the inner layer, called the “stratum cellulare.”
This latter layer is of utmost importance, as it is a chondro-
genic layer, composed of chondroblasts, and is responsible
for cartilage growth. Bairati et al. describe a third, intermedi-
ate layer composed only of connective tissues [14].
8.13 Why Subperichondrial Dissection? 265
Fibrosis is the consequence of the activation of fibro-

blasts, secondary to trauma. Fibroblasts are present in the
connective tissues in the skin, subcutaneous tissue, SMAS,
or the fibrous perichondrium. Fibroblasts are not present in
the inner perichondrium and the cartilage, where the only
cells are chondroblasts and chondrocytes, respectively.
Theoretically, then, a true subperichondrial dissection results
in activation of chondroblasts, not fibroblasts.
With regard to vascularization, as mentioned previously,
cartilage is not a vascularized tissue. Vascularization comes
from the fibrous perichondrium and the surrounding tissues,
and allows the cartilage to be supplied by diffusion of nutri-
ents, metabolites, and oxygen from vessels to the chondro-
cytes [15].
Figure below (histological section of LLC with Masson
trichrome staining) shows the vascularization above and
underneath the cartilage and highlights the absence of vascu- Subperichondrial dissection is a genuinely subperichon-
lar trauma during subperichondrial dissection (white dotted drial dissection when under the inner chondrogenic layer of
line). Veins and arteries are present above and underneath the the perichondrium. If the perichondrium is respected during
cartilage (red arrows). dissection, it does not generate fibrosis or devascularization,
but instead activates the chondrogenic activity of chondro- Let me finish this section with the below photo. When I
blasts, resulting in cartilage production. It is therefore of was in Brazil, I said I was using the ligament described by
paramount importance to take care of the perichondrium Ivo Pitanguy every day, and asked to be introduced to him.
during dissection. So I had the opportunity to meet the little giant man. Ivo
After this article, I made important changes in my prac- Pitanguy passed away after carrying the Olympic flame in
tice. In my own revisions, I observed that the perichondrium 2016.
thickened after subperichondrial dissection. This thickening
will be advantageous for thin-skinned patients. In one of my
patients, I saw that the thickness of the lateral crural peri-
chondrium reached that of the lateral crural thickness. The
changes I made in cartilage were not reflected to the surface
aesthetics enough. For this reason, I also had to intervene in
the thickened perichondrium. For this reason, I use the sub-
SMAS plane in some of my own revisions.
Dr. Üregen shared his experience about resecting the peri-
chondrium. He stated that he could not provide adequate
reduction with subperichondrial dissection in patients with
soft connective tissue and that he needed some fibrosis or
even scar contracture (Personal communication, 2019). In
such noses, the dorsum is dissected in a sub-SMAS plane
and the perichondrium that covers the dorsal cartilage and
ULC is resected. In this way, a scar and scar contracture are
created in the dorsum. I resected the perichondrium in this
manner in three patients. I think it’s really effective.
Septoplasty
9
Abstract In the dissection section (Incisions and Dissection in

Rhinoplasty), we talked about the transfixion incision and
Septoplasty is an integral part of rhinoplasty. The classic
the posterior strut technique. This posterior strut will be left
L septoplasty removes a large amount of cartilage, does
in the columella and the septum dissected.
not necessarily correct the deviation, and makes it diffi-
cult if a revision rhinoplasty is needed. The part of the
septum that causes the deviation is usually the base where
there is an excess. Removing this excess is most of the
time enough to correct the deviation. Dissect the mucosa
only at the base, and remove the excess in the cartilage
and parts of the deviated maxillary spine. On the other
hand, low septal strip needs dissection of all of the septal
and ethmoid mucosa. The deviated ethmoid parts that are
in contact with the middle turbinate should be corrected.
Other than that, there is no need to correct high septal
deviations. Extracorporeal septoplasty should be reserved
for patients with severely deformed septal cartilages.
268 9 Septoplasty
9.1 Dissection
When a posterior strut is created, the cephalic edge of the

septum becomes thick which is an easy place for entering the
subperichondrial plane. Incise the perichondrium with the
blade’s reverse side.
Important
Do not perform an L-strut septoplasty because the
excess part of the septum is usually the base.
Important
There is a group of patients that come for revision rhi-
noplasty. The open approach has been usually used,
Dissect the perichondrium with a thin Cottle or Daniel the posterior septal cartilage removed via L septo-
elevator. plasty, aggressive tip surgery performed, and no
spreader grafts used. It is not wrong to assume that in
these patients excess cartilage has been disposed of. I
do not know whether L septoplasty is taught as a rou-
tine step in rhinoplasty such as lateral crus cephalic
excision. I believe these patients have been mistreated.
L septoplasty is not an effective method for the correc-
tion of septal deviation or treatment of axis deviation.
If you plan a revision in these cases, rib cartilage will
be necessary. The source of cartilage grafts should be
the septum. The size of the left behind cartilage should
9.1 Dissection 269
Reveal the excess part of the septum, cut it with a 3 mm

be recorded in the surgery note. A more rational tech- lateral osteotome and take out the cartilage with a Cottle
nique is to take only as much cartilage graft as needed. elevator or a Çakır perichondrium elevator, taking care not to
The excess part in the septal base meets the graft break it.
requirement in 90% of the patients.
Without removing the excess part in the septal base, no

procedure (not even L septoplasty) can correct axis
deviation.
Important
Cartilage presence in the septum is important for sec-
ondary surgery. The amount of cartilage available in
the septum area can be determined easily by touching
the septum with a cotton bud while examining with a
speculum and light.
Do not completely dissect the septum. Only dissect on the

two sides of your resection area. If you need to score the
cartilage, dissect accordingly.
Note
Low septal strip dorsal preservation techniques need to
dissect all of the septum and deviated PPE.
270 9 Septoplasty
Incise the anterior periosteum of the maxillary spine.
After removing the curved or excess cartilage, dissect the

periosteum of the maxillary crest. Do not dissect completely
before resection as you might injure the mucosa.
Important
You can cause mucosal tears anytime. Defects larger
than 2 cm heal with difficulty. Repair these tears with
a locking microsurgical needle holder and a slim tipped
bayonet forceps. A 6/0 Monocryl suture with a small
round needle will work best. It is difficult to repair the
tear in the nasal cavity with big needles.
9.1 Dissection 271
Dissect the soft tissue with a Cottle elevator. The height of excess parts on both sides using a 4 mm chisel or cut the
the footplates decreases as the amount of dissection increases. bone with bone scissors.
Leave a space 2 mm wide between the septal base and the
anterior maxillary spine. The periosteum and perichondrial
Note
tissue left on the mucosa will fill the space.
When writing the first edition, I was usually dissecting
the periosteum of the maxillary spine. Most patients
required this procedure when a 2 mm posterior strut
was left. I had difficulties when sewing the 2 mm pos-
terior strut onto the caudal septum. So I started to leave
a 0.5 mm wide posterior strut. So I rarely dissect the
periosteum of the spine anymore. In summary, dissec-
tion of the periosteum of the spine is a very effective
maneuver for deprojection. Do not do it routinely at
the beginning of the operation. Dissect it incrementally
as needed.
Correct deviations of the maxillary spine. Do not try to

centralize it in the midline. The bone is tough there and
would mobilize, and you will have to resect it. Trim the Correct deviations of the ethmoid bone.
272 9 Septoplasty
Attention
It is dangerous to advance far too superior in this
region. If you apply excess force on the ethmoid bone,
it can fracture from the cranial base and result in CSF
leakage. The ethmoid bone portions that cause breath-
ing problems and are in contact with the middle con-
chae should be resected. There is no rationale for
correcting superior deviations of the ethmoid bone.
Deviations of the ethmoid and vomer should be
resected in little pieces with bone scissors rather than a
chisel. If bone is removed in big parts, they can easily
tear the mucosa when taking out as they have sharp
edges. In the picture below, note the sharp edges of the
excised portion of vomer.
At this stage stabilize the septum to the midline maxillary

spine using 5/0 PDS. As blunt dissectors were used while
removing the excess cartilage from the nasal base, enough
soft tissue remains on the anterior maxillary spine for sutur-
ing and stabilization. If the septum mobilizes later during
surgery, fixing it to the base will become more difficult. The
transfixion incision is a good incision for fixing the septum
to the base. If the PDS knot remains between the septum and
spine in the 2 mm space, it will not cause any suture reaction.
If the space is larger than 2 mm, you can fill this space by
tying more knots.
A powerful through-cutting forceps is a tool that should

be in every rhinoplasty surgery set. Curved PPE and vomer
bones can be safely excised with it. Ayhan, who is a tool
designer in Medisoft, improved the power arm and tip of the
instrument so that it can be used in confined spaces.
Therefore, I call it Ayhan punch.
9.2 Extracorporeal Septoplasty 273
Important
The silicone splint will already have been placed at the
beginning of the surgery in patients who had a turbinate
intervention. You can perform septoplasty without
removing the splints. If you have difficulty, then remove
them, finish your septoplasty, and finally insert them
back. If you insert the silicon at the end of the surgery,
the blood accumulated under the septal perichondrium
can move to the nasal dorsum and mobilize the grafts.
9.2 Extracorporeal Septoplasty
The septum rarely needs to be reconstructed extracorpore-

ally. But if the septum is severely deformed, it is better to
repair it extracorporeally. It is more rational to take it out
after the septal base and nasal dorsum resections are com-
pleted, because it is more difficult to make resections from
the reconstructed septum. Drawing the silhouette of the sep-
tum on the exterior can be a guideline. Spreader grafts, eth-
moid bone with holes drilled, and horizontal mattress sutures
can be used for extracorporeal correction of septal deviation.
In my view, this approach is too aggressive and should be
employed no more than 2–3 times per 1000 patients.
When septal surgery is completed, check the nasal pas-

sage as it can still be blocked. If there is no problem, insert
the silicon splints. Sometimes a bone or cartilage piece can
tear the mucosa and be exposed to the nasal passage. This
protruding tissue will not be easily epithelialized and can
cause bleeding, crusting, and smell in the nose.
274 9 Septoplasty
9.2 Extracorporeal Septoplasty 275
Classic Dorsal Resection
10
Abstract 10.1 D
issection of the Upper Lateral
Cartilage Mucosa
Classic dorsal resection is still the mainstay in treating the
hump in rhinoplasty despite the more recent preservation
After separating the upper lateral cartilages from the septum,
rhinoplasty techniques which are yet indispensable in cer-
it is difficult to dissect their inner mucosa. Upper lateral car-
tain scenarios. Mucosal dissection is important before any
tilages become extremely mobilized because they are thin,
attempt for dorsal resection. The excess upper lateral car-
and they can be damaged while separating the mucosa.
tilages and septum are separately cut at the same level and
Therefore, dissect the mucosa of the upper lateral cartilages
the dorsal cartilaginous hump is removed, after which the
before separating them from the septum. While holding the
bony hump is removed with bone scissors or a chisel. In
soft tissues with a forceps and stretching them, open a tunnel
deviated noses, more resection is made on the longer side
with the Daniel elevator. Dissect the perichondrium of the
of the osseocartilaginous vault so that equal amount of
septum from the septal angle and take down the internal
bone and cartilage is present between the two sides after
valve mucosa.
resection. The radix can be lowered with a chisel or 90°
ostectomy chisel in small amounts. Attention should be
paid not to injure the periosteum in the radix.
Once the Daniel elevator is in the subperichondrial plane,

dissection will be fast and easy.
278 10 Classic Dorsal Resection
10.2 Dorsal Cartilage Resection
After dissecting the upper lateral cartilage mucosa, dis-

sect the septal mucosa subperichondrially connecting the
dissection planes of the septum and upper lateral cartilage. Dissect the cartilage dorsum from the bony dorsum with an
elevator. In this way you can remove the cartilage and bony
dorsum separately.
The internal valve mucosa was dissected without

damage.
10.2 Dorsal Cartilage Resection 279
If the nasal body is deviated to one side, asymmetric

resections should be made. Less upper lateral cartilage is
resected on the deviated side and more on the contralateral
side. In the example below, there is an axis deviation to the
left; therefore, more resection is made from the right carti-
lage and nasal bone when compared to the left side.
Cut the upper lateral cartilages and the septum separately

at the same level. The cartilage hump can be removed easily
since the cartilage hump was separated from the bony hump
during dissection.
Attention
In deviated noses, less upper lateral cartilage is
removed from the deviated side and more from the
other side. Take out the dorsal cartilage in one piece. If
you are going to use spreader flaps, you should not
make resections from the upper lateral cartilages.
Separate the upper lateral cartilages from the septum
using a blade and fold them inside. I prefer to use the
Libra graft technique if the dorsal cartilage is strong. I
have not been able to achieve strong dorsal aesthetic
lines with the spreader flap technique when compared
to the Libra graft. If I have to use spreader flaps, I try
to give a fusiform shape to the upper lateral cartilages
by suturing them tight near the septal angle and loose
in the keystone area.
10.3 Dorsal Bone Resection
When the dorsal cartilage is removed, the slim edges of bone

will be exposed.
1. Cut the bone from both sides with bone scissors.

2. A few taps to the midline with a 4 mm chisel will get the
bone out easily. It is easy to make additional 1–2 mm
resections using bone scissors. You can then rasp irregu-
larities. Since the bones of Turkish patients are thick, it
can take plenty of time rasping.
10.3 Dorsal Bone Resection 281
Bony dorsum is removed in this patient without using a

4 mm bone chisel.
Left nasal bone is being cut with bone scissors.
In the example below, you can see the right and left nasal
bones cut with bone scissors and the dorsum removed with a
4 mm chisel. Make sure your chisel is not blunt.
Below, the right nasal bone is being cut with bone
scissors.
Bony and cartilaginous dorsum removed with clean cut In the example below, there is an axis deviation to the left;
edges. more resection is done on the right upper lateral cartilage and
the nasal bone when compared to the left side.
10.4 Radix 283
Irregularities can be corrected with a rasp.
10.4 Radix
A 5 mm chisel or a Çakır 90 can be used to reduce the radix.

Removing bone in small pieces with a chisel is a very con-
trolled procedure. Lower the radix by making 1 cm back and
forth movements with a 5 mm chisel. Press the chisel to the
bone when moving forward. Take out the bone pieces with a
bayonet forceps. In order to obtain a balanced radix-to-
dorsum transition, the radix needs to be low enough. Curved
radix rasps are unsuccessful for this maneuver. In addition,
radix rasps can damage the periosteum and thereby expand
the glabella. Protecting the periosteum in the radix area is
very important. If the periosteum gets damaged, bleeding
can occur, leading to glabellar edema. Tissue injury in the It is possible to make bone resections as shown in the fol-
glabella and radix cause long-term edema. lowing photo by pushing the chisel forward five to six times.
You can use a 90° ostectomy chisel in the radix area. It

removes bone when moving both forward and backward.
Removed bone is like dust, not in the form of particles. The
removal is slow but more controlled.
Osteotomy, Ostectomy, and Dorsal
Reconstruction 11
Abstract 11.1 Setting the Dorsal Height

Dorsal height is one of the main targets aimed to be cor-
rected with rhinoplasty. It can be corrected with dorsal Dorsal resection is made before the tip. After finishing the tip
resection or dorsal preservation. This chapter is about surgery, you should check the dorsal height. Adjust the posi-
osteotomies, ostectomies, and dorsal reconstruction after tion of the tip with your finger. If the nasal dorsum is still
dorsal resection. An open roof is formed after dorsal high, lower it as much as necessary.
resection. Depending on the extent of the open roof, addi-
tional osteotomies may be necessary to be able to close
the roof. The open roof will then be closed with lateral 11.2 Checking the Open Roof
and medial oblique osteotomies. Ostectomy is indispens-
able when the bones are thick and their medial displace- Wide dissection is made until the osteotomy lines. Bony
ment after osteotomy without ostectomy will lead to intervention is performed after tip surgery in order to reduce
narrowing of the airway. After closing the bony roof, the swelling.
cartilaginous roof needs to be closed with various tech-
niques so that pleasing dorsal aesthetic lines are obtained.
At the end of dorsal reconstruction, remaining unavoid- Important
able irregularities may be corrected with bone dust. If you prefer lateral osteotomy, don’t make a wide dis-
section on the dorsum.
At the cephalic part of the open roof, remove the bony

triangles and ensure that the roof is opened until the radix,
especially in wide noses. Otherwise, closure of the roof will
not be easy. You can use a 4 mm chisel for this purpose. If
you prefer a saw, you have to use it with caution.
286 11 Osteotomy, Ostectomy, and Dorsal Reconstruction
Important
In patients where less dorsum is removed, the roof will
not be open until the level of the radix. In these patients,
you should open the roof all the way to the radix with
a 4 mm osteotome or saw. If bone in this region is not
removed, the radix cannot be narrowed.
The roof should be opened until where the narrowing of

the dorsum is planned to begin. Opening the roof all the way
to the radix in patients with an already narrow radix will pro-
duce an even narrower radix, which should be avoided.
The radix mucosa should first be dissected for 2–3 mm to
prevent damage from osteotomies.
11.2 Checking the Open Roof 287
When opening the roof with a saw in one or two of my

patients, the saw slipped into the airway and dissected all of
the septal mucosa. So be careful and use short and controlled
movements.
Protect the Webster’s triangle considering the lateral aes-

thetic line. If the base of the radix is wide, make a high-low-
low osteotomy, otherwise a high-low-high osteotomy.
NEVER use a guided lateral chisel in a patient with wide
dissection; otherwise, the bone will collapse. You can per-
form an osteotomy under direct visualization from the inter-
cartilaginous incision with a 2 mm chisel.
Perform the transverse osteotomy perpendicular to the
bone at the radix. In this way the nasal dorsum can be closed
more easily. The osteotomy can be performed as an external
osteotomy with a 1 mm chisel. An internal oblique osteot-
omy creates less of a step deformity, but the bone flaps have
to be sufficiently mobilized. Taştan-Çakır saw is also useful
to make a precise transverse osteotomy.
Important
The chisel should always be sharp. An Arkansas stone
sharpens tools without producing dust. Chisels should
be cleaned after this procedure, otherwise permanent
color changes may appear on the skin after external
osteotomy.
Important
If you perform an inadequate lateral osteotomy at the
medial canthus level and cannot make a radix osteot-
omy, then the roof closes too much at the keystone and
the radix remains open. If you do not use a spreader
graft, you may cause an inverted-V deformity.
11.3 Lateral Osteotomy
It is absolutely necessary to choose the right tool for lateral

osteotomy. Thick-bladed osteotomes can cause premature
fractures. I use a 3 mm Gubisch-Fanous lateral osteotome for
lateral osteotomy. The blade thickness of this tool rarely
explodes the bone.
Dr. Memet Yazar adapted the Shark-fin knife design to the
lateral osteotome (Personal communication, February 2019).
This design can perform a lateral osteotomy without explod-
ing the bone.
11.3 Lateral Osteotomy 289
Note
Starting the osteotomy 1–3 mm cephalic to the
Webster’s triangle may reduce the in-fracture of the
apertura. Opening a very narrow tunnel in the inner
periosteum of the bone prevents the bone flaps from
being overly mobilized.
Make a 3–4 mm incision on the apertura pyriformis

mucosa. Create 2–3 mm wide tunnels under the inner and
outer periosteum of the bone where you will perform lateral
osteotomy. Begin the osteotomy 2–3 mm cephalic to the
Webster’s triangle. Perform a low-to-low or low-to-high
osteotomy.
11.4 Transverse Osteotomy saw. Percutaneous osteotomy with a 2 mm osteotome can be
performed if a narrow dissection is made.
Mark the area on the skin where the bone needs to be nar-
rowed. In case of a wide dissection, a Taştan-Çakır saw can
be used. You can make very clean cuts with a 0.4 mm wide
11.6 Lateral Ostectomy 291
11.5 Medial Oblique Osteotomy oblique osteotomy may create a step on the cranial edge of
the osteotomy which can then be rasped. The medial
I use this osteotomy to join the open roof with the trans- oblique osteotomy can also be performed externally with a
verse osteotomy. If you hold the osteotome vertically, the 2 mm chisel.
narrowing in the radix will be less and vice versa. Medial
In patients with very thick bones, thinning the lateral oste-

11.6 Lateral Ostectomy otomy lines with a 3 mm rasp facilitates lateral osteotomy. It
is necessary to wash and aspirate the chips.
I have not performed lateral ostectomy since 2012. I prefer
thinning the osteotomy lines with the 2 mm rasp.
Note
My fellows using the lateral ostectomy technique have
told me that it was not an easy technique and they were
not satisfied with it. I also have been using it less fre-
quently recently. I have preferred osteotomy more fre-
quently in recent years. Ostectomy can be kept in mind
for patients with thick bones.
Important
Ostectomy feels more controlled in my hands when
compared to osteotomy. Yet, it takes more time
(5–10 min). I am designing tools to simplify this pro-
cedure. Currently I am using a Çakır 90° chisel and a
5 mm chisel.
In the below drawing, the effect of ostectomy before lat-

eral osteotomy in preventing the narrowing of the airway can
be seen.
You can see the surface of the left nasal bone.

Align the edge of the chisel with the osteotomy line.
11.6.1 Ostectomy Technique
Dissect the periosteum until the osteotomy line. This is three

to four times mm more than the usual dissection. Never
insert a chisel into a non-dissected area. Below you can see
the dissection and the ostectomy areas [16].
First, correct superficial bone asymmetries with a rasp or

Çakır 90 chisel.
Use the chisel forcefully at the level of the chin-forehead

line. Check the direction of the chisel while protecting the
eye with your finger. The chisel can be controlled by gently
pressing with your finger.
Using the edge of the chisel, reduce the thickness of the

bone by making scratching movements at the lateral osteot-
omy line. You cannot do this procedure with a blind chisel,
so sharpen it before each surgery. Straight chisels are not
appropriate for ostectomy.
Bone saw dust will start to accumulate in the radix and at

the tip of the chisel. Remove and collect it with a Bayonet
forceps. These grafts can be used to fill the anterior part of
the maxilla and to camouflage irregularities on the dorsum.
11.6.2 Instruments for Ostectomy
I have been using a 90° angled 5 mm chisel for the past 9
years. I performed ostectomy on a sheep scapula with 90°
chisel and piezoelectric tool. As piezoelectric produces heat,
it has to be cooled with water. Ostectomy with a 90° angled
chisel scratches the bone. It scrapes during both forward and
backward movements and produces thinner bone dust. The
bone dust obtained in this way can be used as a more appro-
priate graft material. Below you can see the 90° angled
chisel.
Patient Example
This patient had left axis deviation. Therefore, the right nasal
base was wider. As a result, more ostectomy was made on the
right side. Since the left nasal base was not very wide, the
8 mm chisel was used in a more rotate angle and less ostec-
tomy was made.
Below you can see the bone dust produced with a 90°
angled 5 mm chisel.
Below you can see the endoscopic photos of a patient

with ostectomy. The right nasal bone can be seen at the base.
Lateral ostectomy can be seen on the left. The bone was
mobilized after an ostectomy of approximately 4 mm deep.
If only an osteotomy was made, a 4 mm in-fracture would
have to be made to achieve the same base width.
The left lateral ostectomy region can be seen below. Note
the bone width (the tip of the aspirator is 4 mm wide).
Bone dust particles.
Let’s examine left lateral and transverse ostectomies step

by step.
Two mm lateral ostectomy was made.
The groove was deepened with lateral ostectomy to have

less in-fracture.
Move to the nasal dorsum. Press the entire surface of the

90° chisel to the bone, not only the edge. With 1 cm back and
forth movements, perform a thinning of the lateral walls of
the radix (transverse ostectomy). This procedure decreases
step problems that may occur as a result of mobilization of
the bone.
Note
I am no longer thinning the area where the transverse
osteotomy meets the open roof. In some of my patients,
I caused narrowing in the radix more than desired.
In the model below, you can see where the ostectomy was
made.
Nasal passage after the roof has been closed.

Examine the ostectomy areas in the polygon model.

A medial oblique or transverse osteotomy is also usually

made.
Important
Do not press on the bones near the edge of the open
roof. You may break the naso-maxillary junction.
Instead, press on the maxillary bone.
Wash the inside and remove the bone dust.
Bones are usually mobilized with transverse osteotomy. If

not, they can be mobilized with a gentle finger pressure. If
the bones are not mobilized with gentle pressure, check the
osteotomy. I move the bones medially and laterally with an
elevator and totally mobilize them.
Important
Thin rasps decrease thickness of the base with 10–15°
rotation movement to the lateral. Teoman Doğan has
been making ostectomy with a rasp, and I began to do
so after observing him. But I prefer the chisel to the
rasp. Motorized systems or special saws can be
designed for this region. The aim is to reduce the thick-
ness of the bone, not to cut it. In this way, the roof can
be closed without making an in-fracture.
11.6.3 Why Ostectomy? and the caudal margin. This can cause an open roof inverted-
V deformity.
11.6.3.1 Improved Control
In my opinion, osteotomy is the most uncontrolled step in 11.6.3.2 Function
rhinoplasty. When I used to perform osteotomy, I had great I was very much disturbed by osteotomy-related breathing
anxiety, because I could not really have total control over it. I problems. Although I had been protecting the Webster’s tri-
was looking for a more controlled procedure. Bone thickness angle for years, I still had cases of breathing problems
shows variability among patients and neither is bone thick- because of in-fracture. Bone width at the maxillary base can
ness the same along the osteotomy line. With osteotomy, it is change between 2 and 5 mm. In order to narrow the base by
not easy to perform a greenstick fracture. The bone can be 4 mm, a 4 mm in-fracture is required when using the osteot-
reduced wherever necessary by means of an ostectomy. Bones omy technique. In the ostectomy technique, on the other
are thick especially at the medial canthal level and because of hand, the same result can be achieved with a 3 mm ostec-
bleeding in this region one may be hesitant. Hence, bones tomy and 1 mm in-fracture. Bone constitutes the lateral wall
may not be mobilized sufficiently at the radix and medial can- of the internal valve. In my opinion, there is nothing that
thus, whereas they are mobilized too much at the keystone disturbs breathing as much as in-fracture.
Compare ostectomy on the left with osteotomy on the 11.6.3.3 Steps

right. As the areas in which bone steps may occur are thinned by
ostectomy, steps rarely form.
11.6.3.4 Unsuccessful Osteotomy

In patients with thick bony bases, the osteotomy can be
unsuccessful. In some patients the bone is too long and con-
vex, especially in the region described by Webster, the cau-
dal part of the bone turns towards the septum. Osteotomy has
a negative effect on breathing in these patients and may also
be unsuccessful. Therefore, ostectomy is a better option in
these patients.
11.6.3.5 Bone Surface Problems

It is very difficult to correct bone surface problems with oste-
otomy. Osteotomy moves the bone as a whole. It is possible
to give shape to the bone by thinning the convex parts with
thin rasps. I do not have full control in double-leveled
osteotomies.
11.6.3.6 Bruising
Since osteotomy mobilizes the bone too much, we cannot
dissect all of the periosteum. Injury to the angular artery
passing over the osteotomy line is a common problem and
can cause extreme bruising and edema. As we protect vessels
with dissection to the ostectomy line, bruising seldom
occurs. There will be no need to apply cold.
11.6.3.7 Re-drape Problems

Below, you can see the open internal valve of a patient With limited dissection, re-drape problems occur more often.
whose roof was closed with ostectomy. Re-drape problems can cause wrinkles on the skin in the
long term. Nose size can be reduced more with a wide
dissection.
Patient Example
This patient had two previous surgeries by talented nose sur-
geons, yet the open roof problem continues.
The width of bone at the base was 5 mm. You can see the
ostectomy material. It is not logical to constrict the airway by
making an in-fracture in such a thick bone and besides stan-
dard osteotomy did not work.
11.7 Out-Fracturing the Nose with Ostectomy 305
11.7 Out-Fracturing the Nose

with Ostectomy
It may be necessary to widen the nasal base to correct

breathing problems. If the nasal base widens when the bone
is moved laterally with osteotomy, then ostectomy is
indicated.
The patient below had a revision surgery 2 years after her

first surgery because of tip deviation. She also complained of
her breathing getting worse after the first surgery. Therefore,
the osteotomy lines were thinned with a 90° curved chisel
and the bony bases were out-fractures. In this way, the air-
way was opened without widening of the lateral aesthetic
lines. The deviation in the tip was also corrected.
11.7 Out-Fracturing the Nose with Ostectomy 307
Note the amount of bone dust removed from the patient.
Patient Example
The patient had a previous surgery. She asked for revision
surgery to correct the axis deviation to the left. I used the
osteotomy technique in this patient. In her check-up after 1.5
years, she said that she was not happy with the base of her
nose and had problem breathing. Hence, I performed both
out-fracture in the Webster’s triangle and lateral ostectomy
on her.
In the endoscopic photo below, you can see the left lateral
ostectomy line.
11.8 Bone Check

Bone width in this lateral ostectomy line was measured at Twenty days after surgery, the bone should be checked for
4 mm. symmetry and opening up.
11.10 Reconstruction of the Nasal Dorsum 309
11.9 Bone Massage
In patients who have an in-fracture with osteotomy, bones do

not open easily. As the in-fracture procedure is not used in
ostectomy technique, bones can open because of mucosal
edema. I ask my patients to press on their bones for 10 min
every day, starting on the tenth day and continuing for 1
month.
11.10 Reconstruction of the Nasal Dorsum
The fusiform shape of the nasal dorsum will be formed again.

By using the cartilage taken out from the nasal dorsum, it is

possible to reconstruct it similar to the original anatomy. There
is no need to take any cartilage graft from the septum.
11.11 Dorsal Aesthetic Lines with polygon surface analysis. I think the lines on the bottom
explain the dorsal anatomy better.
The drawings above show traditional dorsal aesthetic lines
whereas the ones below show dorsal aesthetic lines obtained
The splitting and use of nasal dorsum cartilage as spreader

graft was first published by Gürsel Turgut et al. [17].
We previously mentioned that, in normal keystone areas,
the two sides of the bone shelves have notches. Nasal dorsum
aesthetic lines until 3–4 mm above the keystone region are
made of cartilage. The same anatomy will be imitated.
Important
During dissection, the perichondrium in the groove
region of the keystone area should be left under the
skin. Thus this region can be well camouflaged. A
blunt elevator is used here in order to get under the
bone. This procedure protects the soft tissues very
well.
After removing the hump, the bone edges will be formed

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

11.12 The Libra Graft 313
Place the cartilage removed en-bloc from the nasal dorsum It may be more controlled to hold the scalpel on the cut-
onto the table, with the nasal dorsum side facing the table. ting board and moving the graft under the scalpel.
Apply thinning to the septum with a #15 blade, just like
the side view of a plane wing.
Split the cartilage in half with the blade.

Compress the upper lateral cartilages with forceps and

hold them together.
You can make additional resections in order to achieve a
symmetric fusiform shape. As the septal cartilage will be in
the middle of these two grafts, the width of the septum should
also be taken into account.
At the cephalic tips of the Libra grafts, resect the two

edges that are going to be embedded on the two sides of sep-
tum. If the caudal tips of the grafts are too wide, you can trim
them slightly.
The upper lateral cartilage part of the Libra graft that will
be embedded on the two sides of the septum should be nar-
rowed if wide. Do not narrow more than 4 mm.
11.12 The Libra Graft 315
Important Important
The wings of the Libra grafts, which are 2 mm thick If you do not remove the bone edges, Libra grafts can-
near the keystone region, create an angle towards the not fit due to the bones, and this may form protrusions
anterior, as a result raising the nasal dorsum by at the nasal dorsum. The same is valid for Sheen
1–2 mm. Because of this, you should remove 1–2 mm spreader grafts.
more from the septum in the keystone region. Hence,
you will form a nasal dorsum groove in which the
nasal dorsum perichondrium will fit.
11.13 Nasal Dorsum Control
At this point sit on your stool and scrutinize whether the

Libra grafts fit into their places. Examine your nasal dorsum
profile. Libra grafts should be placed without creating a
hump in the lateral view. Raise yourself until you align the
tip with the cheek. In the oblique view, be sure that the small
hump formed by the Libra graft on one side is in the same
position and has the same size with the other side. This angle
gives us information regarding the nasal dorsum aesthetics.
You have to see a parabola that falls in the radix, rises at the
keystone, and falls again at the supratip region.
Important
Do not pass the first loop suture through the Libra
graft. It should only pass through the septum cartilage.
When you tie the suture, the cartilages will be squeezed
and stabilized. This is a very good method for stabiliz-
ing small grafts.
If you are happy with the nasal dorsum width and position
of the grafts, stabilize them.
Note
Since 2013, I pushed the Libra graft a little further. I
have advanced the Libra cartilage to the root of the
nose and fixed it. The Libra cartilage graft covered
even the bones. We have imitated the anatomy of short
nasal bones. Creating an entire dorsum with cartilage
Generally two fixing points are enough. First execute a
is easy and hides the bony edges.
loop suture near the anterior septal angle. Second is a hori-
zontal mattress suture at the caudal part. This suture allows
you to make additional resections from the cartilage without
cutting the suture.
11.13 Nasal Dorsum Control 317
Note
I have abandoned suturing the upper lateral cartilages
to the Libra graft. Suturing them symmetrically is very
difficult and axis deviations may form.
Important
Normally there are many layers between the mucosa
and skin. If the mucosa gets close to the skin due to
surgery, sympathetic system effects such as abnormal
sweating can be seen as a result of innervation distur-
bances. Be sure that the mucosa is embedded in your
surgery. Mucosa should be dissected at least 1–2 mm Examine the harmony between the Libra grafts and the
inwards from the open roof bone border. upper lateral cartilages in the polygon model.
Check again the heights of the upper lateral cartilages.

hold the grafts stable. Since they are not thick like the embed-
Important ded parts of Sheen spreader flaps, they do not pop out.
In the first article on splitting and using of this carti- Furthermore, they never cause extra thickness at the internal
lage, the cartilage was split in the original position valve area, unlike the Sheen spreader grafts. Below you can
before use. The upper lateral section of cartilage fits see the upper lateral cartilage of the left Libra grafts embed-
the nasal dorsum. In Libra grafts, the septum side of ded next to the septum.
the cartilage fits the nasal dorsum.
Why do we rotate it by 90° instead of inserting it in the

original position?
Nasal dorsum cartilage is generally not straight in the lat-
eral view in patients with a hump. If we split it in the original
position, it may not fit completely onto the two sides of a
straight septum. Moreover, upper lateral cartilages become
very thin as a result of splitting.
When the septal side of the nasal dorsal cartilage is used,
straight spreader grafts in the lateral view are obtained. As
the septum is a thicker cartilage, a more stable nasal dorsum
can be obtained. The upper lateral cartilage parts of the Libra
graft that are embedded onto the two sides of the septum
If you are used to spreader grafts, try the Libra graft. It is

an easy technique.
Sheen spreader grafts can be shaped similar to Libra
grafts. Alan Landecker has also discussed this shaping. But
keep in mind that the cartilage hump is the best donor region
for this graft (Personal communication, June 2015). Shaping
the hump cartilage as below is much easier.
Patient Example oblique view. Nasal dorsal aesthetic lines have been formed
Below is the 1-year post-op photo of a patient with Libra in a natural way.
graft. Note the parabolic nasal dorsal aesthetic line in the
11.14 Bone Dust and Cartilage Paste 323
11.14 Bone Dust and Cartilage Paste
In the long term I have seen collapse and irregularities in the

dorsal bone polygon in some of my patients. Nasal dorsum
irregularities can be seen more frequently if the periosteum
is damaged during dorsal dissection.
Protect the periosteum during dissection. Do not think
that you are already protecting it anyway. It is very difficult
to protect the periosteum with a blind dissection and the
wrong tools (round tipped elevators do not fit the bone). You
can protect the periosteum better by visualizing, getting into
the planes laterally and joining them in the middle, as well as
using curved straight tipped elevators. The Daniel-Çakir ele-
vator is particularly useful.
There can be a 1–2 mm distance between the bones even
if the roof is properly closed. This space cannot be seen dur-
ing surgery because of skin edema, but becomes visible after
1–2 years [18].
Grind bone dust from the bone taken out of the nasal dor-
sum by scratching it with a #11 blade. You can mix it with
blood. If you compress the bone dust with a gauze to remove
the water, you can see the real amount. This was mentioned
to me by Volkan Tayfur (Personal communication 2012). I
have been satisfactorily using bone dust since I learned about
its usage from Fethi Orak [19].
Place the bone paste at the end of the surgery. Otherwise

it may disperse on both sides of the bone.
If the amount is not enough, you can increase the volume
by adding diced cartilage.
Below you can see bone dust taken out by means of lateral
ostectomy in another patient.
Important
Work wet while scratching with the knife, so that you
can keep bone dust together.
11.15 Short Nasal Bones 325
If you want a more stable graft, you can use coagulated

blood. You can place it on the nasal dorsum retractor and Important
insert the graft with it. Mithat Akan obtains a single-piece If we allow the bones to shape the nasal dorsum in
graft by mixing it with blood [20]. patients with significant axis deviation, achieving a
Below you can see bone dust particles that have been proper nasal dorsum will be very difficult. If the bones
gathered by an ostectomy performed with a 90° angled are too deformed, taking 1–2 mm and raising this area
chisel. As the bone pieces in this saw dust are very small, by 1–2 mm with cartilage and bone graft will make
they can be used in the nasal dorsum. If you are using the things easier.
ostectomy technique instead of osteotomy, bone dust col-
lected from the two sides will be enough for dorsal
camouflage.
11.15 Short Nasal Bones
In patients with short nasal bones, most of the nasal dorsum

consists of cartilage. In these patients, the resected nasal dor-
sal cartilage is longer. Because of this, Libra grafts prepared
from this cartilage will be longer. With the Libra graft tech-
nique, the responsibility of the surgeon for determining the
patient’s need of a spreader graft length is reduced. In short-
boned patients, most of the keystone consists of Libra graft.
There is no need for making a transition from bone to carti-
lage. As the bone has less contribution to the roof, it becomes
possible to finish surgery without performing either osteot-
omy or ostectomy.
Patient Example
In nasal dorsum resection, it has been noted that most of it
consists of cartilage. The hump was corrected despite the
Important removal of very small amounts of bone.
If the perichondrium is not dissected correctly, at some
point it can take on the form of a flap and cause irregu-
larity in the nasal dorsum. If you have not been able to
obtain a flat nasal dorsal line, even though septum car-
tilage and bone are in good shape, then check the
undersurface of the skin flap.
Below you can see the cartilaginous hump. Note that it is Libra grafts prepared from long cartilages were also long.
longer than normal. As the bony roof did not open, ostec- A nasal dorsum bone polygon was formed, just like the origi-
tomy was not performed. nal anatomy using cartilage.
One-month post-op photos of the patient.

11.16 Dorsal Reconstruction in Men short bones. In these patients, longer Libra grafts are pre-
pared. The widest part of the Libra graft which will constitute
The keystone is much wider and closer to the radix in men the keystone region must be made wider than that of women.
when compared to women. This issue has already been dis-
cussed in the Nasal Polygons chapter. In male patients, longer Patient Example
nasal dorsum cartilages are obtained, similar to patients with Examine the location and shape of the keystone region.
11.16 Dorsal Reconstruction in Men 331
The cartilage hump of the patient.
When cartilages are split, the part of the Libra graft that
constitutes the nasal dorsum cartilage polygon is longer than
normal.
One-year post-op photographs of the patient.

11.16 Dorsal Reconstruction in Men 333
My First 500 Dorsal Preservation
(October 2019) 12
Abstract
Dorsal preservation is part of the preservation rhinoplasty

school that has been gaining popularity in recent years. As
the name implies, this technique preserves the dorsum
and corrects the hump with en-bloc lowering of the dor-
sum. The main advantage of this technique is preserving
the beauty of the natural dorsum and the lack of need to
reconstruct it. This, of course, is only possible if the struc-
ture of the natural dorsal cartilage and the nasal bones is
already in proper shape. Therefore, it is wise to say that
this technique should be applied in selected cases. Dorsal
preservation is not a single technique. The dorsum can be
preserved with a high septal strip, a low septal strip, mid-
dle septal strip or it can be total preservation or cartilage
only preservation with open bony roof. Details on where, I have started learning rhinoplasty in 2004. I had an idea
how, and when to use this technique can be found in this about dorsal preservation techniques having read about it
chapter. but I was only taught the classical dorsal resection tech-
336 12 My First 500 Dorsal Preservation (October 2019)
niques in practice. Yves Saban explained the dorsal preser- ing the technique after I returned back to Istanbul. I still
vation technique to me on cadaver in 2016. Instead of think that there is a lot to learn about dorsal preservation
resection, osteotomies, and reconstruction, he preserved techniques and we need to keep researching. I will share
the dorsum with osteotomies only. The dorsal surgery took with you my dorsal preservation experience in the past 4
only 3–4 min. I was really impressed and started perform- years.
12.1 D
orsal Preservation and Classic 12.3 Which Technique to Do First?
Dorsal Resection
You can start by performing cartilage only dorsal preserva-
The dorsal resection technique can lower the dorsum right to tion with a high septal strip in a patient with a minimal hump
the desired level. The redundant part is resected. Dorsal pres- and no septal deviation. It will be wise to first prefer per-
ervation (DP) is not oversensitive in this. But one always forming DP techniques with an open approach. In this way,
works with a closed roof when reducing the dorsum in DP, you can better see how the dorsum moves. You had better do
which provides a major advantage. Nasal bones remain stable this in 5–10 cases. Your second technique should be a low
when the roof is not opened, as the two side walls keep being septal strip cartilage only dorsal preservation in patients with
attached to each other. When the roof is opened, the necessity high septal deviation. The low septal strip resembles very
to arrange the heights of each of the two upper lateral carti- much the swinging door septoplasty technique. The ENT
lages, the septum, and two bony flaps arises. It is not easy to surgeons may like this technique more. After 20–30 patients,
accomplish this in closed rhinoplasty. Dorsal resection usu- you may start preserving the bone together with the carti-
ally needs dorsal reconstruction and dorsal camouflage. A lage. Upon comprehending the details of the technique, you
C-type crookedness may appear if a classical resection is may start applying osseocartilaginous DP techniques in a
applied in a patient with a beautiful dorsum and high septal closed approach.
deviation. It is not easy to re-obtain dorsal aesthetic lines over
a deviated septum. On the other hand, residual hump and loss
of height in the radix area may appear with DP techniques. 12.4 What Are the Types of DP?
In summary, DP provides convenience for the surgeon in
selected appropriate patients. It is not wise to stick with one According to the preserved structures:
technique in every single patient. I need to make it clear that
surgeons keenly performing rhinoplasty should add DP tech- 1. Osseocartilaginous dorsal preservation
niques to their armamentarium. 2. Cartilage only dorsal preservation: With bony cap, with-
out bony cap
12.2 O
n Which Patients Should Dorsal According to septal resection:
Preservation Be Used?
1. Low septal strip
If the patient has an already beautiful dorsal cartilage, I 2. High septal strip
believe that it had better be preserved. If the nasal dorsum is 3. Middle septal strip
excessively convex, only the cartilage can be preserved and
the bony hump can be managed with classical resection.
12.6 Total Preservation Versus Cartilage Only Preservation 337
12.5 W
hen Do I Use Total Preservation septal deviations. Plastic surgeons may work more on tomog-
and When Cartilage Only DP? raphy and endoscopic examination.
I tried to perform total preservation in every patient for a

while. I was obtaining very good results but I was having a 12.6 T
otal Preservation Versus Cartilage
difficult time during the surgery and besides, some of my Only Preservation
patients ended up with a bony hump recurrence. I have been
thinking over all DP techniques and their indications for the (a) Wide bony dorsum: If the bony dorsum is very wide,
past 2 years. there is no meaning in preserving it. Even if the carti-
I can say that my dorsal surgery at the moment consists of laginous roof is wide, it can be shaped and preserved.
80% DP of which 40% is cartilage only dorsal preservation. (b) Deformed cartilaginous dorsum: If the cartilaginous
The percentages will of course change as my experience roof is very thin and deformed, you don’t need to pre-
evolves. serve it.
(c) Convex hump: It is not easy to correct the bone in
patients with excessively convex humps. A straight dor-
12.5.1 Cone Beam sum can be achieved by preserving only the cartilage.
(d) Narrow nasal base: The nasal base is already at a proper
The ENT surgeons have a more comprehensive knowledge of width in 10–20% of the cases. Osteotomies may not be
the intranasal anatomy. They are more involved in endoscopic necessary in such cases. Lateral osteotomies, which are
examination and evaluation with computerized tomography a must in the total dorsal preservation technique, will
(CT) compared to plastic surgeons. I have started ordering narrow the nasal base more than necessary. Therefore, I
cone beam tomography in every patient at Yves Saban’s sug- prefer cartilage only DP in these cases. There are cases
gestion (Personal communication, September 2019). Cone where I finish the surgery rasping the convex bones
beam tomography is a device more frequently used by den- without osteotomies after lowering the cartilage. The
tists. It gives off less radiation and it is less expensive. It is not surgery becomes very fast and easy. It will be necessary
as sharp as CT but it provides enough information about the to determine the width of the nasal aperture with direct
anatomy. I can decide more accurately on which technique to examination with a speculum, endoscopy, or computer-
use with cone beam tomography. I pay more attention to high ized tomography.
(e) Long perpendicular plate of ethmoid bone (PPE): It is most astonishing maneuver for me was shortening the
necessary to create a space under the bony hump to lower PPE under the dorsal bony hump. Therefore, I prefer to
it. A bony resection deep under the bony hump is needed perform cartilage only DP in patients with long PPEs. I
in patients with a long PPE. A precise bony resection in carry out total preservation in patients who have cartilage
such a deep location both is very difficult and also has the right under the radix osteotomy site. Below you can see
risk of mobilizing the PPE from the frontal bone. The examples of short and long PPEs.
(f) Age: It may be difficult to straighten the dorsum in older a patient where I had the biggest hump recurrence, I
patients. The PPE may easily be mobilized as it is frag- realized that the caudal edges of the nasal bones were
ile. I go for cartilage only DP in such patients. Based on very inferiorly located. So, I made caudal resection to
the personal experiences of Dr. Sercan Göde and Dr. the bones. I managed to correct the recurrent hump by
Günter Hafız, the common characteristics of patients excising bone and cartilage from the K point. The width
with spontaneous cerebrospinal fistulae are middle aged, of nasal bones at the nasal base in some patients may be
over weight, and osteoporotic individuals. It would be as thick as 4–5 mm and this is not a rare finding espe-
wise to make minimum contact with the PPE in middle- cially in some certain ethnic groups. It is not easy to
aged overweight patients (Personal communication, slide these thick bones into the aperture. The nasal base
2018). can be narrowed in the open roof technique. But if dorsal
(g) Thick and long nasal bones: It is difficult to straighten preservation is preferred, a triangular piece of bone up to
the dorsum in patients with a short cartilaginous dorsum the transverse osteotomy line is resected from the nasal
and long nasal bones. When doing a revision surgery on aperture.
12.7 Low Septal Strip Versus High Septal Strip? 339
(h) Concha bullosa: It will be difficult to slide in the bone in 12.7 L

ow Septal Strip Versus High Septal
patients with large turbinates. A cartilage only DP might Strip?
be preferred. A total DP may still be performed if the
concha bullosa is treated. I choose to perform high septal strip in patients with a
straight septum and low septal strip in patients where septal
surgery is required. I started my dorsal preservation journey
with high septal strip. Therefore, I used to go for high septal
strip in every patient. I realized that the PPE was slightly
mobilized in cases where I resected the deviated vomer bone.
This would make me anxious. If the high septal strip tech-
nique is used after correcting the deviations in the septal base
and vomer, the septum becomes attached to only the PPE. As
the PPE is not supported by the vomer anymore, the PPE
becomes attached to the frontal bone and skull base. Each
pressure on the dorsum puts stress on the PPE. This must
have been the reason why the PPE became mobile.
Therefore, I prefer the low septal strip in patients with to go for the high septal strip in such patients. One may
high septal deviation or in patients where I need to detach the encounter rotations in the dorsal cartilage. On the other hand,
septal base from the vomer. When the dorsal cartilage is the high septal strip causes a widening in the dorsal cartilage
wide, the cartilage can be shaped by making resections from when the reduction in the dorsum exceeds 4 mm. This
the upper lateral cartilage (ULC)–septum junction. Such becomes advantageous in patients with an already narrow
resections decrease the stability of the K point. It is better not nasal dorsum.
12.7.1 T
he Relationship of Septoplasty turbinate by forcing the mucosa is hazardous because
and Rhinoplasty with Skull Base cerebrospinal fluid (CSF) leakages occur from the lateral
sides of the middle cranial fossa, not from the midline. It
One gets the closest to the skull base during a septoplasty. is important to work under guidance of CT in patients
The deviations in the vomer–PPE junction may be at a with high septal deviation. We need to know the distance
1.5–3 cm distance to the skull base. When resecting the part between the skull base and deviation. We need to exer-
of the PPE under the radix, the skull is approached by cise with caution in patients with a deep skull base. We
2.5–3 cm. The points to consider during surgery in the vicin- should not make an intervention in high septal deviation
ity can be summarized as follows: without having an imaging study like cone beam
tomography
1. The mucosa dissection under the radix should be kept to
a minimum. The site where the first olfactory nerve
emerges should be avoided. 12.7.2 Removing the Septal Strip
2. Excessive mucosal dissection to excise high septal devi-
ation should not be made. The surgical instruments 12.7.2.1 Low septal strip
placed in this area should not be too large to avoid wid- The septum is approached with a transfixion incision. A car-
ening of the mucosal pocket. A thru-cut forceps of tilage strip of half a mm width at the caudal septum may be
2–3 mm size may be the safest instrument. The pushing left attached to the Pitanguy ligament. The septum is bilater-
of the instruments on the attachment sites of the middle ally dissected.
Do not completely dissect the mucosa at the junction site are avoided. A strip of 2 mm is excised from the septal base.
of the septum with the ULC. In this way, the detachment of Resect minimal close to the maxillary spine.
the ULCs and the right or left torsion of the dorsal cartilage
Because the more the cartilage is excised, the more the A low septal strip can be obtained after detaching the sep-
loss in the height of the supratip region. The first 3–4 mm of tum from the base. Scissors are used for this. But it may be
the cartilage incision is made with a scalpel. The rest of the difficult to take out a properly shaped piece of cartilage.
incision is made with a lateral osteotome. This method Detachment of the septum from PPE: To straighten the
ensures a safe excision of a cartilage strip. I prefer to take a dorsum, you need to start cutting the cartilage from where
strip big enough for a strut graft in the first excision of the the dorsum is at its highest point. Make the incision towards
cartilage. the posterior tail of the septum to spare the maximum amount
of septal cartilage possible.
Note
I take all possible risks into consideration. When I ask
for an osteotome during the surgery, some nurses grab
the hammer. You may need to warn the nurse
beforehand.
The gap that arises after the rotation of the septal flap tilage excised will determine the height of the upper part of
decreases the stability of the septum. The bigger the septal the K point. Over-resection will lead to excessive lowering
cartilage, the more stable the dorsal fixation. Pushing the sep- of the radix. On the other hand, insufficient excision will
tum right or left with the speculum will reveal the high septal cause hump recurrence. The septum is grabbed with an
deviation. The deviations are meticulously fixed. Rotational Adson-Brown forceps. The dorsal height and position of the
forces with a forceps should not be applied to the PPE. Bone K point are arranged. Extra cartilage can be excised from the
scissors, rongeur, or a powerful thru-cut forceps can be used. septal base if necessary. The septal base is fixed to the peri-
A triangular cartilage of 2–3 mm width under the radix is osteum of the maxillary spine with 5/0 PDS.
excised with a 2 mm thru-cut punch. The amount of the car-
I prefer to make such extra excisions and septal position- ceps. In the low septal strip DP, the fixation of the septum to
ing after the tip surgery. I place at least three 5/0 PDS sutures the maxillary spine will determine the position of the K point.
between the periosteum of the maxillary spine and septum. At The resistance points should be checked if there is tension.
this stage, it is necessary to check if the septal tail and the
PPE overlap. Excise the overlapping parts with a thru-cut for-
12.7.2.2 High septal strip:
The septum is bilaterally dissected close to the dorsum. is made with septum scissors so that a 2–3 mm strip is
Starting from the W point, the septum is detached right excised.
under the dorsum with sharp tipped scissors. A second cut
The excised cartilage can be used as the strut graft. tipped scissors will decrease the resistance of the septal car-
Emptying the area under the K point is important for straight- tilage left under the dorsum.
ening the dorsum. Scoring under the K point with sharp
The septum is comprised of cartilage up to the radix espe- excisions are continued until the desired dorsal height is
cially in young patients. A 2 mm thru-cut rongeur can be achieved. There is a possibility of supratip depression with
used to empty the part under the radix. The area below the this technique. Therefore, a higher WASA segment can be
radix osteotomy should be emptied for at least 1 mm. For planned. Otherwise, this depression can also be prevented by
this purpose, 1–3 mm of bone should be excised from the suturing the perichondrium of the WASA segment. This
PPE. I would suggest to perform cartilage only DP if more maneuver prevents supratip collapse as well.
than 2 mm of bone needs to be excised from the PPE. Septal
After the dorsum is lowered to the desired level, it is ben- use bone dust or cartilage grafts for camouflage. The step
eficial to suture the perichondrium on both sides of the sep- may not be palpated because the soft tissue at the radix is
tum to each other with 5/0 PDS at the level of the K point. abundant. Patients can feel the osteotomy line after the edema
Even though the K point seems to be straight during surgery, resolves. The transverse osteotomy lines close to the radix
it may move anteriorly with mucosal edema. Do always will also benefit from grafting.
check the radix osteotomy. Even if there is only a 1 mm step,
A bayonet forceps can be used to check if the space method pioneered by Dr. Sercan Göde (Personal communi-
under the radix osteotomy is empty. This is a practical cation, 2018).
12.7.3 The Resistance Points of DP
Do not push on the K point to straighten the dorsum. Don’t

forget that the force is reflected onto the septum. The dorsum
should settle to its proper position with the force of gravity
only. If not, the resistance points should be checked.
1. Septal resection may not be sufficient.

2. Lateral keystone dissection may be inadequate.
3. There may be bony excess at the nasal aperture. This
excess may be removed with a rongeur.
4. The anterocaudal corners of the nasal bones may prevent
straightening. They can be resected with a rongeur.
5. The mucosal side dissection of the bone may be
insufficient.
6. The resistance may be due to the compaction of the wide
ULC laterally and caudally. The lateral sides of the ULC
may be dissected off the mucosa to release the tension.
Additionally, lateral resections can be made.
7.
If the K point is still high, the bone and cartilage at the K 2. Excise low or high septal strip. The indications have been
point may be shaved off. Sometimes the dorsal perichon- discussed.
drium may have been stripped off from the radix and 3. Dissect the bone subperiosteally. My subperiosteal dis-
gather up at the K point. Either resect it or put it in place. section extends 3 mm beyond the lateral osteotomy line
as I do ostectomy. If lateral osteotomy is to be performed
The surgeons from whom I gained my knowledge through through a tunnel, subperiosteal dissection can be carried
personal contact or talks in meetings are: out as long as a good re-drape of the dorsum can be
achieved.
1. French Yves Saban, High septal strip osseocartilaginous 4. Dissect the dorsal cartilage from the bone subperiosteally
DP [21]. and mobilize the dorsal cartilage. The amount of dissec-
2. Italian Valerio Finocchi, Low septal strip osseocartilagi- tion will be correlated to the amount of hump resection.
nous DP [22]. 5. Resect the bony hump. You can use bone scissors, a
3. Brazilian Luiz Carlos Ishida, Low septal strip cartilage chisel, or rasp. I rough-hew the bony hump with bone
only DP [23]. scissors or chisel and then fix the bony edges with a rasp.
4. Turkish Hüseyin Güner and Portuguese Miguel Ferreira, A short nasal bone anatomy is mimicked in a way. In
High septal strip cartilage only DP [24]. some of the patients lateral rasping makes osteotomy
5. Portuguese Carlos Miguel Neves, Middle cartilage strip. redundant. Normal anatomy needs to be imitated. After
I have no experience with this technique [25]. the open roof, the anterocaudal corners of the bones
usually require to be resected. The edges of the bones
12.7.3.1 Cartilage Only Dorsal Preservation should be 1–3 mm below the dorsal cartilage so that they
are not visible. When the desired bone height is reached,
1. Dissect the dorsum subperichondrially and subperiosteally. you need to thin the bones from the sides by rasping.
Dorsal dissection will be easier before septal strip excision. 6. Close the roof by lateral, transverse, and/or medial
oblique osteotomies.
7. Place bone dust or cartilage gel camouflage between the
K point and radix. Make sure that no bone or cartilage
particles enter the lateral keystone dissection zone.
You may preserve the bony cap together with the dorsal
cartilage. You may also prefer to make a sub-SMAS dissec-
tion. A “V”-shaped osteotomy is performed through the
paramedian grooves with a lateral osteotome. This technique
has little need of camouflage. But the bony cap may break off
when the dorsum is rasped. You may try to preserve the bony
cap. Nevertheless, the breaking off of the bony cap is not a
big loss.
12.7.3.2 Osseocartilaginous Dorsal

Preservation
1. The cartilaginous dorsum is dissected in a subperichon-

drial plane but leave the deep perichondrium filling the
dorsal groove over the cartilage. This perichondrium may
jump over the K point and lead to a perichondrial hump.
This deep perichondrium is also the structure keeping the
bony cap over the dorsal cartilage.
2. Rasp and thin the bony cap and dissect the lateral key-
stone area to straighten the dorsum. The amount of rasp-
ing and dissection changes depending on the case.
3. Excise the low or high septal strip. Plan the radix osteot- when the bones are stable. If an external osteotomy is
omy. I prefer to make the radix osteotomy where the planned, you can leave it to the end.
hump starts on the bone. The more cephalic the radix (a) Transverse osteotomy: I usually prefer the Taştan-
osteotomy, the thicker the bone that you need to cut and Çakır handsaws. This saw can make a cut as sharp as
the larger the PPE you need to excise. piezo. The transverse osteotomy works like a
4. The order of osteotomies: If a saw will be used for trans- screwdriver.
verse osteotomy, make it first. The handsaws work better
The radix handsaw cuts the bone with a C type of move- saw on a piece of wood will be beneficial. A handsaw will be
ment. While the neck of the handsaw is commanded with the sharp enough in the first 100 cases. The bone dust between
thumb of the non-dominant hand and the dominant hand the teeth of the handsaw needs to be cleaned before using it
makes a rotational movement at the wrist, the transverse on the contralateral side. When the transverse osteotomy is
osteotomy can be completed in 30–60 s. You may find it dif- performed in a way so that a 1–3 mm wide bridge of intact
ficult in the first 5–10 patients. Experimenting with the hand- bone is left at the radix, a greenstick fracture can be obtained.
(b) Lateral osteotomy: It is used for pushdown. A high- (c) Lateral ostectomy: This is used for let-down. You
low-high osteotomy can be made with a curved lat- may perform two osteotomies as low to low and high
eral osteotome. In this way, the Webster triangle is to low. The bone between the osteotomies can be
preserved and the transverse osteotomy line entered resected. The bone to be resected needs to be dis-
without moving onto the medial canthal area. As the sected internally and externally before the osteotomy.
width of the aperture is narrower at the level of the The bone slides in minimally in this technique. This
medial canthal tendon, the lateral and transverse technique may be preferred if the bony base is not to
osteotomies should unite in such a way so that a cor- be narrowed. If the bony base is already narrow, it
ner does not form at the junction. Keeping the osteo- will be wiser to perform a cartilage only DP. A baby
tome obliquely, facing medially, will make it easier rongeur may also be used for ostectomy.
to slide the bone into the nasal cavity. This method
can be preferred if the bony base is wide.
12.8 Dorsal Fixation 353
(d) Osteotomy of the radix: The transverse osteotomies

on both sides may be united with a concave handsaw. Important
If a reduction in the radix is not wanted, the trans- You have to know for certain that the radix osteotomy
verse osteotomies on both sides can be approximated line is totally separated from the PPE before attempt-
as close as 2 mm and a green stick fracture can be ing mobilization. Otherwise, the dorsum will mobilize
obtained with digital pressure on the right and left. the PPE. I check the area under the radix osteotomy
(e) Mobilization of the nasal dorsum: Try to mobilize the with a Crile retractor after the initial movement. I
dorsum with a sideways gentle pressure. If the dor- introduce the Cottle elevator inside the radix osteot-
sum cannot be mobilized with gentle pressure, the omy and gently turn it. I make sure that the bony vault
nasal bones may be separated from the maxillary is totally separated from the PPE and it is not putting
bone. Check out the osteotomies until mobilization is pressure on it.
achieved with gentle pressure. The radix may be cut
with a 2 mm chisel from inside to outside. It may
even be safer that the first mobilization is outward,
away from the face. But you need to be sure about the
12.8 Dorsal Fixation
direction of the chisel. While holding the chisel with
one hand, feel the tip of the chisel at the radix with
Low septal strip: The whole septum is attached to only the
the index finger of the other hand.
dorsal cartilage in this technique. As the posterior septal
angle is pulled inferiorly, the K point moves posteriorly and
the supratip anteriorly. The caudal septum pushes the colu-
Important
mella inferiorly. Additional resections are made from the
Do never make the first movement towards the nasal
septal base and the posterior septal angle is fixed to the max-
cavity. An abrupt posterior mobilization may put
illary spine with three to four round needle 5/0 PDS sutures.
excessive pressure on the PPE.
The necessary resections are made from the caudal septum
and the tip is fixed to the septum.
High septal strip: A round 5/0 PDS suture is passed dle from the other paramedian groove and pull the needle
through the septum right below the K point. A long and thin from the inside. If you do not wish to tie the knot in the
needle holder will be suitable for this. Push the needle from empty space, you may pass the needle once again through
below the K point anteriorly so that the needle comes out the septum.
from the right or left paramedian groove. Then pass the nee-
12.9 Dorsal Cartilage Fine-Tuning 355
12.9 Dorsal Cartilage Fine-Tuning Pass through the cartilage and infiltrate the mucosa of the
K-point with a small amount of local anesthetic solution. In
Three problems may be encountered at the K-point this way, mucosal laceration can be prevented. I determine
the excess and go minimally under it after cutting with a
1. Wide K-point blade. I dissect the cartilage with a Daniel elevator and cut
2. High K-point the excess with septum scissors. Sometimes the cartilage at
3. Both of the above the K-point is strong and has a predilection to rise. In this
case, I suture the cartilage defect.
In the next photo, one can see that the height of the K
point has decreased. The bone and cartilage removed from
the right side to shape the K-point can be seen.
Patient Example
Fine-tuning of the dorsal cartilage. The dorsal cartilage was
narrowed followed by low septal strip cartilage dorsal pres-
ervation. Three-month post-op photos.
12.10 No-Dissection DP should be dissected. The lateral osteotomy can be performed

internally or externally. I prefer to make the osteotomy from
The indications are very rare. This may be suitable in patients the inside with a Gubisch lateral osteotome because an inci-
with a beautiful dorsum but an axis deviation. I have per- sion is already made to dissect the lateral osteotomy line.
formed 4 or 5 such cases. I really believe the indications are
very rare. The dorsal cartilage had better be dissected so that
the re-drape of the skin over the cartilage is facilitated and the 12.10.1 Case #1
lateral keystone area can be dissected. The radix and trans-
verse osteotomies are made externally because the periosteum Low septal strip dorsal preservation. No dissection of the
is not dissected. The periosteum over the bone that will slide in bone. Twenty-day post-op photos.
12.10 No-Dissection DP 361
12.10.2 Case #2 preserved. Axis deviations with no hump are really difficult
with dorsal resection techniques which usually result in the
Low septal strip dorsal preservation. No dorsal dissection. need to camouflage the dorsum. Dorsal preservation is a
One-year post-op results. Correction of the dorsal axis devia- really powerful technique in such patients.
tion fixed the tip deviation because the scroll ligaments were
12.10.3 Case #3
Case study of a patient with axis deviation: asymmetric let-

down technique, 10-month post-op results.
12.10.4 Case #4
Case study of a patient ideal for let-down procedure,

10-month post-op results.
12.10.5 Case #5 patients who particularly like such results, there are some oth-
ers who dislike it. You should be aware that you will sometimes
Case study of a patient after dorsal preservation procedure, face a convex dorsum, if you prefer dorsal preservation tech-
1-year post-op results. You may end up with a convex dorsum niques. I share this fact with my patients during consultations.
with dorsal preservation techniques. While there are some Most of my patients tell me that they find it more natural.
12.10.6 Case #6
Case study of a patient after dorsal preservation procedure,

1-year post-op results.
12.10.7 Case #7
Case study of a patient after dorsal preservation procedure

and tip surgery, 1-year post-op results. Bulbous tip with good
dorsum. Moderate thickness skin.
12.10.8 Case #8

and tip surgery, 1-year post-op results. Bulbous tip with good
dorsum. Moderately thick skin.
12.10.9 Case #9

and tip surgery, one-and-half-year post-op results. Severe
right axis deviation treated with an asymmetric let-down
technique.
12.10.10 Case #10
Case study of high septal strip dorsal preservation, 15-month

post-op results.
12.10.11 Case #11 and closed tip surgery were performed as the bone was
broad. One-and-half-year post-op results. Dorsal aesthetic
Case study of cartilage only dorsal preservation with high lines formed beautifully as most of the dorsum comprised of
septal strip. Short and broad nasal bone. Cartilage only DP cartilage.
12.10.12 Case #12–13 for an extended period of time. Nevertheless, early post-op
results make me excited.
Two early post-op (1 month) cases. Low septal strip cartilage
only DP. I haven’t had the chance to follow-up these patients
12.10.13 Complications: Case #1 the beginning. Patients generally find a minimal dorsal hump
natural, but more than 1–2 mm hump is not acceptable.
Dorsal preservation technique has a risk of residual hump. However, fixing this problem is easy. The photographs below
Straightening the dorsum is not easy at the beginning of the show the patient 14 months postoperatively.
learning curve, and therefore, the complication rate is high at
12.10.14 Complications: Case #2 and brought it to the midline. I had not taken the cartilage
strip close to the dorsum. I did not dissect the septum exten-
I have used preservation rhinoplasty techniques in this sively. I removed a 1 mm strip of cartilage from right below
patient. The nasal dorsum was in the midline. An axis devia- the dorsum with a limited dissection. I cut the Pitanguy liga-
tion to the right appeared after the surgery, and a hump on ment and obtained fullness in the supratip region. I dissected
lateral view. Furthermore, the patient asked for a more the upper lateral cartilages from the bone to increase straight-
upturned nose. This was my third revision patient where I ening. I corrected the extremely convex cartilages and also
used the let-down technique. In the first two I rasped the dissected the lateral crura from the mucosa. I slightly
recurrent hump. In this patient, I re-mobilized the dorsum increased rotation.
12.11 Conclusions 377
12.11 Conclusions results are naturally attractive noses with preservation of the
normal anatomy which creates a better aesthetic result and
Dorsal preservation ensures a natural dorsum without the minimizes the complexity of any possible revision.
need for grafts to reconstruct the midvault. Ultimately, the
How Did the Nose Get Deformed?
13
Abstract a parenthesis tip. How is it possible that they have such dif-
ferent noses? Another question in my mind is how one sib-
This chapter focuses on the effect of early nasal trauma on
ling has beautiful tip polygons, while the other has a cephalic
the development of the nose. Trauma in the vomer bone
malposition.
starts a cascade of events by producing more cartilage due
to increased blood circulation. This extra cartilaginous
growth leads to caudal and anterior growth in the septum
13.1 Observation and Theory
which in return causes deviation in the nose. Changes in
the upper lateral and tip cartilages and the footplates fol-
13.1.1 Observations
low. All of these changes lead to a plethora of deformities
that need correction in such a way to revert the effect of
1. Cephalic malposition occurs more often in humped noses.
each of these changes.
2. Fracture in the vomer is more frequent in noses with a
hump.
3. Patients with axis deviation and hump have a history of
trauma before adolescence.
I often look for accompanying members of the patient’s fam-
4. There is a relation between the septal angle and the posi-
ily during my consultations. Sometimes two siblings come
tion of the dome. The dome is located at the bisector
for a consultation, one with a wonderful nose, a perfect tip
angle of the caudal septum and dorsal edges; hence the
and lateral crural resting angle, and the other sibling who
septal angle indicates the dome.
wants surgery, with a hump, septum and axis deviations, and
380 13 How Did the Nose Get Deformed?
5. These patients have weak dome cartilages. 6. Sometimes we can see a fold on the lateral crus that is
2–5 mm away from the domes. It appears as if the dome
should be on that point, but it is in fact on the middle crus.
13.1 Observation and Theory 381
Note the symmetric notches 9 mm away from the current

Patient Example dome.
The patient’s tip cartilages have been dissected.

You can see the finished tip surgery. Nine mm steal is very
rare. Generally, a steal of 4–5 mm is sufficient.
As the reference line on the cheek indicating the position

of the new tip, points out the these notches, the new dome is
created at the level of these notches. Below are the patient’s 1-month post-op photographs.
8. Most of these patients have a short infralobule length and

Important the nose is affected by the depressor and orbicularis oris
Do not plan the new dome at the fold on the lateral crus muscles.
every time you see one. I believe that in some patients,
I am deceived by these notches and steal more than
necessary.
7. In some patients, when the footplate setback and lateral

crural steal surgery are completed, the location of the
dome at the beginning of surgery becomes the columellar
breakpoint. Examine the example below. The domes in
the first photo have then become the C′ point in the
second.
13.1.2 Theory 1 0. Footplates move anteriorly.

11. As depressor and orbicularis oris muscles are attached to
1. All cartilages are connected to each other. the footplates, they pull the lip upwards. These muscles
2. Trauma occurs in the vomer as a result of an impact, and cause an increased movement of the nose while laughing
blood circulation increases because of wound healing in and talking.
that region.
3. A broken vomer produces more cartilage. Example
4. Septal cartilage grows caudally and anteriorly. The below photo I took in 2008 is the most important
5. As the septum cannot fit into the nose, it causes right or source of inspiration for me to think about lateral crural
left axis deviations. surface problems. While the patient’s tip was deformed, her
6. Dorsal cartilage is connected to the upper lateral carti- sister had a beautiful tip. How can these two siblings have
lage and pulls it anteriorly as well. so different nasal tips? My patient fell down and broke her
7. Upper lateral cartilage is connected to the cephalic part nose when she was a child. Her nose got deformed during
of the lateral crus, and it adolescence. There seems to be cephalic malposition in the
(a) Pulls the cephalic edge of the lateral crus anteriorly, tip. The nostrils of the two sisters were the same. The nos-
(b) Makes an external rotation in the lateral crus, tril crease produces the lower edge of the lateral crus. As a
(c) Expands the lateral crus. result their lateral crura end at the same point. Parenthesis
8. Septal cartilage moves caudally and pulls the columella view occurs as a result of lateral crural surface problems
caudally and anteriorly. The distance between the upper and is not related to the long axis of the lateral crus. Thus,
lateral cartilage and medial crus increases. repairing surface problems will be wiser than repositioning
9. Footplates expand with the caudally moving septal the lateral crus.
cartilage.
Below are also identical twins. Notice how different the

tips are.
13.2 Discussion 389
Examine the cartilage anatomy of the patient below. Pay

attention to the relation between the cephalic edge of the lat- Note
eral crus, the anterocaudally located septum, and upper lat- I need to change my statement about not doing any
eral cartilages. It would not be incorrect to state that the depressor intervention. If the depressor muscle is low-
septum seems to be responsible for the deformity in the lat- ering the tip of the nose and nostril apex deprojection
eral crus. is not planned, then I make an intervention in the
depressor muscle. I make a 3–4 mm incision at the
base of the nostril 5 mm inside the base. I dissect the
depressors from the maxilla. I put cartilage grafts in
the pockets formed. In this way, I free the origins of the
depressor nasi muscles.
12. The weakest point of the tip cartilages is the middle

crus. As the septum growth is abnormal, the septal
angle goes down and forward. With the pushing power
of the septum, the lower lateral cartilages bend at the
weak middle crura. This may be the reason for the very
weak cartilages in the dome. So it is the middle crura
that are forced by the septum to become the dome. If
this dome is taken as the real dome, tip grafts need to be
used and a lateral crural shortening made.
Tension nose is one of the most fascinating topics for me.

Note Most patients have a tension nose [26].
I saw patients lifting their lower lips to close their However, I do not agree with performing a reprojection
mouths. These patients have mental muscle hypertro- (i.e., increasing the projection), usually with grafts.
phy which leads to a 2–3 mm retruded appearance of Generally, the total length of the medial and lateral crus is
the chin. As the tension in the nose disappears, the lips sufficient for having a beautiful nose. When we use the lat-
relax. eral crural length for infralobule height, that is, when we per-
form a steal from the lateral crus, a graft is rarely needed for
projecting the tip.
Important
13.2 Discussion
In plunging nasal tips when laughing, if the problem is
diagnosed as a strong or short depressor, muscle resec- The nose should be repaired in the same way as it was dam-
tion needs to be made. I think that the problem is the aged. I perform deprojection by taking footplates posteriorly
forward displacement of the footplates because of the as described in Johnson and Godin [26]. However, I perform
overgrowth in the septum. If the footplates are dis- reprojection by the lateral crural steal technique, not by tip
sected and moved towards the anterior maxillary spine, grafts.
the pulling effect will decrease. I have not made any
depressor intervention for a long time.
1. Taking footplates posteriorly decreases the effect of the –– Footplate setback for 5 mm, 6 mm stealing from lateral
active depressor. –– Footplate setback for 3 mm, 5 mm stealing from lateral,
2. When the footplates are moved posteriorly, tip projection 3 mm medial crus overlap
and nasal rotation decrease. So the patient becomes an
ideal patient for lateral crural steal. This gives the oppor- If we can organize these combinations properly, tip graft
tunity to perform a lateral steal for patients who have or camouflage techniques will rarely be needed. If we can
excessive tip projection. The infralobule can also be elon- understand the puzzle, we can solve it.
gated in this way.
3. When lateral crural steal is made, the infralobule extends
and rotation increases. Note
4. Stealing from the lateral crus without changing the posi- I got a lot of questions about what I meant by footplate
tion of the footplates in over-projected noses just makes setback and how it is done. I added a section about
the nose uglier. If you combine lateral crural steal with projection to the introduction. It would be useful to
footplate setback, everything will fit in place. read this section. Briefly, the projection of the base of
the nose is reduced by cutting and dissecting the peri-
osteum of the maxillary spine.
Important
Consider the issue in the following way: How can we
combine lateral crural steal and a footplates setback?
Important
Try to imagine the effects of the following
The key point of this puzzle is the lateral crural length.
combination.
If the right lateral crural length can be determined,
everything else will fall into place easily and quickly.
–– Footplate setback for 2 mm, 3 mm stealing from lateral

–– Footplate setback for 4 mm, 4 mm stealing from lateral
TIP Surgery
14
Abstract 14.1 Auto-Rim Flap

Tip surgery constitutes an important part of nasal surgery.
Steven Denenberg has published on his website about lateral
In my practice, I perform tip surgery in certain steps.
crural caudal resection in patients with bulbous tips [27].
These steps are the auto-rim flap, marking, lateral crural
This is a powerful technique. I also use it when necessary.
resection and or preservation, lateral crural steal proce-
dure, cephalic dome suture, dome equalization, figure-of-
My Experience
eight suture, columellar strut graft, loop suture for strut
1. In most patients, there is caudal excess of the lateral
graft stabilization (tie suture), C suture, columellar stabi-
crura.
lization suture, lobule stabilization suture (bow-tie suture)
2. In thin-skinned patients, direct resection of the caudal
and medial crural overlap. Each step is discussed in detail
excess can cause alar retraction.
with pre-op, intra-op and post-op photographs in this
3. I incised the caudal excess and left it on the mucosa; some
chapter.
of my patients had asymmetry.
4. Finally I left the excess cartilage on the skin. I am happy
with this technique and have been using it since 2012.
The Sequence of Tip Surgery
5. A cartilage more than 3 mm in width should not be used
1. Auto-rim flap.
as an auto-rim flap. Such a big piece of cartilage will not
2. Marking.
turn towards the nostril. I want the auto-rim flap to turn
3. Lateral crural resection and/or preservation.
inside and support the facet polygon.
4. Lateral crural steal procedure.
5. Cephalic dome suture.
In the example below, you can see a patient with lateral
6. Dome equalization.
crural caudal resection. In the one-year post-op photos, you
7. Figure-of-eight suture.
can see that the tip is well narrowed, but the facet polygon is
8. Columellar strut graft.
not clear.
9. Loop suture for strut graft stabilization (Tie Suture).
Caudal resection in thin-skinned patients can easily cause
10. C suture.
alar retractions.
11. Columellar stabilization suture.
12. Lobule stabilization suture (Bow-Tie Suture).
13. Medial crural overlap (if necessary).
392 14 TIP Surgery
14.1 Auto-Rim Flap 393
394 14 TIP Surgery
14.1.1 When to Apply an Auto-Rim Flap ing to the distance between the lateral crus and the nostril
edge.
If the lateral crus polygon stretches over the facet polygon One percent of the cases had a normal lateral crural width.
narrowing the facet region, an auto-rim flap needs to be per- Twenty percent had excess cephalic width. Another 20% had
formed. Eighty percent of my patients have this indication. excess caudal width and 59% had both cephalic and caudal
Ali Murat Akkuş proposed the idea of classifying the width excess.
indications for auto-rim flap (Personal Communication, July Type 1: No excess; Type 2: Only cephalic excess; Type 3:
2011). So we classified 30 of my consequent patients accord- Only caudal excess; Type 4: Cephalic + caudal excess.
There is no auto-rim flap indication in the first two groups. group makes most of my cases. The lateral crura are usually
Cephalic trimming is contraindicated in the first and third convex in shape. You can treat this group effectively with a
groups. If you try to correct caudal excess using cephalic trim- combination of auto-rim flap, 0–1 mm caudal resection and
ming, you will create a defect between the upper lateral carti- 2–3 mm cephalic resection. In this group of patients, perform-
lage and the lateral crus. If the skin is thin, the lateral crus will ing only a cephalic trim will cause problems.
retract cephalically until it contacts the upper lateral cartilage. The case below is one of my own where caudal and
Since this will affect alar position, nostril asymmetries or cephalic excess was treated with cephalic resection only as I
notching can appear. The auto-rim flap and 1–2 mm caudal had not started using the auto-rim flap technique yet. The
resection will be more appropriate for these patients. The final resulting retracted nostrils can be seen in the photos.
Let’s have a look at the drawings on the photos of a thin- the cartilage on the skin. You can see the photos of the patient
skinned patient. In the oblique view you can clearly see the 10 months after surgery. Note the changes in the facet
caudal edge of the lateral crus which is curved towards the polygon.
facet polygon. The incision is made by leaving this part of
396 14 TIP Surgery
14.1.2 Is the Auto-Rim Flap Difficult An additional 2 mm caudal resection was performed.
to Perform? Thus 5 mm narrowing of the lateral crus was achieved.
The only difficult part is cutting in the right place. I do not Important
recommend you to use this technique on your first 100 rhino- In patients with an auto-rim flap, an additional caudal
plasty patients. When new to the technique, incise a 1 mm resection facilitates angling of the auto-rim flap into
auto-rim flap. You can increase the auto-rim flap size as time the facet polygon. This is not always necessary; how-
goes by. ever, some patients require this additional caudal
resection.
14.1.3 What Is the Rationale for the Auto-Rim

Flap?
The curved cephalic piece of the lateral crus is most of the

time resected in surgery. However, the curved portion in the
caudal part is left behind. It is very difficult to designate the
lateral crural polygon lower edge using this curved caudal car-
tilage. A good light reflection cannot be obtained with this car-
tilage in the lateral view. So it is reasonable to leave this curved
piece on the skin. The incised 3 mm caudal cartilage piece
turns inwards when cut, creating the auto-rim flap. Since the
auto-rim flap is attached to the skin, it is stronger than a nor-
mal rim graft. The remaining lateral crus relaxes as a result of
horizontal shortening, and its bulbosity decreases. With
cephalic resection, the bulbosity decreases even more. Thus,
the flat middle part of the lateral crus is used effectively.
Important A flat area in the middle of the lateral crus will now be
Convex lateral crura have a more resistant shape available by making a 2 mm cephalic resection as well. The
because of their short cephalic and caudal borders. The lateral crura convexity is easily decreased without the use of
auto-rim flap technique decreases this resistance, any sutures.
hence enabling the suture techniques to work better on
the lateral crus.
In the example below, the lateral crura are dissected with

3 mm auto-rim flaps. There is still caudal excess. Pay atten-
tion to the curved cartilage piece marked on the caudal edge.
5 mm lateral crural steal is performed.

398 14 TIP Surgery
Here you can see the completed tip surgery. Making repetitive cephalic resections for treating bulbous
cartilages creates nothing but trouble. A defect is created
between the upper lateral cartilage and the lateral crus. The
remaining caudal crus shows cephalic migration over time,
causing alar retraction. Equal resections from both the
cephalic and caudal parts can prevent this migration and
hence alar deformities. A defect will not be created between
the upper lateral cartilage and the lateral crus, facilitating
reconstruction of the scroll area.
Pay attention to how the auto-rim flap supports the facet

polygon.
Important
Rim flap technique works with lateral crural steal. We
can easily create a new dome on a wide lateral crus. If
we do not make rim flap without shortening the lateral
crus, the facet polygon may expand more than neces-
sary. Therefore, the rim flap technique should be
appreciated as a whole concept together with the lat-
eral crural steal technique.
14.1.4 How to Perform an Auto-Rim Flap
Evert the nostril rim with a double hook and mark the caudal
edge of the lateral crus and an inner curve 2–3 mm from the
lateral crural edge which is where the incision will be made.
Leave the cut off part of the caudal edge of the cartilage on
the skin and continue the surgery as usual. The caudal piece
will behave like a rim graft. At the end of the surgery, there
is a possibility of puffiness in the infralobule polygon in 5%
of the patients. Stealing from the lateral crus can cause the
tip of the auto-rim flap which is normally placed laterally to
extend into the infralobule polygon. In this case, you can
shorten the medial part of the auto-rim flap by 2–3 mm.
Surgery using the in situ cartilages is more controlled and
easier than using plenty of grafts.
The patient’s lateral crura are close to the nostril edges.
The facet polygon width is not more than 2 mm. Here I will
lengthen the facet polygon in a controlled manner using the
auto-rim flap technique.
400 14 TIP Surgery
Three mm auto-rim flap, 2 mm lateral crural caudal resec-

tion, and 4 mm lateral crural cephalic resection were planned.
Notice how narrow the facet polygon is.

The auto-rim flap is created from the curved caudal part

of the lateral crus.
Desired facet polygon width is marked.
The lateral crural caudal edge is marked.
I will let this portion turn inwards.
The marking for the incision is drawn 3 mm cephalic to

the lateral crural caudal edge. This incision will be the new
border of the facet polygon.
Note
I do not make a rim flap larger than 6–7 mm × 2–3 mm.
Otherwise the facet can be too large and difficult to
control.
402 14 TIP Surgery
A 2 mm deep incision is made.
Incisions are closed by stitching only the mucosa without

passing through the cartilages.
You can clearly see the change in the facet polygon if you
compare this photo with the pre-op photo.
Important The patient’s 1-year post-op photos. Clear acceptable

If the suture is passed through the cartilage, the auto- facet polygons have been created when compared to the
rim flap cannot rotate into the facet polygon. almost indistinguishable facet polygon preoperatively.
See how the facet polygon enlarges. The auto-rim
flap is now inside the facet polygon in between the two
markings.
404 14 TIP Surgery
Convexity of the lateral crus has been significantly

decreased.
Alar support has also been increased with the increase in

the facet polygon size.
406 14 TIP Surgery
Important
If excessive puffiness is noted on the facet polygon at
the end of the surgery, you can make a cephalic resec-
tion from the auto-rim flap. Cephalic resection from
the auto-rim flap is not necessary unless the flap is
wider than 2 mm.
Let’s take a look at some patient examples. Note the changes

in the facet polygons in the photographs below. In the basal
view, the excess on both domes has been used as auto-rim flaps.
Think about how many structural grafts are usually needed to
form this triangular shape in the basal view.
The excessive puffy region of the dome becomes part of
the facet polygon as the auto-rim flap.
Case Example
In the patient below, you can see the effects of a decrease in
tip projection and use of the auto-rim flap technique on the
nostrils.
Case Example
In the front view, note the dome lights getting farther away
from the nostrils.
Case Example
The heights of the dome and the facet polygons should be
similar. In this example, the dome triangle has been short-
ened and the facet polygon widened. Ten-month post-op
photos.
408 14 TIP Surgery
Lateral crural caudal excess has been reduced, while a

strong facet polygon has been obtained.
410 14 TIP Surgery
412 14 TIP Surgery
I have presented the auto-rim flap technique at the Turkish

Aesthetic Surgery Society in 2014. After the presentation, I
had the chance to talk to Dr. Ahmet Seyhan. He told me:
“Barış, the cartilage you left behind gets under the dome at
the end of the surgery due to the steal and therefore supports
both the dome and the soft triangle. This is an important
advantage and you should talk about this” (Personal com-
munication, January 2014). I am indeed indebted to Seyhan
for this. Examine the auto-rim flap-dome relationship in the
drawing below.
14.2 Marking and Lateral Crural Resection 413
14.2 Marking and Lateral Crural Resection
If you are using a closed technique, always make markings.

Do not operate with an imaginary sense of proportion only.
You should always make sufficient markings, and the tip of
the marking pen should be thin. If thick, thin it yourself.
Enter beneath the domes with an un-serrated pickup for-
ceps and bring the domes together by creating an upward
traction in the midline. Mark the exact contact point. This
point will be a reference point.
The tip cartilages will be shaped with cephalic dome

sutures. Cephalic dome suture makes the lateral crus rotate
medially. Surplus in the cephalic part of the lateral crus pre-
vents this rotation. Resection that allows medial rotation is
enough. More than 3–4 mm cephalic resection is rarely
needed. If the resection is not sufficient for rotation, an addi-
tional resection from the caudal part of the upper lateral car-
tilage can be made. Do not adjust the rotation amount with
cephalic resection. In the photo below, cephalic resection
will be made on the lateral crus.
Using serrated and un-serrated pickup forceps simulate a

lateral crural steal. Place a mark on the estimated new dome Imitate the lateral crus resting angle with a forceps.
point. Check for symmetry of the caudal edges of the lateral
crus and perform 1–2 mm caudal resection if necessary.
414 14 TIP Surgery
Mark the part that prevents the lateral crus from rotating Check whether the remaining parts of the lateral crus are
inwards and remove it. equal.
Let’s have a look at the decision making on the amount of
cephalic resection in another patient.
For cephalic resection, you should have serrated super-cut

scissors. Stabilize the lateral crus with Adson Brown tissue
forceps, hold the scissors crosswise, and cut the cephalic sur- The lateral crus is curved inwards with a forceps. The part
plus of the lateral crus. that prevents this rotation is marked and removed.
14.3 Lateral Crura Preservation 415
Keeping the blade beveled, incise the lateral crural

cephalic excess and enter under the body of the lateral crus.
Note
I used to make lateral crural resection as I didn’t need
to make more than 2–3 mm cephalic resection thanks
to the rim flap. I started lateral crural preservation with
Dr. Daniel’s suggestion (Personal Communication,
December 2019). I don’t have much experience, but it
looks like I will love it.
14.3 Lateral Crura Preservation
This technique was first described by Selahattin Özmen [28].

A more stable lateral crus can be obtained with this tech-
nique and besides pinching of the lateral crura can be pre-
vented with the cephalic dome suture. This technique does Suture the cephalic cartilage flap with 2–3 simple sutures.
not lead to formation of a gap between the lateral crus and
the upper lateral cartilage. This additional affect can support
tip rotation.
Technique: Infiltrate the area where the cephalic trim will
be made.
416 14 TIP Surgery
How should the assistant hold the hook?

The assistant gets support from the cheek with his or her
fingers. In this way, the assistant holds the hook without
moving. The cartilages are hung up by using the hook as a
seesaw. Thus, the working area of the surgeon expands. The
surgeon’s and assistant’s hands do not touch.
14.3.1 Lateral Crural Steal
14.3.1.1 The Ellipse Model

Important I had investigated the geometry of the lateral crural steal
Examine the ellipse model. Stealing from the lateral technique with my father, who was a math teacher, on milli-
crus has several effects. Because of mixed results, it is metric paper in 2010.
not very popular. If you can control the lateral crural
steal technique, you will rarely use tip grafts. The lat-
eral crus expands as it moves away from the dome, and
it is difficult to fix the new dome on this big cartilage.
It is however easier to make a new dome on the lateral
crus which is narrowed with an auto-rim flap from the
caudal edge.
418 14 TIP Surgery
The Ellipse
He said that this technique can be explained with an
an ellipse is the locus of all
ellipse model. points of the plane whose
The ellipse is a curve on a plane surrounding two focal distance to two fixed
points add to the same
points, such that a straight line drawn from one of the focal constant
points to any point on the curve and then back to the other PF 1+PF 2 = 2a
b
focal point has the same length. e = f/a
P 0 < e <1
–a –f f a
F1 C F2
–b
Projection and Rotation
p x
p = –x + a . cos 2
+ tan–1
y
+a
Ali Rıza Öreroğlu has designed and integrated the math-

ematical formula of the ellipse model into an Excel program. a = 180° –
180°
cos–1 a + x + y – b
2 2 2 2
p
We examined the standard lateral photographs of 70 patients, 2a x 2 + y 2
marking the starting and ending points of the lateral crura.

Medial and lateral crural lengths were measured with
Photoshop. Nasolabial angles were measured. Rotation and
projection changes related to the amount of steal were simu-
lated and examined on Excel.
420 14 TIP Surgery
Change in Tip Rotation 5. The amount of lateral steal and the increase in the height
70 of the infralobule are equal. This effect is free from rota-
maximum average minimum
tion and projection.
60
degrees change in tip rotation
50 Important
If you understand the logic of this combination, you
40
can spare your patient’s septal cartilage; an onlay tip
30
graft will rarely be needed.
20
Make lateral crural steal until the tip comes to the desired
10 position. Dissect the footplates and take back as much as you
need. If the infralobule rises too much or hangs, make a mid-
0
0 1 2 3 4 5 6 7 8 9 dle crural overlap.
mm steal from the lateral crus
Change in Tip Projection Important

4
maximum average minimum The key point in tip surgery is lateral crural length.
2
mm changed in tip projection
–2
Patient Example
This can easily be illustrated with the help of the following
–4 patient. You can see the photo of a patient who has all the
–6 problems mentioned above and her results at one-year
post-op.
–8
–10 • Tension nose.

• Axis deviation to the right.
–12
0 1 2 3 4 5 6 7 8 9 • Septum deviation to the left.
mm steal from the lateral crus • Hump.
• Thin skin.
14.3.1.2 Results • Short infratip polygon.
1. Lateral crural steal procedure is especially effective on • High tip and nostril apex projection.
rotation. • The patient’s domes are tight and asymmetric; caused by
2. The domes are mostly situated at the highest projection the middle crura.
point. Thus, the steal procedure cannot increase projec- • When the patient smiles, the nose is pulled down with the
tion with the footplates being stable. After 1–2 mm of overly active depressor.
lateral steal, projection starts decreasing. This finding • The footplates are over-projected which can be seen at the
astonished me. I was expecting that lateral crural steal basal view.
would increase projection. • As the nasal base stays in front, gummy smile is seen in
3. A 1 mm steal from the lateral crus causes approximately this patient.
an increase of 8.78° in rotation. The first millimeters cre- • Lateral crura are wide in both cephalic and caudal direc-
ate more rotation and thereafter each mm causes less tions, long and convex.
parabolic rotation. • The lateral crus deserves to be diagnosed as cephalic mal-
4. Footplate setback changes the axis of the ellipse and position. If you are not sure about the presence of cephalic
decreases tip projection and rotation (the lateral crural malposition in the front views, please see the top views as
steal performed after the setback now increases the I used two soft boxes as lighting.
decreased projection and rotation).
The tip of the nose moves less with smiling.

422 14 TIP Surgery
In the photo below, the footplates have been repositioned

and the length of the infralobule polygon has increased
because of the lateral crural steal procedure.
Cephalic malposition appearance has disappeared.

The scars of the skin resection in the nostril base are

invisible.
424 14 TIP Surgery
• The lateral crural resting angle was corrected with the

cephalic dome suture. Dog ears that formed in the caudal
dome were resected.
• A strut graft was fixed.
• Low-to-low and external transverse osteotomies.
• Libra spreader graft was placed.
• Projection control suture.
• Excessive mucosa in the membranous septum and inter-
nal valve region were resected.
14.3.1.3 S
urgical Technique of Lateral Crural
Steal
1. Fold the dome using two forceps and find the new domal
point.
2. Resume folding as the peak point of the lower lateral car-
Surgery note: tilage comes to the same level with the lines marked on
• Excision was made from the septal base. the cheek and mark the identified point on the cartilage.
• The deviated vomer was excised.
• Four mm lateral crural cephalic resection.
• Two mm auto-rim flap.
Important
• Six mm lateral crural steal.
This should be done after cephalic resection because
• Two mm medial crural overlap. Thus the infralobule
there can be a 1–2 mm change after resection.
extends for 4 mm.
• Dissection of depressor and orbicularis oris muscles. The
footplates were 8 mm posteriorly repositioned and tip
projection decreased. If you are at the right side of the patient, make a simula-
• Small contour grafts were placed in front of the medial tion on the right lateral crus, and vice versa.
crura.
Markings on the cheek help to identify the new tip point.

Examine above the line on the cheek and tip position at the Important
end of the surgery. If you perform a steal only for rotation or shortening of
the nose, simulate the lateral crus steal by stretching
the latter crus anteriorly. If projection is to be reduced,
you may have to steal 1–2 mm more. In this case, sim-
ulate the lateral crural steal procedure by placing the
forceps 1–3 mm posteriorly and steal more. In this
way, you will have taken into account the effect of the
footplate setback as well.
426 14 TIP Surgery
3. If the nasal tip is in the midline, use reference points for

the first marking. Measure the distance between the new
dome and reference point with scissors. Put a mark for
the new dome on the other lateral crus with the guidance
of the open blades of the scissors.
4. Symmetry of the new dome should be evaluated.
14.3.1.4 Dome Symmetry Test

While pulling on the lateral crura with two forceps, join the
domes in the midline. The new dome marks should be
aligned when the cartilages are in the midline. In patients
with tip deviation, an asymmetric lateral steal should be
made. Otherwise deviated tip cannot be corrected. A lateral
steal difference of 1 mm between the right and left domes
can cause a middle axis deviation of 10°. I use this geometri-
Important cal power for correcting tip deviations. The nasal tip bends to
Since 1 mm steal creates approximately 6–8° rotation, the side with more steal.
it is very important to be precise. That’s the reason why
a reference line needs to be drawn on the patient’s
cheek.
Important Important
Perform the symmetry test at the patient’s head side. Dorsal preservation techniques affect tip symmetry
and rotation with the scroll connection. You may per-
form tip surgery after dorsal surgery, because tip devi-
ations may disappear in patients with axis deviation
without the need for an asymmetric steal.
428 14 TIP Surgery
14.4 Cephalic Dome Suture
14.4.1 How I Started Using the Cephalic Dome

Suture
I have been using this suture since 2008. When Gruber pub-
lished this technique in 2010, I realized that I was too late to
publish my results based on 200 patients [29]. At the time, I
was frequently using the lateral crural steal procedure. In
order to make a new dome, I used to put the transdomal
suture several times. Of course, these domes were fragile. I
used to place several trial sutures between the medial and
lateral crural cephalic edges in order to find the correct dome
location. After a while, I saw that these trial sutures gave a
better shape compared to the transdomal suture and thereaf-
ter cephalic dome suture became my dominant dome suture.
I asked Gruber at the Vancouver Rhinoplasty Society meet-
ing whether he used only this suture, and he told me that he
usually combined it with a transdomal suture. I also place
transdomal sutures in addition to the cephalic dome suture in
half of my patients. This suture constitutes the most practical
technique for giving the domes the triangular shape. Cakir
et al. have discussed this technique in detail [1]. In the article
this technique was named as “cephalic dome suture.” Ali
Teoman Tellioğlu named it as such.
Technique:
Three mm inferior to the new domal point, pass the suture
from the medial and lateral crural cephalic edge, biting 2 mm
wide cartilage. This will form a dome triangle. This suture
results in a dog ear at the Ti point where it causes a rise.
14.4 Cephalic Dome Suture 429
Important
I do not fix the nasal tip to the septum. Therefore,
lengths of the cartilages should be designed according
to the shape of the planned nose. Rotation is achieved
by shortening the lateral crus.
Note
After the first 100 operations, your hand will get used
to the tip surgery and you will complete it in one go.
Actually do get to that level as soon as possible. Place
the cephalic dome sutures, test dome symmetry, then
keep working on the tip surgery.
While a second stitch is needed in the excessively bulbous

noses, a single stitch will be sufficient for noses with less
problems.
There may be a tight attachment of the cartilage to the

underlying soft tissues at the cephalic dome suture site. If
this should occur, soft tissue dissection under the cartilage
for 2–3 mm will make it easier to put the cephalic dome
suture. If a subperichondrial dissection is made, this will
rarely be necessary.
430 14 TIP Surgery
Markings were made.

Important
The caudal edges of the medial and lateral crura will
form the facet polygon. Therefore, rather than the
suture itself, concentrate on the shape of the cartilage.
In approximately 60–70% of patients, lateral crural steal

will correct the height of the middle crus. The infralobule is
short in most patients and stealing from the lateral increases
its height.
Note
When the position of the footplates is stable, lateral
steal cannot increase tip projection by more than 1 mm
(see the ellipse model). The infralobule projection
increases depending on the amount of lateral steal.
Patient Example
The left dome of the patient was amorphous and the right
dome regular.
Cephalic dome suture was placed on the left dome.

14.4 Cephalic Dome Suture 431
The abnormal dome was made similar to the normal dome

with only one suture.
Advantages of the Cephalic Dome Suture
1. It is a simple technique.
2. The domes are turned into a triangular shape more
easily.
3. It corrects the lateral crural resting angle.
4. As it supports the nostril edges, you will rarely need a rim
graft.
5. It does not narrow the facet polygon.
6. Creates a new dome on the lateral crus easily. The bend-
ing effect is more powerful than the transdomal suture.
7. Fixes the hanging columella and cephalically placed lat-
eral crura problems.
432 14 TIP Surgery
14.5 Dome Equalization In the open rhinoplasty below, you can see the split inter-
domal and Pitanguy ligaments. When these tissues are
The dome triangles have been separately formed, and now sutured, they will have a cushion effect between the dome
they will be joined. Please do not forget the polygon drawings and septal angle and form a projection of 2–3 mm.
at this stage. The nurse should also know these drawings and
the polygon model. The nurse will have to hold the domes in
the right position for you to fix them in that position.
1. Get the domes out of the nostril on your side.

2. Place the hooks on the domes. Holding only the dome
which is farther away from you with a hook may usually
be enough.
At this stage, I tell this to the surgical nurse: Please sit

down, put your hand on the patient’s forehead, hold this
hook, and do not move. The loop suture through the tissues
on the medial faces of the domes (the interdomal ligament)
passes through just under the cephalic corners of the dome.
This suture equalizes the domes and prevents them from
jumping over each other.
Important
If you haven’t split the Pitanguy ligament while deliv-
ering the domes, it will be sufficient to repair the tis-
sues on the medial face of the domes.
14.6 Figure-of-Eight Suture
Join the cephalic edges of the domes with a figure-of-eight

suture. Suturing the domes by passing the suture in the same
direction on the right and left sides makes a good
equalization.
14.7 Columellar Strut Graft 433
Important
Do not suture the dome inside without visualization.
The joining angle is very important.
14.7 Columellar Strut Graft
I always use a strut graft. If you use this graft, you can stabi-
lize the dome better and form a better interdomal polygon.
Place the strut graft once you have repaired the soft tissue
between the two medial crura and the dome. After place-
ment, it will be fixed with sutures passing from the medial
crus, dome, and strut graft.
14.7.1 Where Is the Best Graft Donor Area?
The strut graft should be thin enough to avoid filling the col-
umellar polygon, but it should also be strong enough. The
cartilage removed from the septal base is a perfect strut graft
material, but the thickness must be reduced before use.
14.7.2 Strut Graft Placement
1. With sharp tipped small scissors, enter between the foot-

plates from a point near the cephalic edge of the medial
crus. In this way you will not damage any artery, nerve, or
vein.
2. Move forward 3 mm with the blades of the scissors
closed.
434 14 TIP Surgery
3. Open the blades of the scissors for 3 mm and expand the
tunnel. If you open the tip of the scissors too much, you Important
may damage the ligaments and tear the footplate- The strut graft should be embedded between the medial
narrowing suture. crura. If you do not leave a space for the superficial
4. Close the blades of the scissors and move 3 mm forward. SMAS between the medial crura, the columellar poly-
Repeat this procedure until you touch the bone with the gon will become rounded.
scissors. Stay in the midline to avoid tip asymmetry.
5. Pull your scissors backwards without completely taking
them out, open the blades of the scissors, and put the strut Below you can see the superficial SMAS and medial cru-
graft between them. Do not try to insert the strut graft ral perichondrium.
after pulling out the scissors completely; otherwise, it
will be very difficult.
14.8 L
oop Suture for Strut Graft
Stabilization (Tie Suture)
Fix the strut graft by adding a loop suture passing through

the cephalic edges of the dome triangles. In this way, you can
embed the strut graft between the domes. It will remain
invisible, and the interdomal polygon will not be narrowed.
This suture does not pass through the graft.
Important
If you dissect more superficially, you may cause bleed-
ing and numbness in the tip.
14.8 Loop Suture for Strut Graft Stabilization (Tie Suture) 435
You can see the domes fixed with the figure-of-eight

suture. Examine the embedding of the strut graft into the top
of the interdomal polygon with a loop suture.
Examine the relation between the strut graft and dome

cartilages in the polygon model.
Let’s examine another patient example showing the place-

ment of a strut graft.
Cartilage removed from the septal base was shaped with a
#11 blade.
436 14 TIP Surgery
The split Pitanguy ligament was repaired with two differ-

ent loop sutures.
A secure pocket was opened with thin scissors. A strut

graft was placed beyond the legs of the scissors into the
tunnel.
14.8 Loop Suture for Strut Graft Stabilization (Tie Suture) 437
Note Note
I abandoned splitting the Pitanguy ligament in 2013 Placement of the strut graft. I was placing the strut
after reading an article by Pshenisnov [30]. If the graft after suturing the domes together. Some of my
medial crura are widely dissected, there is no need to patients were experiencing tip asymmetry. I think
split the Pitanguy ligament to deliver the domes. Dr. some of these asymmetries may be due to the asym-
Kirill showed that, apart from the lymphatic vessels, metric placement of the strut graft. That’s why I started
there were hormone-dependent Suquet-Hoyer chan- opening the pocket for the strut graft before joining the
nels that, he thought, were responsible for the circula- domes. I try to open the pocket right in the midline. I
tion of the nasal tip. These channels also exist in the feel the maxilla bone with the tip of the scissors and try
chin and they prevent cold burns in the endpoints like to stay in the midline.
the nose and chin. It seems that the functional effects
of the Pitanguy ligament, besides its static effects, will
be discussed in the following years.
I achieved substantial changes in my results by pre-
serving the Pitanguy ligament; the rate of loss of pro-
jection lowered; the need for tip contour grafts
decreased. On the other hand, some of my thin-skinned
patients experienced complications like over-
projection, over-definition, and excessively prominent
supratip break points. In the revision surgery of these
patients, I loosened the Pitanguy ligament or totally
divided it to fix the problem. Unfortunately, such prob-
lems occur during periods of change in surgical
technique.
I prevent the scissors from moving to the right or left of

the maxillary crest.
The below photo shows the placement of the scissors
between the medial crura.
438 14 TIP Surgery
Opening of the pocket.
Partial drawing back of the scissors and placement of the

graft.
14.9 C Suture
14.9.1 Columellar Breakpoint
The columellar breakpoint (C′ point) is the joining point of

the infralobule polygon and columellar polygon.
1. If the columella is straight from the nasolabial angle to
the tip, the appearance will be very artificial. In a beauti-
ful nose, the C′ point should be evident.
14.9 C Suture 439
2. In beautiful noses, the C′ point is at the same level as the 14.9.2 Technique
nostril apex.
1. First pass through the strut graft 6 to 7 mm inferior to the

dome with 6/0 PDS, then pass deeper close to the cephalic
edge of the medial crus. Make sure not to pass through
the mucosa.
440 14 TIP Surgery
4. Turn back by passing through the cephalic edge of the

medial crus. When the knot is tied, the strut graft will be
embedded and the C′ point formed. You will have a colu-
mellar polygon facing downwards and an infralobule
polygon facing 45° downwards.
2. Then pass near the caudal edge of the medial crus.
3. Without passing through the strut graft, pass from the

caudal edge of the other medial crus.
14.10 Stabilization of the Columellar

Polygon
The columellar polygon should be stabilized by using a hori-

zontal mattress 6/0 PDS suture that passes through the medial
crura and the strut graft. Unlike the C′ suture which passes
through the strut graft only once, here the suture passes
through the strut graft twice. Start by passing through the
strut graft, then the medial crus, turn back and pass through
the strut and then the other medial crus and turn back again
to tie the knot.
14.10 Stabilization of the Columellar Polygon 441
While using this suture, pay attention to have the strut

graft embedded between the medial crura. The strut graft
should be at least 2 mm cephalic to the caudal edges of the
medial crura as this will create a space for the superficial
SMAS that was preserved behind the columellar skin.
442 14 TIP Surgery
Important
I have been using 6/0 PDS in tip surgery. There is no
need for permanent sutures in the tip. Even if you use
a PDS, the knots should remain between the cartilages.
Mithat Akan who taught me open surgery is particu-
larly sensitive about this point: knots should stay
inside. Suture reaction destroys the beauty of the nose.
Important
You can use SMAS resections in order to get sharper
tip facets. If you think that the facets are depressed,
you can fill them with tiny grafts.
14.11 B
ow-Tie Suture (Figure-of-Eight,
Horizontal Mattress Suture)
Pass the suture in the same direction from the edges of the
middle crura which form the infralobule polygon, trying to
approach the cephalic side as much as possible. When you
tie the knot, the suture will form an 8 shape on the cartilage
and fix the strut graft. This suture prevents the strut graft
from filling the infralobule polygon. The tip of the strut graft
can escape the classical horizontal mattress suture.
14.12 Medial Crura Overlap 443
over-projected noses, the Photoshop design will show you

that the planned new design of the nose stays inside the
shadow of the existing nose. You may predict that you will
need to perform a medial crural overlap.
Placing the incision on the cartilage

1. Dome: Cutting the dome results in sharp edges. The need
for camouflage occurs, and its control is difficult.
2. Middle lateral crus: This can create depression in the nos-
trils as the area beneath it is empty. You can cut and slide.
In thin-skinned patients, the sliding point can be seen
from the outside.
3. Lateral crural sesamoid cartilage: Division at the lateral
crural sesamoid cartilages can be performed to shorten
the lateral crus. This is part of lateral crural transposition.
That is, the lateral crural transposition technique divides
the lateral crus from the sesamoid cartilages. This tech-
nique needs mucosal release.
14.12 Medial Crura Overlap
In patients with over-projection, the total lower lateral carti-

lage length is more than normal. In this situation, you should
divide the lower lateral cartilages and shorten them. In such
444 14 TIP Surgery
14.12.1 W
hat Is the Most Reliable Lower Medial crural overlap is usually done in long and big
Lateral Cartilage Cutting Point? noses if the infralobule height is normal. Evaluate if this pro-
cedure is necessary after placing the domes under the skin.
This should be the middle crus. The area beneath is not This procedure is irreversible. It is done in two ways, total
empty. When you overlap them, they do not produce puffi- and partial.
ness. Overlap in this region also strengthens the middle crus.
14.12.2 Total Medial Crural Overlap

Important
Do not forget that, in approximately 30–40% of your Cut the medial crus from the most bulging point. Generally
patients, you should cut the lower lateral cartilage. this is at a distance of 5–7 mm from the new dome. Cut the
Otherwise, you cannot solve problems related to over- medial crus with the blade in an oblique fashion to avoid cut-
projection and you may cause a hanging columella. Do ting the dome sutures. Dissect the part under the dome with
not open the dome sutures, as hanging and elongation a blade until the part that the overlap ends. Slide the upper
occurs in the infralobule after making a lateral steal. piece onto the lower piece. Place 6/0 PDS sutures at the cau-
This puffiness can be corrected with middle crural dal edge. You will get a firm stabilization with this.
overlap.
In order to lower the entire tip projection, dissect
the periosteum of the maxillary spine.
Note
All of my surgery practice is in Istanbul. The statistics
I have mentioned in this book are suitable for the
Caucasian race with cartilage dominant, medium and
thin skinned noses.
Patient Example
The tip is delivered through the nostrils.

446 14 TIP Surgery
5 to 7 mm lateral crura steal is planned.
After tip surgery, the resulting over-projected lobule is

planned to be corrected with medial crural overlap.
The C′ suture is removed.

The medial crura are cut in an oblique fashion.
The overlap is fixed with 6/0 PDS sutures. The C′ suture

is placed again.
448 14 TIP Surgery
Normal lobule projection is achieved.
Patient Example
Lateral crural steal was made in this patient, but the infralob-
Note ule is still hanging. As the infralobule length was still insuf-
I complete the tip surgery and decide on the medial ficient, a partial medial crural overlap was planned.
crural overlap. In this way, one can make a more accu-
rate decision. I just open the C′ and columellar sutures
and make a medial crural overlap.
14.12.3 P
artial Medial Crural (Caudal)
Overlap
The partial medial crural or anterior overlap can be used if

the infralobule is hanging but not long after the lateral crural
steal. If a total overlap is made, the infralobule height will
decrease. Cut the most bulging part of the medial crus until
1–2 mm cephalic part is left intact. Make an overlap of
2–3 mm at the caudal edge and suture it. This procedure
repairs the middle crural bulging without shortening the
medial crus. After the overlap, resume stabilizing the new
position of the lower lateral cartilages using second and third
cephalic dome sutures.
The bulging part was treated without shortening the

infralobule polygon.
450 14 TIP Surgery
Patient Example
The C′ and columella sutures were removed and partial

medial crural overlap was performed. The C′ and columella
sutures were placed again.
Patient Example
Short infralobule, anteriorly placed footplate, high tip
projection.
Domes were delivered and markings made. A steal of

The nasal dorsum was dissected and a 4 mm hump 6 mm was made laterally.
removed. The footplate was set back and resection was made
from the anterior maxillary spine.
Note
Now I am first doing the tip surgery and after that,
decide whether or not deprojection is necessary.
The patient’s infralobule polygon was extended by 6 mm.
In the photo below, I am showing where the tip position

was when I started the surgery.
452 14 TIP Surgery
Two mm of medial crus was overlapped and the infralob- The nostrils were reduced in size.
ule polygon was shortened by 2 mm.
One-year post-op photos.

454 14 TIP Surgery
456 14 TIP Surgery
Patient Example The following patient’s tip is bulbous. Nasal length is

The amount of lateral steal changes from patient to patient. long enough to cover the lip. The patient has a little hump.
So I wanted to give different patient examples. The main problem is the length of the lower lateral carti-
lages. Both lateral and medial crura are long.
I planned both shortening of the nose and rotation in this A medial crural shortening of 8 mm was planned. This
patient. was achieved by shortening of the medial crus by 3 mm and
an overlap of 5 mm. Thus, both the lateral crus and infralob-
ule polygon were shortened.
The patient’s infralobule height is long. I made a lateral

steal of 7 mm.
458 14 TIP Surgery
The patient’s 1-year post-op photos.

460 14 TIP Surgery
Patient Example
Absence of left lower lateral cartilage. There was no signifi-
cant problem in the examination. Only after the surgery, I
learned that the patient had suffered a nasal infection in her
childhood. A left lateral crus was created with a cephalic
dome suture.
462 14 TIP Surgery
A septal graft was fixed to the left medial crus with a loop
suture without passing through the graft.
A cephalic dome suture was used at equal distance from

the point of the graft.
Cephalic dome suture was used on the right dome. A
3 mm lateral steal was made at the right dome. The length of
the defect in the left medial crus was determined by measur-
ing the other medial crus and marked on the cartilage graft.
Note that a natural dome is produced when the graft is

bent with the suture.
With the second cephalic dome suture, the free tip of the
graft rotated inwards and formed a nice resting angle.
A strut graft was placed.

464 14 TIP Surgery
An onlay tip graft was planned because the skin of the

patient was thick and the cartilages weak. But as the left
dome was reconstructed with one graft, one-piece Peck graft
was preferred. The Peck graft was designed for creating the
dome triangles.
One-year post-op photos of the patient.

466 14 TIP Surgery
Tip Projection and Rotation
15
Abstract I believe that some other parameters are necessary to

define deprojection. I decided to measure nostril apex pro-
Adjusting projection and rotation of the tip is one of the
jection because locating the footplates in the profile photo
basic elements of rhinoplasty. These two parameters
was difficult. My intention in producing new terminology is
affect each other. When examining tip projection, it is
not to create further confusion but this was the only way for
necessary to evaluate projection as nostril apex and lobule
me to clarify projection. Alar crease can be used as a refer-
projections separately. Thus, the maneuvers required for
ence point. It is actually used frequently in the literature but
the targeted rhinoplasty result regarding projection can be
the anatomy may be altered with alar surgery. Therefore, I
decided more clearly. Changing rotation is a more
used the mid-pupillary line as the reference point. It does not
straightforward process than changing projection. In this
make a difference at the end, no panic.
chapter, I will explain tips and tricks for both variables.
• Tip projection: The distance from the mid-pupillary line

to the tip.
Any intervention on the tip affects both projection and rota- • Nostril apex projection: The distance from the mid-pupil-
tion at the same time. For example, reducing NAP projection lary line to the nostril apex.
also reduces rotation. Likewise, lateral crural steal increases • Lobule projection: The vertical length of the lobule.
lobule projection while increasing rotation at the same time.
The concepts of rotation and projection should be studied Tip projection equals to the sum of nostril apex projection
under one title. and lobule projection.
15.1 Projection
The editor of Operative Techniques in Plastic Surgery

asked me to write a chapter about projection [31]. I had a
hard time. In a meeting, the chairman showed a patient, and
asked the panelists to analyze the nose. The two surgeons
before me said the projection was low whereas I said it was
high. Then I started thinking that what I perceived as pro-
jection was totally different from what other surgeons per-
ceived. I think that they misdiagnosed the patient as having
insufficient projection while the patient actually had insuf-
ficient lobule projection. Tip projection needs to be further
analyzed.
470 15 Tip Projection and Rotation
So, how do we analyze patients? We are all familiar with

Photoshop editing. By using overlaying photos, changes in
the lobule, tip, and nostril apex can be tracked.
In this patient, tip and nostril apex projections have been Studying tip projection under two headings will make it
decreased whereas lobule projection has been increased. easier to analyze it.
15.1.1 Nostril Apex Projection
To decrease nostril apex projection

1. Dissection of the periosteum of the maxillary spine.
2. Maxillary spine resection.
3. Resection of periosteum, perichondrium, and mucosa
from the maxillary spine region.
Note
These maneuvers slightly decrease tip rotation as well.
15.1 Projection 471
To increase nostril apex projection Tip grafts are rarely required if the Pitanguy and scroll
1. Suturing of the footplates to each other. ligament system is preserved in Caucasian noses. For
2. Premaxillary augmentation. Hispanic or Asian noses and secondary cases tip grafts will
3. A long and strong strut graft. be necessary.
4. Septal extension graft also increases NAP projection. Increasing, decreasing, or keeping the projection of these
three structures will yield 27 different possibilities. Maybe
now, you have appreciated my perplexity. Evaluating tip pro-
15.1.2 Lobule Projection jection with these two different parameters will provide cor-
rection of the columella lobule ratio.
To decrease lobule projection:
1. The most powerful technique is medial crural overlap. Case Study
Tip projection is high because of high lobule projection.
To increase lobule projection: Nostril apex projection is normal. Treatment: Shortening the
1. Lateral crural steal is the most effective technique. lobule. I removed the tip grafts.
2. On-lay tip grafts.
Case Study
Tip projection is high because of high nostril apex projec-
tion. Lobule projection is normal. Treatment: Dissection of
the maxillary spine.
472 15 Tip Projection and Rotation
Case Study Treatment: Spine resection, lateral crural steal, and medial
Nostril apex projection is decreased. Lobule projection is crural overlap.
slightly increased. Altogether, tip projection is decreased.
Intervention to the depressor muscle was not required muscle unnecessary. If the NAP is fine and the depressor is
because of deprojection. More than 4 mm deprojection active, I dissect the origin of the depressor muscles and place
releases the depressor muscle, making an intervention on the grafts under them.
15.2 Tip Rotation 473
15.2 Tip Rotation 4. Upper lateral cartilage caudal resection.

To decrease tip rotation:
To increase tip rotation: It is rarely seen in Caucasians. It is usually associated
with over-projection. Another scenario is excessive rotation
in previous surgery in revision cases.
Important
For a sufficient rotation, there should be adequate pro- 1. NAP deprojection.
jection in the nostril apex and lobule. 2. Lobule deprojection.
3. Medial crural steal. This maneuver is useful in patients
with excessively shortened lateral crura when the medial
1. Lateral crural cephalic resection. crural length is sufficient.
2. Lateral crural steal (most powerful). 4. Septal extension grafts.
3. Caudal septal resection. 5. Extended spreader grafts.
6. Internal valve composite grafts (for secondary cases).
Tip Asymmetry
16
Abstract It is possible to treat asymmetrical noses with a closed

approach. Let’s examine the surgery of a patient with severe
Tip asymmetry is a common condition in patients
asymmetry of the tip. The left dome is higher and in a verti-
demanding rhinoplasty. In this section, I will examine a
cal position, the right dome is lower and in a more horizontal
patient with tip asymmetry and explain the surgical steps
position.
to correct the asymmetry.
476 16 Tip Asymmetry
The left middle crus is hanging lower than the right side.
16 Tip Asymmetry 477
Dissections were made in the subperichondrial plane and

cartilages prepared.
Note the curves in the left lateral crus. There is a bulging in the middle of the left lateral crus.
Lateral crural deformities appear in excessively wide and
long lateral crura that cannot fit into their soft tissue pockets.
After correcting the length and width, most of the deformi-
ties can be solved with cephalic dome sutures.
Making a wide dissection in the subperichondrial plane

gives the opportunity to improve asymmetries.
A 2-mm steal from the left lateral crus was planned.
There are asymmetries in the cartilages as predicted

before surgery.
The left dome is 2 mm higher than the right. Also, the

right dome is curved more sharp.
Cephalic dome sutures were placed.
The new dome point was determined on the other lateral

crus, while holding the lateral crura tightly in the midline. A
4-mm steal was planned in the right dome.
Bulging on the left middle crus was corrected with a

3-mm medial crural overlap.
The domes were checked to verify that they are in the

right place. Cartilages were put back into the nose and rota-
tion was checked.
A 3-mm medial crural overlap was made on the right mid-
dle crus.
A strut graft was placed. The C′ suture was fixed with

columellar and infralobule polygon sutures. Dog ears that
formed in the domes were removed.
Holding up the new domes tightly, the middle and lateral

crural lengths were checked. Additional cephalic dome
sutures were placed.
Domes were equalized with a figure-of-eight suture. Six-month post-op photos of the patient.
Cephalic Malposition
17
Abstract Sheen described [32] cephalic malposition as the longitudi-

nal axis of the lateral crus showing the medial canthus
Cephalic malposition is a disputed topic in rhinoplasty. It
instead of the lateral canthus. Since the problem is described
was described as the longitudinal axis of the lateral crus
in this way, a lateral crural repositioning surgery is sug-
showing the medial canthus instead of the lateral canthus
gested. The lateral crus is dissected totally, a pocket is opened
by Sheen. The two factors determining the axis of the lat-
inferiorly, and the lateral crus is reinserted.
eral crus are the starting and ending points of the lateral
If a long lateral crus, wrong resting angle, horizontal and
crus. Apart from this, the relative sizes of the tip and nos-
vertical convex plane problems, and cephalic and caudal sur-
tril lobules, the presence of pinched-parenthesis tip or high
plus problems coexist, then the nose will look as if cephali-
supraalar groove create this issue. The subject of pseudo-
cally malpositioned (parenthesis tip). The cephalic edge of
cephalic malposition adds more confusion to the topic.
the lateral crus becomes prominent and it shows the medial
The treatment of real cephalic malposition consists of
canthus. As the caudal edge of the convex cartilage is folded
polygon concept tip surgery and lateral crural tail transpo-
into the nose, it cannot be seen through the skin, and this cre-
sition whereas polygon concept tip surgery on its own is
ates the illusion of insufficient cartilage in the alae.
adequate for correction of pseudo-cephalic malposition.
488 17 Cephalic Malposition
This idea is supported in new anatomy studies by Daniel I think that there is total chaos in the definition, therefore
[33], revealing the formation of a ring by the lateral crura and the diagnosis, and frequency of cephalic malposition. The
turning of the crus towards the nostril sill. Daniel argues that diagnosis is made based on the frontal view but photographs
the lateral crus ends at the same point in all people; all by various surgeons do not have a common standard. As an
changes take place in the body of the lateral crus. example, there seems to be cephalic malposition in the pho-
tograph on the left but not on the right. But the only differ-
ence between the two is the lighting.
Important
You can solve most of the problems if you entirely
mobilize the lateral crus by repositioning it inferiorly.
In my opinion, the main effect of the repositioning
technique is mobilizing the lateral crus with dissection,
rather than moving the cartilage inferiorly (once the
lateral crus is dissected from skin and mucosa, the con-
vex shape softens, hence solving the long lateral crus
problem as the cartilage spreads).
I think that the diagnosis of cephalic malposition is best groove. The supraalar groove splits into two at the level of the
made with the profile photo. Let’s first examine the anatomy tail of the lateral crus. The first part follows the lobule circle
of the lateral crus and nostril lobule. The nostril sill becomes and ends at the turning point. The second part follows the
deeper laterally forming the nostril crease and it unites with cephalic edge of the lateral crus and forms the scroll line. The
the nasolabial fold at 3–9 o’clock level forming the supraalar right and left scroll lines unite at the supratip break point.
17 Cephalic Malposition 489
Examine the drawing below. –– The lateral crural turning point is more anteriorly located
If the nostril lobule is larger than the tip lobule, there is in noses with cephalic malposition.
cephalic malposition (left). –– The lateral crus makes a larger circle in patients with a large
If the tip lobule is larger than the nostril lobule, there is no nostril lobule compared to patients with a small lobule. This
cephalic malposition (right). anatomic finding increases the lateral supratip fullness.
Noses with bulbous or pinched-parenthesis tip deformity The patient below has a real cephalic malposition. The
which have large nostril lobules or high supraalar grooves nostril lobule is large and therefore, the supraalar groove
have real cephalic malposition. On the other hand, noses with high. The lateral crural turning point is placed medially.
bulbous or pinched-parenthesis tip deformity and small nostril
lobule can be termed as pseudo-cephalic malposition.
In the next patient, the tip has a bulbous-parenthesis pseudo-cephalic malposition. The problem lies in the lateral
deformity; however the nostril lobule is small. The lateral crus which is wide, long, and convex-concave, and has an
crural turning point is placed laterally. This patient has impaired resting angle.
In the clay models below, there is pseudo-cephalic malpo-

sition on the left and cephalic malposition on the right. Note
the nostril lobule sizes.
Important tioning moves the ending point of the lateral crus

The two factors determining the axis of the lateral caudally and shortens it, and thereby solves the
crus are the starting and ending points of the lateral problem. Tip rotation with lateral crural steal, that
crus. The starting point of the lateral crural vec- is, moving the starting point of the lateral cru-
tor is below normal in patients with droopy tips. ral vector superiorly, decreases the appearance of
Therefore, patients with droopy tips may seem to cephalic malposition. This effect of lateral crural
have cephalic malposition. Lateral crural reposi- steal should be kept in mind.
Important will be perceived as beautiful. After asking for permis-

Not all noses with big nostril lobules are unappealing sion, I had taken photographs of one of my breast aug-
to the eye. As long as the width and length of the lateral mentation patients. Despite the fact that the patient had
crus are in harmony with the big nostril lobule, the nose huge nostril lobules, the nasal tip looked wonderful.
17.1 Treatment 17.2 Summary
Whereas polygon concept tip surgery is usually sufficient 1. Pseudo-cephalic malposition: Polygon concept tip sur-
in patients with pseudo-cephalic malposition, it may not gery (rim flap, sliding flap, lateral crural steal, if required
correct lateral supratip fullness in patients with real medial crural overlap technique). The model on the left of
cephalic m alposition. I have been performing transposi- the following photo.
tion of the lateral crural tail over the past 2 years. The 2. Cephalic malposition: Polygon concept tip surgery + lat-
polygon concept tip surgery will be mentioned in the tip eral crural tail transposition. The model on the right of the
section. following photo.
17.2 Summary 495
Let’s have a look at how polygon concept tip surgery

changes the lateral crural longitudinal axis.
17.3 Transposition of the Lateral Crural Tail
Tail transposition is removing an elliptic tissue under the lat-

eral crus. If you want to reduce the volume of the nostril
lobule, cut deeper and remove more tissue in addition to the
mucosa.
Draw 2 symmetric ellipses lateral to the turning point.
Lateral crural tail transposition decreases fullness of lat-

eral crural tail and softens supraalar groove.
See the area without cartilage because of the big nostril

lobule. The lateral crural tail is placed more cephalically.
17.3 Transposition of the Lateral Crural Tail 497
Starting the incision at the lower border of the ellipse

makes mucosa resection easier. If you always follow the lat-
eral crural caudal border, retrograde mucosa resection will
be more difficult.
Important
Do not perform LLC cephalic resection or ULC caudal
After finishing tip surgery, pull the mucosa downward resection lateral to turning point. After tail transposi-
with mild tension to reduce lateral supratip fullness and tion, the fullness will decrease. If you make unneces-
decrease supraalar groove depth. sary cartilage resection, you may need cartilage
grafting between ULC and LCC afterwards.
Remove bilateral symmetric mucosa with gentle pulling.
Tail transposition is the same what Dr. O’Halloran does

for valve collapse. Dr. O’Halloran [34] makes the first inci-
sion at the caudal edge of the lateral crus. I make the first
incision on the mucosa with no underlying cartilage where I
want to transpose the tail.
Note
If a thick ellipse is removed, the nostril lobule is
reduced. If more tissue is removed, the nostril lobule
margin is also slightly elevated.
Note
Tail transposition also decreases the supraalar groove
depth.
Place a 6/0 Monocryl suture in the middle of the ellipse
first to close the mucosal incision evenly.
Patient Example
Cephalic malposition with pinched nose deformity.
Note
I would have achieved better results if I performed a
lateral tail transposition in this patient. I used rim grafts
to soften the transition from the lateral crus to the nos-
tril lobule and support the nostril rim.
In the basal view, you can see that especially the left
external valve is closed because of cephalic malposition.
The top view can give better information about the lateral
crus anatomy, independent of lighting equipment.
The infralobule polygon is short, the facet polygon nar-

row, the lateral crus long and wide. The lateral crus is
convex.
A 3 mm auto-rim flap was left on the skin.
You can clearly see the lateral crural surface problem.

Since the long and wide lateral crus cannot fit into the nose,
it takes a convex shape in the vertical and horizontal axes.
The caudal edge of the medial crus was cut by 5 mm and Remember the nose deterioration theory.
the two incisions were joined. Tip cartilages were dissected
in the subperichondrial plane and exposed.
The resting angle is imitated with a forceps. Thus, the

caudal edge of the lateral crus can be seen more clearly out-
side the nose. We will set in the cephalic edge of the lateral
crus, which causes the appearance of a parenthesis. Therefore,
there will be a resistance in the horizontal axis. This resis-
tance will open the external valve.
Two mm caudal resection was possible without causing a

retraction thanks to the auto-rim flap. In thin-skinned
patients, it is possible to cut the 1 mm caudal excess and
leave it attached to the mucosa as a mucosal auto-rim flap.
The caudal surplus is marked.

A 3 mm auto-rim and 2 mm additional caudal resection

caused a reduction of 5 mm in the lateral crural width.
Therefore only 2 mm cephalic resection was enough.
The resting angle was corrected with a cephalic dome

suture.
Three mm lateral steal was planned. The height of the

infralobule polygon increased by 3 mm. Wide dissection of
the lateral crus in the subperichondrial plane created a relax-
ation in the lateral crus topography. The caudal part which is
inverted towards the nostril is used as an auto-rim flap, and as
a result the straight middle part is used.
elongated as a result of a 3 mm lateral steal, but since the

infralobule rotated too much, a partial medial crus overlap
was planned. This problem was solved without shortening
the infralobule with a partial medial crural overlap.
Strut graft was placed.
The domes were equalized.
The strut graft was stabilized with a figure-of-eight hori-

zontal mattress suture which passed through the middle crus.
You can see that the lateral crus polygon was corrected in
the photo taken before the complete stabilization of the car-
tilages. When the resting angle is corrected, the parenthesis
appearance disappears. The short infralobule was 3 mm
Examine the two incisions that were formed on the lateral

crural caudal side in the polygon model (scroll facet).
The skin takes its own shape over the years. The lateral
crus procedure will not be sufficient to change the memory
of the skin. Thus, in order to control the healing process, rim
grafts were placed.
With two 3 mm incisions on the lateral crus, the cephalic

parts were allowed to curve inwards.
The external valve opened since the lateral crus turned to

the horizontal axis in the basal view.
Note the enlargement in the facet polygon with the auto-

rim flap.
Examine how the external valve was corrected in the
surgery.
One-month post-op photos.
The supratip break is controlled by the Pitanguy

ligament.
Scroll lines can be clearly seen in the views from the top.
Unfortunately the patient asked for a revision surgery to reduced in the revision surgery. In the same session, periocu-
reduce tip projection. The projection and nostrils were lar fat injection was made.
Fine-Tuning
18
Abstract 18.1 Narrowing of the Footplate Polygon

The result after the tip and dorsum surgeries should be
scrutinized from every angle so that minor problems can The footplate polygon is frequently wide and should be nar-
be identified. Solving these problems will only take rowed in most of the patients because of the septal cartilage
15–20 min, have a huge impact on the results, and save getting in between them.
you from a revision surgery. The changes that can be
made during fine-tuning include narrowing of the foot- Important
plate polygon, additional transdomal sutures, caudal In normal anatomy, there is a space between the foot-
resection from the dome to narrow the tip, infralobular plates and the septum, which is filled by the Pitanguy
caudal contour grafts, C graft, tip grafts, nostril apex pro- ligament. We preserve this anatomy with the help of
jection setup, supratip graft, Pitanguy on-lay graft, tip the posterior strut technique.
camouflage, extra columellar strut, and rim grafts.
1. Mark the footplates externally; symmetry is of great

After tip and dorsum surgeries are finished, examine the nose importance.
from every angle by walking around the patient. Ask the sur-
gical team’s opinions. Be sure to complete the shortcomings
you have identified. Taking an extra 15–20 min for fine-
tuning can save you from a revision. Fine-tuning has a huge
impact on the result.
1. Narrowing of the footplate polygon.

2. Additional transdomal sutures.
3. Caudal resection from the dome to narrow the tip.
4. Infralobular caudal contour grafts.
5. C graft.
6. Tip grafts.
7. Nostril apex projection setup.
8. Supratip graft.
9. Pitanguy on-lay graft.
10. Tip camouflage.
11. Extra columellar strut.
12. Rim grafts.
516 18 Fine-Tuning
2. Attach hooks to the transfixion incision. 4. Pass the suture back through the same hole and exit
through the contralateral footplate.
3. Pass a 5/0 Prolene suture through the transfixion incision

under the mucosa, out through the footplate marking.
Note
The only permanent suture I use in rhinoplasty is the
footplate narrowing suture.
18.1 Narrowing of the Footplate Polygon 517
5. Pass the suture back through the contralateral hole and 6. Tying the knot caudal to the posterior strut will narrow
back through the transfixion incision. the footplate polygon.
Note
A large sharp needle provides convenience for foot-
plate narrowing. It is easier to re-enter the hole where
the needle comes out. PDS can also be used if tissue
has been removed between the footplates. However,
there is a possibility of damaging vessels and nerves.
So I use Prolene. However, I softly tie the knot to avoid
pain.
18.1.1 Asymmetrical Footplates
It is well known that rhinoplasty patients pay close attention

to nostril symmetry. In fact, that is the first thing they look at
after the surgery. Footplates directly affect the shape of the
nostrils. Asymmetrical “footplates” are not uncommon.
Nostril asymmetry can be reduced by passing the suture
more caudally on the more prominent side.
518 18 Fine-Tuning
Important
Footplate suturing results in lowering of the footplates
since the septum does not get in between the foot-
plates, hence pushing them downwards. This results in
lowering of the nasolabial angle for 3–4 mm. Even if
not planned, one may have to shorten the caudal sep-
tum at this level. If caudal resection of the septum is
not sufficient, resection from the maxillary spine
should be performed.
However, some patients may need this effect. Suturing the

footplates in the patient below will result in blunting of the
nasolabial angle and a better-looking nostril shape.
18.2 Dissection and Augmentation of the Origin of Depressor Nasi Muscle 519
18.2 Dissection and Augmentation

of the Origin of Depressor Nasi
Muscle
I do this intervention in patients with overactive depressors.

After closing all the incisions, I make a 5 mm incision at the
base of the nostril and cut the periosteum with a scalpel. I
dissect the periosteum with a Cottle elevator and place small
pieces of bone and cartilage into the pocket. I close the
mucosa with a single 6/0 Monocryl suture.
520 18 Fine-Tuning
18.3 Additional Transdomal Sutures
I use transdomal sutures in addition to cephalic dome sutures

in 30–40% of my patients.
1. It is used when the caudal definition of the domes is not

enough after tip surgery is finished. Patients with thick
skin may need it more often.
2. It can be used to expand the interdomal and infralobular
polygons.
18.3.1 Increasing Dome Definition

18.3 Additional Transdomal Sutures 521
Patient Example
18.3.2 Expanding the Interdomal

and Infralobular Polygons
I marked the points where the transdomal suture should pass

to move the caudal break of the dome from line 1 to line 2.
Dean Toriumi places this transdomal stitch obliquely. This
transdomal suture is placed obliquely by Dean Toriumi [35].
522 18 Fine-Tuning
18.4 R
esection of the Caudal Edge
of the Dome
If the tip is wider than normal, you can perform 1–1.5 mm

additional resection from the caudal part of the dome. Note
that the height of the dome triangle polygon should not be
shorter than 5 mm. This procedure imitates the domal notch.
In thin-skinned patients caudal edge resection of the dome
should be performed carefully. More than 1.5 mm resection
will cause a retraction in the facet polygon. One mm resec-
tion was planned in the following case.
18.5 Infralobular Caudal Contour Grafts 523
The tip width could be narrowed by 2 mm without open-

ing the tip sutures.
Resection was made with a #11 blade.
18.5 Infralobular Caudal Contour Grafts
The middle crura are the thinnest part of the lower lateral
cartilages. However, even weak middle crura can, together
with the soft tissue, create a resistant structure. But dissec-
tion makes this weak region even weaker. If you see folding
or weakness when you put the cartilages in place, you can
use infralobular caudal contour grafts. These grafts can be
used in every region that is injured during dissection. If you
repair the connections between the domes, graft indication
will be less than 5%.
524 18 Fine-Tuning
1. At this stage of the surgery, you should have ample

amount of cartilage. Find thin pieces of cartilages that are Important
4–5 mm × 1 mm. Use thick grafts in thick-skinned noses. Be careful
2. Moisten them and put them at the caudal edges of the while working with thin-skinned patients. Choose
weak middle crura. grafts that are thinner and hide them in the infralobule
3. Pass 6/0 PDS 2 mm away from the edge of the middle polygon as much as possible.
crus. Do not pass the suture from the graft.
4. Tie the knot and squeeze the cartilage in between.
5. You should use a second suture to stabilize the graft. Such
Important
a suturing can also be used with spreader grafts. I have
If interdomal tissues are repaired anatomically or the
learned this suture from Ismail Kuran.
Pitanguy ligament is preserved, you will rarely use tip
6. Cut the excess part in the columellar polygon.
grafts in primary rhinoplasty. I use infralobule caudal
7. You may elongate this graft until the Ti point.
contour grafts usually in secondary patients. If you fre-
quently need using tip grafts, I recommend you to con-
sult the section on nasal ligaments once again.
526 18 Fine-Tuning
Patient Example Tip height was increased with infralobule caudal contour
This patient has had surgery before, and his tip cartilages grafts. Additionally, tiny grafts were freely placed on the tip.
were deformed.

528 18 Fine-Tuning
530 18 Fine-Tuning
Erhan Eryılmaz separates the middle crus from the

mucosa and places a graft beneath it. I have been inspired by Note
him regarding the infralobule caudal contour graft, but I pre- In the profile view, if the height of the infralobule is
fer to place it on the cartilages, not underneath. adequate but the Ts point is too prominent, then:
If you need an extra 2 mm tip projection, you can extend
1. You may not have removed the dog ear at the Ts
the middle crural edge grafts to the caudal edges of the dome.
point. You can resect the dog ear.
You will have to place an additional 6/0 PDS suture. Cut the
2. The Ti point may be far behind the Ts point. You
tip of the cartilages oblique, as they should not be visible.
can raise the Ti point with a middle crural caudal
If you need more projection, you can put Peck grafts
contour graft.
behind the contour grafts, similar to dome triangles.
Important
If the Ti point is below the Ts point, the tip highlights
will not be obvious. You can raise the Ti points to the
level of the Ts point with contour grafts.
18.6 Tip Grafts 531
18.6 Tip Grafts
In closed rhinoplasty, an on-lay tip graft is rarely needed,

because the Pitanguy ligament is preserved. The Pitanguy
midline ligament has a width of 2–4 mm. This width stays
under the dome and acts as a cushion. It also makes a 2–3 mm
projection and contributes to the mobile nature of the tip. In
the photo below, you can see the thickness of the Pitanguy
ligament.
Note how the Pitanguy ligament pushes the dome over the
septal angle.
18.6.1 Boomerang-Shaped Peck Graft
Tip grafts may be needed in secondary surgeries. If there is a

need in the domal region, I prefer Peck grafts that look like
the domal triangles (boomerang-shaped).
532 18 Fine-Tuning
Costal perichondrium provides both camouflage and an

additional 1 mm projection.
If there is a deficiency in the lobule area, I use a shield

graft. Peck and shield grafts can be used in combination.
Only the perichondrium can be used to decrease defini-

tion in patients with thinned skin.
18.6 Tip Grafts 533
If the lobule projection is sufficient but you want to

achieve some more definition, leave the strut graft 1–2 mm
longer. Sew a stick cartilage to the back of the strut graft and
above the domes.
534 18 Fine-Tuning
Patient Example
Boomerang graft.
Three-month post-op results.
18.6 Tip Grafts 535
536 18 Fine-Tuning
I simulate deprojection and reprojection in a patient with

Important a short lobule. I show this to my patients who ask me if their
The biggest advantage of ligament preservation tech- lips will be lifted after surgery. I tell my patients with tension
niques compared to structure tip plasty is that the nasal noses that even the pulling effect of the nose on the upper lip
tip remains soft. Ligament preservation in cartilage will be relieved.
dominant Caucasian noses is usually sufficient for
maintaining the position of the tip.
18.7 Deprojection of Nostril Apex Projection (NAP) 537
18.7 D
eprojection of Nostril Apex
Projection (NAP)
NAP marks the tip base height and even the projection of the
footplates. The nostril apex is used because it is easier to
measure.
Important
Do not complete NAP deprojection before tip surgery
is finished. Always gradually deproject by 1 mm as
needed, because the effect of projection increasing
maneuvers like projection suture during tip surgery
cannot be totally relied on in the long term.
Caudal septal resection provides some deprojection.

538 18 Fine-Tuning
Maxillary spine resection is the most powerful NAP

The first NAP deprojection maneuver is cutting and dis- deprojection maneuver. Spine resection can be done with
secting the periosteum of the maxillary spine. This provides bone scissors, rongeur, or chisel.
1–3 mm deprojection.
A 4 mm chisel can be used for anterior maxillary spine

resections.
18.8 C′ Graft 539
18.8 C′ Graft
In some patients, despite the C′ suture, the C′ point will not

be prominent. At the end of the surgery, the C′ point can be
modified by cartilage grafts. A crushed round cartilage graft
will be appropriate for the C′ point. Do not forget that the C′
point is at the same level as the peak point of the nostril in
lateral view.
In patients with a retruded premaxilla, the spine can be

cut with a 4–5 mm chisel and the bony pieces pushed down
to the front of the maxilla.
For further NAP deprojection, the periosteum and peri-
chondrium around the maxillary spine can be resected.
540 18 Fine-Tuning
Below you can see the 45-day post-op results of a patient

where C′ graft was used.
18.8 C′ Graft 541
542 18 Fine-Tuning
18.10 Extra Columellar Strut 543
18.9 Tip Camouflage
At the end of the surgery, if minute asymmetries are present,

crushed or thinly sliced small pieces of cartilage can be
placed under the asymmetric surfaces. Do not expect too
much from these grafts. Use them for only small asymme-
tries or depressions. These grafts are needed in 2–3% of my
primary patients. I use a maximum of 2–3 pieces. Do not
forget that they can become visible in thin-skinned patients.
I use an additional strut in 5–10% of my patients. I gener-

ally use one extra graft and rarely two.
Note
For a long time, I have not been placing additional strut
grafts except for patients with very droopy tips. The
rate of additional grafts has decreased prominently as I
have started preserving the ligaments better.
18.10 Extra Columellar Strut
If you press on the tip with your finger and do not feel the tip
support, you may insert additional strut grafts.
544 18 Fine-Tuning
18.11 Rim Grafts
If you have closed all incisions and there is still alar asym-
metry or weakness, you can use additional rim grafts without
removing the stitches. You can place a graft by opening a
pocket with the help of a 21G needle and 1 mm chisel.
Important
In patients needing a dramatic increase in rotation, an
additional strut graft angled towards the lip can help
achieve it.
Stabilization of the Nasal Tip
19
Abstract
The way the incisions are repaired has a big impact on the
outcome of surgery. The perichondrium at the transfixion
incision should be sutured back to the septum to prevent
any thickening that may cause breathing problems and to
secure tip projection. Mucosal resection at the transfixion
incision and perichondrial resection at the posterior septal
angle may be necessary in patients with a long droopy
nose where a substantial shortening of the caudal has
been made. On the other hand, repairing the scroll liga-
ment is important both for function and the aesthetic
result.
546 19 Stabilization of the Nasal Tip
I suture the perichondrial flaps under tension. I think this is At the end of the surgery, I suture the perichondrium of
important for function and tip projection. Suturing the septal the two sides to the caudal septum with 5/0 PDS starting
perichondrium to the caudal septum gives another 1–2 mm from the septal angle.
tip projection which was lost with septal dissection. This
maneuver also prevents tissue thickening at the transfixion
incision.
The incision is just over the caudal septum.
I leave a 0.5 mm strip of caudal septum on the Pitanguy

ligament.
19 Stabilization of the Nasal Tip 547
To shorten very long noses, it may be necessary to remove

the perichondrium from both sides of the posterior septal
angle.
Shortening the caudal septum more than 4–5 mm may

make it necessary to perform mucosal resection. Resect the
excess mucosa and perichondrium bilaterally.
Bilateral resection of mucosa and perichondrium frees the On the other hand, in patients with loose connective tis-
distal Pitanguy ligament from the septum. Therefore the dis- sue, the membranous septum can be extremely elastic. In
tal Pitanguy ligament needs to be sutured to the septum with these patients, 1–2 mm of tissue can be removed without
3–4 5/0 PDS sutures after fixation of the septal revealing the medial crura. After removing the tissue, 3–4
perichondrium. septocolumellar sutures are placed with 5/0 PDS. These
stitches are placed between the soft tissue in the cephalic part
of the medial crus and the caudal septum.
Important
If you make subperichondrial dissection in the caudal
septum, the membranous septal mucosa will be very
thick. If this mucosa is not removed, breathing prob-
lems or a hanging columella will be encountered. In
surgeries shortening or reducing the nose, not remov-
ing the excess mucosa will cause problems. If you are
not using the techniques such as tongue in groove or
septal extension graft for fixing the tip to the septum,
redundant mucosal length will lead to dropping of the
tip in the long term.
19.1 Vertical Scroll Reinsertion 549
19.1 Vertical Scroll Reinsertion
Try to see the junction of the scroll ligament and the Pitanguy
midline ligament with a small retractor. You will see a
1.5 × 3 mm-sized sesamoid cartilage just at that point. Suture
this cartilage with 5/0 PDS to the caudal part of the ULC or
the scroll mucosa. Suturing the scroll sesamoid cartilages
creates little pits at both sides of the supratip break point,
which are actually created by an intact Pitanguy ligament. In
this way, you can stabilize the peak point of the mucosa to
the area above and the lateral supratip skin to the base.
Repair of the scroll ligament on the left side.
The second suture passes through the ULC caudal and the
long scroll cartilage.
I usually use three stitches for the scroll area. Stitch #2
and #3 correspond to the middle part of the internal valve.
This may act as the reinsertion of the nasalis muscle. It is
known that this muscle affects the valve and these stitches
open the valve.
Note
Do not suture the scroll sesamoid in patients with a
short lobule. Extra space is needed for the extended
lobule. Recall that Pitanguy ligament dissection is
Remember the endoscopic view below. The short sesa- extended in these patients.
moid cartilage is sutured to the septal perichondrium at 11
o’clock and the long sesamoid cartilage is used for repair of
the scroll region.
Note
When I used to make an intercartilaginous incision, I
was stitching the mucosa with the scroll ligament.
Scroll repair is more effective after an infracartilagi-
nous incision.
The bulging in the ULC caudal is visible. The redundancy

is marked. The excess was incised with a scalpel and snapped
off with a forceps.
With the third stitch, the tip and dorsum compartments

will be separated.
The photo below shows the dissected scroll region. This
dissected area is anatomically corrected at the end of the sur-
gery. I think this is the most important relationship of SMAS
in the nose with the internal valve.
I want to show another example of scroll repair because I

got the question whether the first suture is through cartilage.
I pass the first stitch through the caudal part of ULC.
Dissection of the scroll area:
19.1 Vertical Scroll Reinsertion 551
Scroll repair was performed with 5/0 PDS suture through I start closing the marginal incision laterally.
ULC caudal and vertical scroll ligament.
Then I close the medial crural mucosal incision.

I close the transfixion incision with separate stitches. I use
a 6/0 round needle Monocryl. I no longer use continuous
stitches.
Using a small double hook, I close the middle crural

mucosa.
19.2 S
uturing the Pitanguy Ligament
in the Open Technique
The Pitanguy ligament is marked before being cut in the

open technique. At the end of the surgery, repair the marked
Pitanguy ligament such that it stays between the dome and
septal angle.
This suture decreases supratip bulging. You can treat

supratip bulging by increasing projection.
The suture is passed through the marked Pitanguy liga-

ment under the supratip skin.
In the patient below, subperichondrial dissection was per-

formed. The Pitanguy ligament was marked and cut.
19.2 Suturing the Pitanguy Ligament in the Open Technique 553
The suture is then passed through the Pitanguy ligament

under the dome.
In the open technique, repairing the scroll ligaments on

both sides of the Pitanguy ligament serves to hold the liga-
ment in the middle. Hence you should perform internal tap-
The supratip skin is stabilized after repairing the Pitanguy
ing with three sutures in the open technique.
ligament.
The scroll ligament on both sides of the repaired Pitanguy
ligament was repaired as well.
Important
19.2.1 Repairing the Superficial SMAS
Try not to suture the “Pitanguy” ligament with plica-
tion and shortening. The “Pitanguy” ligament can be
To avoid depressions in the infralobular and columellar poly-
tilted to the right or left of the septal angle which can
gons, the superficial SMAS that fills these areas should be
cause tip deviation. Therefore, if the septal angle is
repaired.
very pointed, cut 2–3 mm of the septal angle.
19.2.2 Membranous Tongue in Groove
I heard of membranous tongue in groove from Dr. Nazım

Çerkeş and Dr. Eren Taştan (Personal communication 2019
May). I excised mucosa and narrowed membranous septum
in all my patients between 2008 and 2015. Between 2015
and 2019 I only excised mucosa in big noses and used hemi-
transfixion incision for the rest. I used to strive to preserve
membranous septum not to damage the Pitanguy ligament
passing through it. I experienced tip rotation loss in some of
the thick skin droopy nose patients. I had chosen hemitrans-
fixion incision in those patients. I dissected mucosa bilater-
ally and excised excess mucosa and managed to bring the
caudal septum and medial crura closer in their revision sur-
geries. Turkish patients often need reduction surgery.
Transfixion incision is almost always applied for them. Since
Since this maneuver decreases the tension on the wound, 2019, I have resected bilateral mucosa to form a tip-septum
it increases scar quality. relationship as in tension noses (Eren Taştan, Personal com-
munication, June 2019). If the patient has tight soft tissue I
use the posterior strut technique; if the patient has loose soft
tissue I use membranous tongue in groove technique. You
can see the difference between them below.
cartilage resection mucosa resection
posterior strut
membranous septum preservation

Close the skin with 6/0 round needle rapid Vicryl or
Prolene. mucosa resection
Spliting membranous septum
membranous tongue in groove
Membranous tongue groove technique: Transfixion

incision should be positioned 4–5 mm posterior to the ante-
rior border of the caudal septum in order to leave the incision
on the septum to prevent scar contracture and vascular com-

promise of the membranous septum.
Dissect the other side of the septum.
Make bilateral mucosal incision and reach the perichon-

drium. Make 3–4 mm back-cut towards the internal valve.
Mark the midline of the membranous septum.
Perform retrograde perichondrium dissection until caudal

septum is reached.
Incise the membranous septum 2–4 mm deep with help of

double hooks. Preserve the tissues in between middle
cruras.
The columella will move 3–5 mm cranially with this dis-

section without removing a big piece of caudal septum, leav-
ing excess bilateral mucoperiosteal flaps. The necessity for
caudal septum excision is greatly reduced.
Finish septoplasty, tip and dorsal surgery and set up the
tip dorsum relationship. Place the caudal septum into the
membranous septum pocket and determine the amount of
excess mucoperichondrial flap to be excised.
The caudal septum will fit into this pocket.
You may resect 1–2 mm cartilage from the caudal septum

if it is weak.
Use horizontal mattress sutures to stitch the septal peri-

chondrium by pulling it through the anterior and posterior
septal angle. It is important for tip support and preventing
membranous septum thickening.
Tip stability will improve by suturing mucoperichondrial

flaps bilaterally. I believe in the power of perichondrium flap
suturing before mucosa closure.
The Pitanguy ligament over the dorsal septum attached to

the middle crura should not be split. This part of the ligament
will rest over the anterior septal angle. With this maneuver
we can control the supratip and create ligament septal exten-
sion effect for the lobule projection.
Nostril Surgery
20
Abstract
Frequently overlooked, nostril surgery has actually a huge

impact on the result of rhinoplasty. Nostril problems may
appear in various forms. The base of the ala may be thick,
the nostrils big, or the ala hanging. The surgical technique
will depend on the present problem. Apart from the hang-
ing ala, where the incision is on the free margin of the ala,
the incision in nostril surgery stays in the nostril groove
and becomes almost invisible over time.
560 20 Nostril Surgery
20.1 Problems and Solutions margin of 1 mm. My personal experience is that a scar on

the alar crease is less visible.
1. The base of the ala may be thick.
Treatment: Simple elliptic resection.
2. Nostrils may be big.
Treatment: Nostril sill advancement flap.
Important
If the nostril sill is hanging, internal rotation is added
while advancing.
3. Nostrils may be big, and the alar base thick.

Treatment: Nostril sill advancement flap and elliptic

resection can be combined.
4. Ala may be hanging.
Treatment: Alar margin resection.
Important
Do not perform a resection without markings.
20.2 T
hick Alar Base: Simple Elliptic
Resection
This is done when the nostril is normal but the ala thick. It is
a simple elliptic tissue resection.
1. Draw an ellipse on the area you want to thin. The incision

must be placed on the alar crease. Do not leave a suture
20.2 Thick Alar Base: Simple Elliptic Resection 561
Important
The most important part of this resection is drawing of
the markings, rather than the cutting and suturing.
2. If the integrity of hair follicles and sebaceous glands in

the skin is disturbed, wound healing will be impaired. So
it may be more appropriate to make an incision parallel to
hair follicles and sebaceous glands.
3. Take out just enough tissue so that a tension-free skin clo-

sure can be obtained. Try to protect the muscles.
Note
“Protect the muscles as much as possible,” says Dr.
Hossam Foda [36]. Sometimes there are such patients
where it is necessary to reduce the muscle mass. In this
case, I also perform muscle resection. Below you can
find a case example of muscle resection.
4. Place one or two subcutaneous 6/0 PDS sutures. Try to go 5. The skin should be closed by loose and continuous stitch-
through the deep dermis or muscle. If you do not bury the ing with round needle 6/0 Prolene. If you tighten the
sutures well under the skin, it will cause a reaction and stitches excessively, they will be buried and it will cause
you will have pockets where debris accumulates. scarring. This area will swell after surgery, and even not
so tight sutures will become tight and leave scars.
Important
If the nostril sill is thick, the elliptic excision may
include the nostril sill, but the incision should not
extend beyond it. If not, the nostril will also get smaller.
6. Take the stitches out on the tenth day.

Ten-day post-op photos of the patient above.
Seven-month post-op photos of a patient with elliptic skin

excision. Note the invisibility of the scars.
Seven-month post-op photos of another patient.

20.3 B
ig Nostrils: Nostril Sill Advancement The scar should stay on this line. Anatomic resection is
Flap not practiced by many surgeons. I have learned this tech-
nique from Nuri Çelik (Personal communication, 2011).
One needs to know nostril sill anatomy to perform this pro- Jack Sheen [37] makes an incision 1 mm above the alar
cedure. Take a close look once more at the nose drawings. crease. Millard [38] was in disagreement with Sheen and
The outline used while drawing the nostril base is where you argued that the incision should be in the alar crease. Because
will place your incision. alar surgery takes place in close proximity to the lips, I have
to agree with Millard who is an authority in cleft lip
surgery.
Important
The alae attach to the upper part of the lips by embryo-
logical twisting and thinning.
Note
Do not refrain from alar surgery because of experience
of bad scarring. You should perform alar treatment if
needed.
1. Drawing: In cases where the nostrils are big, the distance

between the nostril sill and footplate is generally long.
The aim is to narrow this area.
20.3 Big Nostrils: Nostril Sill Advancement Flap 569
3. Elevate the flap and decide where to put it by pulling with

a forceps. You can mark the right point by grasping and
squeezing it with the forceps.
Remember how the nostril sill is drawn. The nostril sill

ends by thinning and narrowing 2–3 mm away from the foot-
plates. The incision should extend from the alar crease to the
footplate. Mark the tissue to be resected.
2. Incision: The incision should follow the nostril sill. The
nostril sill has an anatomy that rests on the lips. 4. Hold the tip of the flap using the forceps and stretch it.
Next, lay it onto the base and holding it there, remove the
excess part.
5. Put a key suture at the tip of the flap. Repeat the proce-
dure on the contralateral side.
6. Place two subcutaneous 6/0 Monocryl sutures. Close the

skin from medial to lateral with a 6/0 round needle
Prolene using a continuous suture technique.
One-year post-op photos of a patient who had nostril

reduction with a nostril sill advancement flap.
Another Patient Example

One-year post-op photos of a patient who had nostril

reduction with a nostril sill advancement flap.
Scars remain in natural lines; therefore, they are not visi-

ble in this 1-year post-op close-up photo.
Important
The incision in alar base surgery should not extend
beyond 8 and 4 o’clock. The area between 8 and
4 o’clock is where the problem lies and surgery in this
area can solve most of the problems. Remember from
the drawings that the alar crease becomes smooth
above 9 and 3 o’clock. An incision that extends beyond
the 3–9 o’clock line will ruin the normal anatomy and
result in an unpleasing appearance. It will be very dif-
ficult to hide a scar over 9–3 o’clock.
20.4 S
uperior Repositioning of the Nostril
Sill
This is performed if the patient’s nostril sill is hanging on

front view. The nostril sill flap will lift the nostril sill. Make
an internal rotation towards the inside of the nostril and set
the resection level. This is a combination of advancement
and internal rotation.
20.4 Superior Repositioning of the Nostril Sill 577
Below is the 1-year post-op result of the above patient.

20.4 Superior Repositioning of the Nostril Sill 579
Important
Make the incision with respect to nostril sill anatomy.
Consider how we settle the nostril sill flap to the lips in
cleft lip surgery.
20.5 Big Nostril and Thick Alar Base: Combination of Nostril Sill Advancement Flap and Elliptic Resection 581
20.5 B
ig Nostril and Thick Alar Base:
Combination of Nostril Sill
Advancement Flap and Elliptic
Resection
Perform elliptic resection first, then do an advancement flap

for easy planning.
In the patient below, nasal projection was reduced. The

nasal alae were thick.
When the projection was reduced, the nostrils became
even bigger than before. Nostril sill advancement flap and
elliptic resection were combined.
Ten-day post-op photographs of the patient.

Patient Example
Two-year post-op photographs. (Note: photography lights
are not identical between post-op and pre-op.)
20.6 Common Mistakes
1. Incisions that disrupt the continuity of the nostril sill.
20.7 Hanging Alae
Patients with hanging ala have large nostril lobules and usu-
2. Resections that are done on the body of the nostril sill. ally have cephalic malposition deformities. Resection can be
made from two areas to lift the hanging ala. The first resec-
tion takes the tail of the lateral crus inferiorly. This resection
raises the alae indirectly because it reduces nostril lobule
volume. Resection #2 can be made in excessively hanging
alae. Resection #1 was discussed in Chap. 17.
20.8 Alar Rim Excision 589
20.8 Alar Rim Excision
I use Millard’s technique [38].

Some patients have an abundance of skin rather than car-
tilage. This generates a flabbiness of the alae. Patients want
to get rid of this fleshy appearance as well. It is not possible
to satisfy these patients with cartilage only shaping. Alar rim
resection is a radical technique.
Note
Do not perform this procedure on your first 100
patients or if the patient has an excessively oily skin.
20.8.1 Marking
Mark a point 1–2 mm lateral to the lowest edge of the hang-

ing ala. Draw it throughout the excess skin. While finishing
the line at the base, slightly turn to the nostril. The anterior
corner of the elliptic drawing should be on the free margin
not to create a notching.
20.8.3 Resection
Stretch the tissue with a forceps and shorten the flaps with
tissue scissors. I still hold my breath at this point. Please act
very carefully. You can do additional resection if necessary.
The nasal alae will rise as you make a resection.
20.8.2 Incision
Cut the ala along the marking so that it splits the ala right
from the middle using a #15 blade. The incision should be
deep in the middle, but superficial at the top and bottom. For
the first 2–3 mm, cut obliquely towards the lateral in order to
have a thin lateral skin flap. This will also let you turn the
lateral flap easily while suturing.
20.8.4 Suture
Suture the skin very loosely by inverting the wound edges

Important
with a continuous 6/0 round needle Prolene. Do not place
After closing the wound, the ala will seem erect and
subcutaneous sutures. While suturing, the axis of the needle
the nostrils bigger. This is a transient effect. Do not
should always be towards the center of the nostril. In this
perform a nasal base resection taking this appearance
way the end points of the incision will not be visible from the
into account, and bear in mind that there will be wound
outside. Washing the wound with 1/5 diluted corticosteroid
contracture.
solution when suturing is finished will make the wound heal
better. Remove the sutures on the tenth day.
Ten-day post-op photos of the patient.

Irrigating the suture lines with triamcinolone.
Seven-year post-op photos of the patient. Other photos

are in the “Case Studies”.
Patient Example
A more aggressive resection was performed.
The most important thing to note is the smooth transition

and symmetry of the vertex of the nostrils. The elliptical
resection should end on the free edge of the ala.
Patient Example
Thick-skinned patient with hanging alae. Six-month post-op
results.
Patient Example
Asymmetric nostrils, more skin resection was made on the
left side.
One-year post-op results.
Patient Example
Skin resection from alar free margin, 8-month post-op.
This is a good example of how strong the effect of skin
resection is. Direct removal of skin is more effective than
defatting.
Patient Example
Skin resection from caudal margin of alae in a revision
patient.
Patient Example
One-year post-op photos of a patient with skin resection to
correct hanging facet polygon skin.
Patient Example
Skin resection was performed from right nostril apex to
improve nostril asymmetry in a cleft lip patient.
Patient Example: Composite Graft

Traumatic scar contracture in the right nostril. Tissue
removed from the left alar base was adapted to the contracted
region as a composite graft. Seven-month post-op photos.
Deviated Nose
21
Abstract
Axis deviation is a very common and difficult to correct

problem. Septum deviation, trauma, and size differences
in nasal cartilages may be the cause. Axis deviation leads
to abnormalities in upper lateral and tip cartilages, nasal
bone, anterior maxillary spine, and even the soft tissues of
the nose. A reference point should be taken for marking
the midline. I usually take the midline of the glabella.
Wide dissection, asymmetric resection from the dorsal
cartilage and bone, septal base resection, and asymmetric
lateral crural steal are necessary in correcting the devia-
tion. On the other hand, I have been using dorsal preserva-
tion techniques to correct nasal deviations more
effectively. Low septal strip dorsal preservation is very
useful in correcting septal deviations.
620 21 Deviated Nose
Sixty-five percent of my patients have axis deviation. Left 9. Anterior maxillary spine is deviated to the left anteriorly
axis deviation is more common. Axis deviation is a very and to the right posteriorly.
common and difficult problem to correct. 10. The left turbinate is hypertrophic.
The main reason for axis deviation is septal deviation. A 11. Soft tissues are also deviated in noses that have been
septum that does not fit inside the nose can bend the nose to deviated since childhood and the muscles attached to the
one side. Trauma prior to adolescence can affect the growth nose have asymmetric lengths as well. Ali Teoman
of the nose. Size differences in nasal cartilages can occur as Tellioğlu reported that a part of the levator labii superi-
well. oris alaeque nasi muscle is connected to the lateral crus,
stating in an article that this connection should be surgi-
cally cut. For very deviated noses, I think this has a simi-
21.1 Problems with Left Axis Noses lar effect as performing a very wide dissection on the
lateral crus at the subperichondrial plane until the pyri-
formis aperture [39].
1. Right lateral crus is longer.
2. Right lateral crus is wider. If the soft tissue deviations tend to pull the nose to the
3. Right upper lateral cartilage is higher. same side after surgery, I ask my patients to massage their
4. Right upper lateral cartilage is longer. noses. The patient pushes the nose with his/her palm to coun-
5. Right nasal bone is higher. teract the pulling effect that may lead to deviation. The
6. Right bony base (lateral aesthetic line) is wider. patient needs to massage 10–15 min/day. I also ask the
7. Bony surface problems usually accompany deviation. patient to lengthen the levator muscle through smiling exer-
Concave and convex bones are usually seen in patients cises. A regular massage in the first 2 months provides a cor-
with axis deviation. rection of 1–2 mm.
8. The septum is deviated to the right posteriorly, and to the In order to correct the deviation, all of the above problems
left anteriorly. should be solved step by step.
21.2 Reference Points 621
21.2 Reference Points What should the reference point be in asymmetric faces?
Asymmetries are commonly seen at the mandibula. The
Surgery of patients with axis deviation should be done asym- midlines of the chin and forehead may not be in alignment. I
metrically. We need reference points during the operation. usually take the eyes as reference. People usually look at
We cannot fix the nose based on rule of thumb. Thus, we each other’s eyes while talking.
should mark the midline of the patient’s face before surgery.
Put midline marks on the glabella and vertex. Even the radix Deviated Nose Example
may not be at the midline. For this reason the radix must not A very thin-skinned patient with left axis deviation has a sep-
be taken as a reference point. tum deviation to the right.
Dissection was advanced laterally.
Local infiltration was made before prepping the patient.

As the patient was prepped and draped, the nose had already
turned white.
The bone was reached over the upper lateral cartilage.
Left turbinate submucosal resection (SMR) was per-

formed. The subperichondrial plane was entered from the
septal angle.
21.3 Nasal Dorsal Resection 623
21.3 Nasal Dorsal Resection

The bone was incised with a blade and the subperiosteal
plane entered. (The subperiosteal plane can also be found by Resections were made while pushing the nasal cartilages
scratching the edge of the bone with an elevator.) A wide dis- medially. In this way, more resection could be made from the
section was made until the osteotomy lines. In this way, it is long right upper lateral cartilage. If a patient has a weak dor-
possible to reach all the deviated areas. sal cartilage, use spreader flaps or grafts.
Important
Additional 1–2 mm resections are generally needed for
symmetry after osteotomy. It is reasonable to perform
resections conservatively. The bones were also resected
asymmetrically at the level of the upper lateral carti-
lages. The right nasal bone was further reduced.
Important
The nasal roof of patients with axis deviation should
be opened asymmetrically to get a symmetric roof, as
desired, after osteotomy.
21.4 Septoplasty 625
21.4 Septoplasty
Important
The septal base was exposed by subperichondrial dissection. 1. If you do not separate the septum from the maxil-
Excess cartilage was removed starting 2 mm anterior to the lary spine, you cannot correct the deviation easily.
septal base. A 2 mm space was left between the septum and You will usually need camouflage techniques.
maxillary spine. This space will be filled with the thickening 2. The excess in patients with axis deviation is at the
of the perichondrium and periosteum. septal base. Emptying the posterior septum with L
septoplasty does not have any effect on correcting
the deviation. Scoring techniques are not effective
enough on a septum on which an L septoplasty was
performed.
3. If you perform an L septoplasty to obtain cartilage
grafts and separate the septum from the maxillary
spine, the septum will become excessively
mobilized.
4. If you use Libra grafts or spreader flaps, you do not
need to take an additional graft from the septum.
The cartilage that has been removed from the base
is more than enough.
Important
The maxillary spine is one of the basic points of the
The anterior maxillary spine was dissected after cartilage nose. The base must be symmetric for a symmetric
removal and made symmetric by thinning it from the right septum. The midline of the forehead should be taken as
and left sides with respect to the midline markings. reference while thinning the maxillary spine. The max-
illary spine is quite hard. You cannot perform a green-
stick fracture. If you break the spine to move it to the
midline, it may be mobilized too much. It is safer to
create a bone segment in the middle by trimming the
deviations on the sides.
21.4 Septoplasty 627
You can control the alignment with the help of a bayonet

forceps.
The septum was stabilized to the periosteum above the

maxillary spine by making two loop sutures with 5/0
PDS. The knot was placed in between the bone and septum.
Important
The septum must be stabilized at this level. The septum
can be mobilized during radix osteotomies and it will
be difficult to stabilize the mobilized septum in the
correct position.
1. In tip surgery even a 2 mm asymmetry can tilt the axis of

21.5 Tip Surgery the tip.
2. Acquiring a symmetric tip without correcting the lengths
Tip cartilages were exposed by dissection in the subperi- of the asymmetric lateral crura is hard to obtain.
chondrial plane after an auto-rim flap technique. The domes 3. The dome symmetry test is very important to obtain a
were taken into traction and brought to the midline. Reference symmetric result in tip surgery.
points were marked on the cartilage by holding and stretch-
ing the medial crura.
A 2 mm lateral crural steal was performed on the left and
4 mm on the right.
Dr. Alan Landecker usually performs the surgery from

above. So I emptied the head side of the operating table so
that I could view the patient from above and do the symmetry
tests. I highly recommend you doing the same. Viewing the
patient from the side during surgery can make you miss
Important important information about asymmetries.
Performing asymmetric steals from the lateral crura is
a very effective maneuver. In this patient, a 7° midline
deviation was corrected by performing an asymmetric
steal with 2 mm difference.
21.5 Tip Surgery 629
the right facet polygon. Therefore, the tip of the right auto-
rim flap was shortened by 2 mm.
Cephalic dome sutures were placed.
When 2 mm steal is made from the lateral crus, the medial
crus is extended by 2 mm. A 2 mm overlap was made on the
right medial crus and a strut graft was placed. Then the C′
suture was placed. The columellar polygon was stabilized.
The tip cartilages were put back under the skin and the
mucosa repaired.
A right lateral ostectomy was performed. Since the right

maxillary base was wider, more ostectomy was made on the
right compared to the left.
The split Pitanguy ligament was repaired. The lateral cru-

ral steal on the right was 2 mm more than that on the left so
the right auto-rim flap was longer and caused a bulging on
A lateral chisel was inserted between the right nasal bone

and septum. The chisel was advanced cephalically into the
bone to a depth of 4 mm with the aid of a hammer. The chisel
was turned outwards.
Important
If lateral ostectomy is not adequately performed, espe-
cially at the medial canthal level, the opening osteot-
omy will be unsuccessful. The opening osteotomy
increases the height of the bone. If it is longer than
desired, we can perform additional resections up to
1–2 mm with bone scissors. Do not use a rasp at this
level because the bone can be mobilized too much.
Bone scissors are one of the safest tools for performing
A transverse ostectomy was performed. a resection on a bone that has been osteotomized.
Important
Performing transverse ostectomy is important. The
bone at the medial canthal level is very thick. If it is not
thinned enough, the nasal bone can separate from the
maxillary bone during the osteotomies.
A lateral osteotome was put between the left nasal bone

and septum, and advanced about 4 mm deep into the bone. Important
Then it was pulled to the right with the ethmoid bone to Although we perform resections according to opening
which the septum was affixed. and closing osteotomies, additional 1–2 mm upper lat-
eral cartilage, septum, and bone resections may be
needed.
Important
During this maneuver you should hear a cracking
sound from the bone.
In order to close the open left nasal bone onto the cor-
rected septum and right nasal bone, lateral and transverse
ostectomy were performed. The nasal base on the left is
thinned with a Çakır 90 chisel. Since the left nasal base was
narrower, less bone was removed when compared to the
right. Thinning was continued until the bone could be frac-
tured with finger pressure.
In order to take the caudal septum to the midline, a 45°

scoring was performed starting from the attachment point of
the septum to the ethmoid bone.
Important
In septal base surgery, most of the axis problems are
fixed with the radix opening and closing osteotomies
and scoring. Spreader grafts are used to stabilize the
structure. Unless asymmetric resections are made
while taking the nasal dorsum into the midline, there
will be axis deviation again when the upper lateral car-
tilages are repaired. If the resections are made appro-
priately, a stabilized axis correction can be achieved
when the upper lateral cartilages are fixed with Libra
grafts.
Important
Perform scoring on the same side of the deviation. If
Scoring was performed until the septum aligned with the you want to bend the septum to the right side, do the
midline. scoring on the left side.
The following can be an alternative to scoring. Instead of

making cuts on the cartilage, scratches can be made like
meshing a skin graft. Less effective than scoring, but the
integrity of the cartilage is better preserved.
You can check the position of the septum with the help of The excess mucosa was resected.
a bayonet forceps.
After the septum was placed in the midline, the Libra

graft was stabilized to the septum and the upper lateral carti-
lages were sutured to the Libra graft.
Important
Note You should perform mucosal resections with correct
I have not been fixing the upper lateral cartilages to the measurements. In a patient with left axis deviation,
Libra grafts for a long time. It is very difficult to more redundant mucosa is seen on the right membra-
control. nous side and right internal valve area.
Three millimeters of cartilage and mucosa were removed

from the caudal edge of the right upper lateral cartilage.
Here you can see the nasal dorsum which has been stabi-
lized by means of the Libra graft technique.
Note
After I have abandoned intercartilaginous incisions, I
have no more needed to make resection from the inter-
nal valve mucosa.
The final view after surgery.

Ten-day post-op photos of the patient.

Deviated Nose Patient Example

Ten-month post-op photos.
Deviated Nose Patient Example

Two years after surgery, a minimal deviation to the right has
become evident although the patient had left deviation
preoperatively.
Deviated Nose Example

Five-year post-op photos.
21.6 Swinging Door Septoplasty

Note
I get much better results with dorsal preservation tech- I used to completely separate the septum from the maxilla
niques in deviated noses. I have been using dorsal pres- and vomer, especially in deviated noses. When low septal
ervation techniques since 2017. It is not uncommon for strip dorsal preservation technique is used, the septum is
deviation to recur in the long term, especially when the completely separated from the ethmoid bone (swinging door
cartilaginous roof is opened. Even if you finish the sur- septoplasty). The septum is only continuous with the dorsal
gery with a straight nasal dorsum, the septum sepa- cartilaginous roof. It may be possible to obtain results simi-
rated from the upper laterals continues to shape the lar to Dr. Wolfgang Gubisch’s extracorporeal septoplasty
dorsum. When you start using dorsal preservation technique [40]. Therefore, low septal strip septoplasty tech-
techniques, you do not want to open the cartilage roof, nique can be called intracorporeal septoplasty. When the sep-
especially in deviated noses. tum is completely separated from the maxilla, vomer, and
ethmoid bones, it easily comes to the midline and there is
almost no need for scoring. Swinging door septoplasty gives
opportunity to resect high septal deviations on the perpen-
Important dicular plate. This is so important to fix septal and axis
When the dorsum is fixed with dorsal preservation, the deviations.
tip asymmetry improves or decreases thanks to the
scroll ligaments. For this reason, I first correct the dor-
sum of the nose and then operate the tip.
Secondary Rhinoplasty
22
Abstract
Secondary rhinoplasty is one of the challenging issues

that rhinoplasty surgeons can face. Depending on the
severity of the deformity, different amounts of cartilage
grafts are required. Septal cartilage has often been used in
the primary surgery and will not be sufficient as a graft
source in the revision surgery. In this case, it is usually
necessary to take costal cartilage. The costal cartilage can
be completely removed or the partial split technique can
be applied. The removed cartilage can be used as a block
in dorsal augmentation or as strips of cartilage in the cor-
rection of tip deformities and as spreader grafts. Oblique
split technique is important to prevent warping of the cos-
tal cartilage. On the other hand, cartilage chips or paste
can be used to correct small deformities and the perichon-
drium is important in covering the reconstructed tip espe-
cially in patients with thin skin.
650 22 Secondary Rhinoplasty
22.1 Septal Cartilage 22.2 Rib Cartilage
I do not remove a large amount of cartilage from the septum If the patient had previous surgery with no cartilage left in
except for secondary surgeries. In primary rhinoplasty, a car- the septum, cartilage from the rib or ear will be needed.
tilage graft taken from the septal base is enough for the Whereas ear cartilage is mostly used for filling, the rib pro-
surgery. vides straight and strong cartilage grafts. If rib cartilage is
When cartilage is needed for secondary surgery, the graft necessary, take it before starting rhinoplasty. Since taking a
should be removed with correct planning, and markings rib segment causes serious pain and potential complications,
made according to the respective needs. The graft is cut with I prefer to take split cartilage. I learned this technique from
a #11 blade. Sacit Karademir (Personal communication, June 2011).
22.3 Cartilage Chips
Cartilage chips serve as excellent filling material. Rib carti-

lage chips are best prepared by rubbing with a Çakır 90
chisel which is actually used for ostectomy.
22.3 Cartilage Chips 651
Patient Example
Closed technique rhinoplasty was performed on the patient.
• A septal perforation of 5 × 4 cm

• Pinched nose
• Hanging columella
• Alar retraction
• Left axis deviation
• Thin skin due to previous surgery
22.3.1 Surgery spreader grafts. Since the skin was very thin, block cartilage
was not inserted in the nasal dorsum. The nasal dorsum was
A dome-delivering closed approach was used. The pinched augmented with cartilage chips that were taken from the rib.
nose was corrected with lateral crural strut grafts. The sep- One-year post-op photos.
tum was taken to the midline by scoring and stabilized with
22.3 Cartilage Chips 653
22.4 Block Cartilage 655
22.4 Block Cartilage
I use block cartilage in major defects and definitely combine

it with cartilage chips. Coagulated blood is an excellent
adhesive for holding grafts together. The appearance of a
grafted nose can be avoided by shaping the block cartilage in
a fusiform shape. The edges should be sharp and the base
concave.
Block cartilage was combined with cartilage chips as

shown below.
Note
I have achieved very good results with this technique,
but it takes a long time to prepare a patient-specific
block cartilage graft. That's why I use combinations of
cartilage strips and diced cartilage.
22.5 Oblique Split Rib Grafts
This is Eren Taştan’s technique [41]. Normally, I use a 2 cm

long incision and remove the anterior perichondrium first. I
go under the cartilage with an angulated elevator. I was able
to take the below photo because I had made a larger incision
because the patient had a simultaneous breast implant
surgery.
The oblique split method: a novel technique for carving
costal cartilage grafts [41].
Important
It is crucial to design the strut, spreader, and especially
lateral crural strut grafts before splitting the rib carti-
lage, because after splitting it is difficult to thin the
grafts.
Removing 2 mm strips on two sides of the cartilage makes

it easy to harvest the graft.
22.5 Oblique Split Rib Grafts 657
Note
Rib grafts tend to jump off the table. First dry the graft
with a gauze. Work on the graft in the middle of the
table over the gauze.
Another Example
Tip cartilages were structurally damaged. Symmetric thin lateral crural strut grafts are prepared. I
usually place the lateral crural strut grafts over the lateral
crura.
Grafts are prepared.
A strong strut graft is placed.

Shield graft designed to form the lobule polygon and I use very thin grafts for small asymmetries.
strengthen the weak middle crura.
Intraoperative result.
Perichondrial graft sutured over the tip graft.

I prepare spreader grafts in the oblique split technique as

follows. In this way, the thick part stays in the dorsal part and
the thin part rests towards the inside of the nose. It does not
create thickness inside and does not open the bones more
than necessary.
22.6 Partial Oblique Split Rib Grafts the table, I make the oblique incisions directly on the carti-
lage before harvesting without disturbing the costal cartilage
This technique can be used when a sheer amount of grafts is integrity. Since the deeper part of the rib is intact, the patient
not needed. Partial oblique split technique doesn’t provide will have very little pain.
wide lateral crural strut grafts as oblique split technique
does.
It is possible to get strip grafts from the rib, keeping the 22.6.1 Surgery
deeper part of the rib intact. Half of these cartilages curve
when submersed in saline. I use the curved ones for filling. I Make a 1.5–2 cm incision in the medial part of the right
make strut and spreader grafts from the straight ones. This is inframammary fold. Dissect the muscles in a vertical direc-
not an easy technique. tion and expose the cartilage. Dissect the perichondrium if
The major problem with rib cartilages is bending. I have you need a perichondrial graft. Mark oblique incisions on the
even used K-wires for this problem; however, one of my cartilage. Make 4 mm deep incisions with a blade. Sacrifice
patients had the K-wire exposed from the nasal tip 2 years one strut in order to remove the other struts easily. Use a thin
after surgery. Cottle elevator to get under the struts and separate them from
Whereas Dr. Eren Taştan [41] harvests the cartilage in the main cartilage.
block form and makes extracorporeal oblique incisions on
22.6 Partial Oblique Split Rib Grafts 663
Example of cartilage harvesting with partial oblique split These grafts bend very little.
technique.
22.7 Cartilage Paste
This is a technique I have seen from Dr. Abdülkadir Göksel

(Personal communication, March 2014). When you rub the
scalpel at a 90° angle on the cartilage, tiny pieces of cartilage
can be produced. Since these cartilage pieces easily stick
together, they look like a paste. While the augmentation
effect is very small, the camouflage effect is very strong. It is
almost impossible to notice them under the skin with
palpation.
The deeper part of the rib cartilage is intact.

22.7 Cartilage Paste 665
22.8 Turkish Delight
It is a technique popularized by Dr. Onur Erol [42]. This is

the technique I use most frequently in dorsal augmentation.
After chopping the cartilage with a #11 blade or a derma-
tome knife, I draw out the water with an aspirator. I drip
2–3 cc of blood on it. After waiting for 5–10 min, a bulk of
cartilage that comes together forms. It is not very stable but
it works very well for me.
22.10 Nasal Dorsal Dissection in Secondary Rhinoplasty 667
22.9 Rib Perichondrium 22.10 N

asal Dorsal Dissection in Secondary
Rhinoplasty
I use rib perichondrium to cover the cartilages and the tip in
noses with thin skin. This is the camouflage material I trust Dorsal dissection in patients with thin skin is very traumatic.
the most. I have a very practical suggestion in such patients. Instead of
dissecting the dorsum and then finding the septum, first dis-
sect the septum. After dissection of the tip, the septal angle is
reached.
Dissect both sides of the septum.

When these two planes are joined in the dorsum, the dor-
sum will have been dissected. In this way, mucosal tears are
rarely encountered.
If needed, it is possible to find the ULC perichondrium

through this tunnel. An alternative way is to go over the lat-
eral crus, find the caudal edge of the ULC, dissect the outer
perichondrium, and join with the dorsal plane.
The dissected dorsum can be seen in the photo below. Four-month post-op photos of this patient.
22.10 Nasal Dorsal Dissection in Secondary Rhinoplasty 669
22.11 Hanging Columella 671
22.11 Hanging Columella 2. In order to elevate the nasal alae, the cephalic part of the
lateral crus is usually excised; but this is not the only way.
Hanging columella will be discussed in three categories: Depending only on lateral crural resection is not wise. An
retracted nasal alae, hanging columella, and a combination excessive cephalic resection from the lateral crus is often
of the two. I often see a combination of retracted nasal alae made. It is more logical to resect just enough for the lat-
and hanging columella in patients who come for revision eral crus to turn inside with a cephalic dome suture. When
surgery. an auto-rim flap is used, 2–4 mm cephalic resection will
Increased columellar show is more frequent in open sur- generally be enough. If only lateral crural cephalic exci-
gery. In the revision surgeries of these patients, I frequently sion is used to elevate the nasal alae, the possibility of a
encounter long caudal septum and untreated hypertrophic pinched nose increases. Primary cartilage contact is very
maxillary spine. important in the scroll region. If alar rotation solely
depends on lateral crural cephalic excision, a cartilage
defect will occur in the scroll region. Although this defect
may seem normal during surgery, it will pull the nasal
Important
alae in the long term.
Increased columellar show occurs as a result of a dif-
ference in the raising of the nasal alae and columella
during rotation and shortening of nasal length. A pro- Important
portional rotation must be made on columella and Do not treat the wide lateral crus with cephalic exci-
nasal alae. A common problem is the insufficient rota- sion only. In a very wide lateral crus you may have to
tion of columella while making nasal alae rotation with perform about 8 mm resections. It is not possible to
lateral crural cephalic excision. Medial crura that have repair the primary scroll region in a patient where
been left too long can also cause increased columellar 8 mm cephalic excision has been made. There will be
show. a big gap between the upper lateral cartilage and lateral
crus. If these two cartilages do not contact each other,
the lateral crus shows cephalic migration and its rest-
1. Remove cartilage and mucosa from the caudal septum to ing angle deteriorates. Its silhouette under the skin dis-
elevate the columella. Removing only cartilage is usually appears, and it may appear as cephalic malposition;
not enough. Excess mucosa can push down the columella even a pinched nose may result.
or disturb breathing by forming a thickness at the mem-
branous septum in the long term.
22.11.1 Preventing Alar Retraction

Note
A cephalic excision of 7 mm should be made to decrease the Since 2019 I have been using the sliding flap for
width of the lateral crus from 15 to 8 mm. In the auto-rim cephalic excess of lateral crura. In this way, I can pre-
flap technique, a 3 mm wide auto-rim flap and an additional serve the lateral crura to a maximum.
1 mm caudal excision will narrow the lateral crus 4 mm on
the caudal side. A 3 mm cephalic excision will make 7 mm
narrowing in the lateral crus width in total, ending in an
8 mm wide lateral crus. The 3 mm wide cartilage in the auto- Important
rim flap stays in the facet polygon so that it supports the alar In order to support alae and generate a lateral crural
edge. Another important disadvantage of wide cephalic caudal edge highlight, the lateral crus should have sup-
resection (7 mm in this example) is that the caudal half of the port from the other lateral crus and upper lateral
lateral crus, which is convex and weak, is kept. The part cartilage.
curving to the facet polygon does not allow for a nice high-
light on the skin.
In the auto-rim flap technique, the middle part of the lat- Patient Example for Hanging Columella
eral crus, which is straight and strong, is used. The nasal alae Let’s examine a secondary case with hanging columella.
are supported by the auto-rim flap. The scroll region can be Excessive cephalic resection was made with a closed tech-
repaired in such a way as to provide contact between the nique. Columellar elevation is not enough. Nasal dorsum and
upper lateral cartilage and lateral crus cartilages. bone/cartilage transition are disturbed, and there is a left axis
deviation. There is a bulbous tip. The lateral crura are
convex.
22.11.2 Surgery
The excess cartilage and mucosa at the caudal side of the

septum were resected and the tip cartilages exposed.
The fibrotic tissue between the lateral crus and upper lat-
eral cartilage was released. The new position of the domes
was determined. The lateral crura are often left long in these
patients. Hence, a lateral crural steal was made as needed.
The amount of steal has been discussed in the Tip Surgery
The right lateral crural excess has been resected and so chapter in detail.
the lateral crura have been moved cephalically.
A 6 mm lateral crural steal was performed in this patient. downwards and the medial crus upwards. In other words, this
is a good solution for patients with both hanging columella
and supratip thickness. But if the lateral crus is weakened
because of extreme cephalic excision, the cephalic dome
suture cannot show the desired effect. Therefore, the lateral
crus will need to be strengthened.
The domes were shaped with cephalic dome sutures. This

suture will strengthen the alar rim. The cephalic dome suture
between the medial and lateral crura stretches the lateral crus
22.12 Lateral Crural Cephalic Strut Graft 677
22.12 Lateral Crural Cephalic Strut Graft
It is similar to a middle crural contour graft aiming to

strengthen the weak edge. It serves for the stabilization of the
cephalic resection area. The graft is secured with a loop
suture. If excessive cephalic resection has been performed, a
thicker graft can be used.
C′ suture was used.
A strut graft was inserted.
The columellar polygon was shaped.

Spreader grafts were placed for dorsal aesthetic lines.
The stabilized tip aesthetics.

Seven-year post-op photos of the patient.

Patient Example
This patient had two previous surgeries with an open
approach. After the first surgery retraction in the nasal alae
had occurred; therefore, lateral crural strut grafts were placed
in the second surgery. But neither axis nor tip could be cor-
rected. The patient had a hanging columella. The columella
was elevated by means of mucosa and cartilage resections.
The nasal alae were lowered with lateral crus strut graft and
scroll grafts.
22.13 Pinched Nose Deformity 687
22.13 Pinched Nose Deformity
Pinched nose deformity appears in noses that were narrowed

without shortening the lateral crural length and forced to
rotate. The patient in the example below had come to me for
a consultation before she had her surgery elsewhere and I
had a chance to take her photographs (note: photography
standards are not the same). I had told her that I would do the
surgery once she turned 18. Then she decided to have her
nose surgery by another surgeon. This is a good example of
a pinched nose. The patient had a short lobule, bulbous tip,
long lateral crura, and lateral crural caudal excess. Cephalic
resection was performed without shortening the lateral crura,
and when forced to rotate, the lateral crura collapsed and
completely blocked the airway. The tip grafts placed for
short lobule worsened the situation. The puzzle would have
been easily solved if the caudal excess had been treated with
an auto-rim flap and the excess lateral crural length used to
lengthen the lobule.
At first, an auto-rim flap was performed.
The grafts were adherent to the dermis. This may be the

reason for the rash on the nose.
Tip grafts were removed.
The tip cartilages were very decent. Tip surgery is completed.
The long lateral crus was released by subperichondrial One-month post-operative photos.
dissection from the mucosa. This is what I mean by saying
“All the cartilages must fit the new nasal shape.” Cartilages
left long or wide bulge either in or out.
Taping and Splinting
23
Abstract
Proper taping and splinting is necessary for proper heal-

ing of the nose after rhinoplasty. The tapes should be
applied without squeezing the nose. A thermoplastic
splint is used to close the open roof and also to prevent
swelling. Inappropriately applied taping and splinting
may ruin the facets and cause necrosis and fossa forma-
tion under the domes. The tapes should be extended to
infraorbital area to prevent bruising. If the right tech-
niques are used during the surgery and if postoperative
care is good, bruising should be minimal. One can find
my postoperative prescription and recommendations in
this chapter.
696 23 Taping and Splinting
23.1 Fixing the Silicone Splints:
At the end of the surgery, find the silicone splints placed

right after septoplasty. They will be located deep in the nasal
cavity and pull them up. Fix them to the septum with 5/0
prolene or 5/0 PDS. The tip of the silicone should close the
transfixion incision. Do not over tighten the stitch. Otherwise
it may be painful. Do not use silk for fixing, because it is a
non-slip suture, which can cause pain when removing the
splints.
23.2 Drains
Using a #11 blade, split an 18G intravenous cannula with its

needle still inside, such that 3 mm at the tip remains unsplit.
If you do not keep the tip intact, the plastic will bend while
inserting the cannula. Insert the drains through the lateral
osteotomy incisions, aiming towards the medial canthus.
Turn the split side of the cannula to the bone in order to avoid
clogging. Remove its needle and cut it so that 2 cm of the
cannula remains outside the mucosa. After 4 days remove
them with the internal silicone splints.
23.3 Taping and Splinting 697
Cut the body of the cannula.
Important
You should keep the drains long enough to avoid for-
getting them inside.
23.3 Taping and Splinting
In order to avoid a pinched nose, do not also squeeze the

nasal tip with tapes. To prevent a tube-like appearing nose
from the front, do not also squeeze the base of the splint so
as to avoid in-fracture. Use the splint to close the roof. Apply
taping and splinting to prevent swelling from adversely
affecting the surgical outcome. Apply taping fitting the con-
tours of the nasal tip. You can protect the facets by placing
small tapes. Excessively tight taping can cause necrosis and
destroy the shape of the cartilages.
Taping the eyelids may decrease bruising. Squeeze the cast gently at the base.
Apply a cold gauze on the external splint.

23.3 Taping and Splinting 699
23.3.1 Prevent Fossa Formation Under Domes
If the incisions of the middle and lateral crura get in contact

because of tightening the tip with tapes, the two incisions may
adhere. A fossa forms behind the adhesion. Nasal hair grows in
this area and bad smelling dirt may accumulate. Fossa formation
is rarely seen with closure of the incisions and proper taping.
Avoid tapes crossing the nostrils.

23.4 Postoperative Care
Keeping the patient’s head positioned at an angle of 30° is

usually sufficient. It is not necessary to apply cold. If you are
meticulous with the surgical steps, you should rarely see any
bruising. With the right techniques, it is virtually impossible
to damage large vessels. It is very difficult avoiding an injury
to a vessel with 4–5 mm lateral osteotomy chisels. Tape the
lower eyelid when the surgery is finished to take edema
under control. If the periosteum is not torn at the dissection
border, bruising and edema rarely happen at the upper eye-
lids. When removing the internal splint, you can also shorten
the tapes that are placed on the lower eyelids. You can remove
the external splint on the tenth day and place tapes for five
more days.
The mucosa of the domes should stay open like the fol-
lowing photograph.
Note
I follow my patients in the hospital for at least 6 h. On
the fourth day, I remove the silicones and drains. I
remove the external thermoplastic splint on day 10–12.
I do not usually make additional taping. I urge you to
check the bones in 20 days.
Patient Example
Below you can see the 2-day post-op photo of a patient who
had ostectomy and hump removal.
Below you can see the appropriate taping and plaster.
The internal splints were removed and the tapes on the

eyelid shortened.
23.4 Postoperative Care 701
Ten-day post-op, with the external splint removed. Patient’s photographs before and 10-day post-op.
One-month post-op photos of the same patient.

23.4 Postoperative Care 703
The post-op prescription and recommendations vary 23.5 Prescription After Rhinoplasty
greatly between surgeons. I will write my own personal
preference. 1. Dexketoprofen 25 mg 2 X1.
2. Low pressure application of saline with bicarbonate.
3. Oxymetazoline spray, for 5 days, in the evenings, if there
is nasal congestion.
23.4.1 Postoperative Order
Head elevation
23.6 Recommendations After rhinoplasty
%5 Dextrose Lactate Ringer solution 500 cc/4 h
Zofer® (Ondansetron HCl), 4 mg iv
• Sleep with three pillows for 5 days.
Perfalgan® (paracetamol), 1 g iv
• Avoid warm environments.
Liquid diet 2 h after surgery and mobilization at 4 h
• Avoid movements that can elevate blood pressure. Do not
bend the head.
For prophylaxis, 1 g of Cefazolin Sodium is administered
• Try to stay in a vertical position when not sleeping.
intravenously 30 min prior to anesthesia. I have not been pre-
• You can take a shower for 2–3 min. Water will not harm
scribing post-op antibiotics for the past 10 years in primary
the plastic splint. The splint can get wet.
rhinoplasty. In patients where I use ear or rib cartilage grafts,
• If swelling occurs, apply cold compress.
I prescribe Augmentin® (amoxicillin/clavulanate potassium)
• From the tenth day on, you can consume green tea or
1 g, PO twice a day for 5 days.
parsley to remove edema.
Case Studies
24
Abstract Patient Example

Thin-skinned and over-projected nose.
Case studies are important to understand the decision
Closed tip surgery; lateral crural steal 4 mm; spreader flap
making in rhinoplasty. In this chapter, different case
for dorsal reconstruction.
examples, the outlines of the surgeries, and postoperative
Seven-year post-op result.
results can be found.
I do not have vast experience with spreader flaps, so some
of my spreader flaps resulted in supratip widening. The tip is
nice in such a thin-skinned patient after 7 years.
706 24 Case Studies
24 Case Studies 707
708 24 Case Studies
24 Case Studies 709
Patient Example closed tip surgery, lateral crural steal 3 mm, caudal septum
Thin-skinned nose. and upper lateral cartilage (ULC) caudal resection 5 mm;
Tip projection is increased 1 mm; nostril-apex projection Libra graft for dorsal reconstruction.
(NAP) is same; lobule projection (LP) increased 2–3 mm; Three-year post-op results.
710 24 Case Studies
24 Case Studies 711
712 24 Case Studies
Patient Example
Thick-skinned patient with a high radix. Tip projection (TP)
is high because of high NAP. LP is normal.
Lateral crural steal 3 mm; medial crural overlap 2 mm;
ULC caudal resection 2 mm; osseocartilaginous dorsal pres-
ervation (DP) with high septal strip.
Two-year post-op results.
24 Case Studies 713
714 24 Case Studies
24 Case Studies 715
716 24 Case Studies
Patient Example
Bulbous tip, moderate thickness skin, left axis deviation, tip
asymmetry.
Lateral crural steal, right 6 mm, left 4 mm; medial crural
overlap 2 mm; rim flap 2 mm; lateral crural caudal resection
1 mm; symmetrical osseocartilaginous DP with high septal
strip.
24 Case Studies 717
718 24 Case Studies
24 Case Studies 719
720 24 Case Studies
24 Case Studies 721
Patient Example overlap 3 mm; spreader flap to the right side, Sheen spreader
Hanging columella, bulbous tip, thin skin, tip asymmetry. graft to the left side.
Rim flap 2 mm; lateral crural caudal resection 2 mm; min- Four-year post-op results.
imal cephalic trim; lateral crural steal 5 mm; medial crural
722 24 Case Studies
24 Case Studies 723
724 24 Case Studies
Patient Example deprojection 1–2 mm; asymmetrical osseocartilaginous DP

Moderate thickness skin, right axis deviation, bulbous tip. with high septal strip.
Rim flap 2 mm; cephalic resection 3 mm; lateral crural One-and-a-half-year post-op results.
steal, left 5 mm, right 4 mm; medial crural overlap, 3 mm;
24 Case Studies 725
726 24 Case Studies
24 Case Studies 727
728 24 Case Studies
Patient Example 5 mm, left 2 mm; additional rim grafts; Libra graft for dorsal
Thin-skinned nose with severe left axis deviation, bulbous reconstruction; left nasal base augmentation.
tip. Five-year post-op results.
Rim flap 2 mm; cephalic resection 1 mm; lateral crural
steal, left 4 mm, right 7 mm; medial crural overlap, right
24 Case Studies 729
730 24 Case Studies
24 Case Studies 731
732 24 Case Studies
Patient Example reconstruction; skin resection from the caudal free margin of
Moderate thickness skin, high radix, retruded forehead and the nostril; fat injection to the forehead and cheek.
cheek, bulbous tip, hanging ala. Seven-year post-op results.
Rim flap 3 mm; cephalic resection 3 mm; lateral crural
steal 2 mm; ULC caudal trim 3 mm; Libra graft for dorsal
24 Case Studies 733
734 24 Case Studies
24 Case Studies 735
Patient Example
Thin-skinned, over-projected nose with left axis deviation.
Lateral crural steal, left 2 mm, right mm; medial crural
overlap 3 mm; high septal strip osseocartilaginous dorsal
preservation.
Two-and-a-half-year post-op results.
736 24 Case Studies
24 Case Studies 737
738 24 Case Studies
24 Case Studies 739
Patient Example
Moderate thickness skin with low TP, low NAP and low LP.
Lateral crural steal 2 mm; no dorsal reduction; radix and
premaxillary augmentation; ULC caudal resection 6 mm.
Eleven-month post-op results.
740 24 Case Studies
24 Case Studies 741
742 24 Case Studies
24 Case Studies 743
Patient Example
Moderate thickness skin with droopy tip and convex lateral
crura.
Lateral crural steal 5 mm; lateral crural turnover flap
(Göksel); Libra graft for dorsal reconstruction.
One-and-a-half-year post-op results.
Note
Writing a book is so informative for the author as well.
With the below patient example, I realized that I have
to focus more to straighten the lateral crura with slid-
ing (Özmen) [43], turn-under (Tellioğlu) [44], or turn-
over (Göksel) [45] flap techniques.
744 24 Case Studies
24 Case Studies 745
746 24 Case Studies
24 Case Studies 747
Patient Example
Thick-skinned nose, left axis deviation, droopy tip.
Lateral steal, right 4 mm, left 3 mm; two strut grafts, C
graft; Libra graft.
Five-year post-op results.
748 24 Case Studies
24 Case Studies 749
750 24 Case Studies
Patient Example
Medium thickness skin, hump, droopy tip.
Classic dorsal resection; Libra graft; lateral crural steal,
4 mm; medial crural overlap, 2 mm; Pitanguy ligament pre-
served; scroll ligament repaired.
Six-year post-op.
The shape obtained in the immediate post-op period has
not changed in 6 years. Thanks to preserving the Pitanguy
ligament, the elasticity of the tip of the nose is not lost.
24 Case Studies 751
752 24 Case Studies
24 Case Studies 753
754 24 Case Studies
24 Case Studies 755
Patient Example
Thin-skinned nose.
Hump resection; Libra graft; lateral crural steal, 4 mm;
medial crural overlap, 2 mm.
756 24 Case Studies
24 Case Studies 757
Facet polygon improved with rim flap technique.

758 24 Case Studies
24 Case Studies 759
Patient Example
Thin-skinned nose with high TP and high NAP.
Rim flap 2 mm; caudal resection 1 mm; lateral crural steal
4 mm; ULC caudal resection 2 mm; Libra graft for dorsal
reconstruction; elliptical resection from nostril base.
Three-year post-op results.
760 24 Case Studies
24 Case Studies 761
762 24 Case Studies
24 Case Studies 763
764 24 Case Studies
Patient Example
Thin-skinned small nose with right axis deviation.
Rim flap, 2 mm; lateral crural steal, left 3 mm, right
2 mm; ULC caudal resection, 2 mm; high septal strip osseo-
cartilaginous dorsal preservation.
24 Case Studies 765
I performed a revision surgery 3 years after the primary

surgery because of recurrence of hump and axis deviation. I
opened the cartilaginous dorsal roof, rasped the bones, and
used camouflage. I didn’t touch the tip.
Below you can see 3-month post-op results after
revision.
766 24 Case Studies
24 Case Studies 767
768 24 Case Studies
Patient Example
Thin-skinned nose with low LP, high NAP, normal TP, and
C-type dorsal deviation.
Rim flap, 2 mm; caudal resection, 2 mm; cephalic resec-
tion, 3 mm; lateral crural steal, 7 mm; medial crural overlap,
4 mm; ULC caudal resection, 2 mm; Libra graft for dorsal
reconstruction; fat injection to the forehead, cheek, and chin.
Six-year post-op results.
24 Case Studies 769
770 24 Case Studies
24 Case Studies 771
772 24 Case Studies
24 Case Studies 773
Patient Example 3 mm; ULC caudal resection, 4 mm; Sheen spreader graft for
Thin-skinned nose with low LP, high NAP, low TP, and left dorsal reconstruction.
axis deviation. Three-and-a-half year post-op results.
Rim flap, 2 mm; caudal resection, 2 mm; cephalic resec-
tion, 4 mm; lateral crural steal, 4 mm; medial crural overlap,
774 24 Case Studies
24 Case Studies 775
776 24 Case Studies
24 Case Studies 777
Patient Example
Thin skin patient.
Lateral crural steal, 4 mm; classic dorsal resection; Libra
graft reconstruction.
Nine years after rhinoplasty, 7 years after fat injection to
the forehead, cheek, and chin.
778 24 Case Studies
24 Case Studies 779
780 24 Case Studies
24 Case Studies 781
The patient asked for more rotation and a narrower nose. No tip
surgery was performed. Mucosal resection from the membra-
nous septum, premaxilla augmentation, and lateral osteotomies
without dorsal surgery. Twenty days after surgery.
782 24 Case Studies
Patient Example
Thin-skinned patient with lateral crural caudal excess.
Rim flap, 2 mm; caudal resection, 2 mm; lateral crural
steal, 3 mm; ULC caudal resection, 2 mm; hump treated high
septal strip osseocartilaginous preservation.
24 Case Studies 783
784 24 Case Studies
24 Case Studies 785
References
1. Çakir B, Doğan T, Öreroğlu AR, Daniel RK (2013) Rhinoplasty: 21. Saban Y, Daniel RK, Polselli R, Trapasso M, Palhazi P (2018)
surface aesthetics and surgical techniques. Aesthet Surg J Dorsal preservation: the push-down technique reassessed. Aesthet
33(3):363–375 Surg J 38(2):117–131
2. Sheen JH, Sheen AP (1987) Aesthetic rhinoplasty, 2nd edn. CV 22. Valerio F, Rollin K, Daniel RK, Palhazi P (2020) Modified SPQR
Mosby, St Louis, MO Cottle rhinoplasty. In: Preservation rhinoplasty, 3rd edn. Septum
3. Gottschalk GH (1955) The transverse osteotomy: a new rhinoplastic Publisher, Istanbul
technique. AMA Arch Otolaryngol 62(3):322–325 23. Ishida LC, Ishida J, Ishida LH, Tartare A, Fernandes RK, Gemperli
4. Isik S, Sahin I (2012) Contour restoration of the forehead by lipofill- R (2020) Nasal hump treatment with cartilaginous push-down and
ing: our experience. Aesthetic Plast Surg 36(4):761–766 preservation of the bony cap. Aesthet Surg J 40(11):1168–1178
5. Yaremchuk MJ (2003) Improving aesthetic outcomes after alloplas- 24. Santos M et al (2019) Spare roof technique in reduction rhinoplasty:
tic chin augmentation. Plast Reconstr Surg 112(5):1422–1432 prospective study of the first one hundred patients. Laryngoscope
6. John B (2008) Tebbetts primary rhinoplasty: redefining the logic 129:2702–2129
and techniques. Elsevier Mosby, St. Louis 25. Neves JC, Arancibia Tagle D, Dewes W, Ferraz M (2021) The seg-
7. Benlier E, Top H, Aygit AC (2006) Management of the long nose: mental preservation rhinoplasty: the split Tetris concept. Facial
review of techniques for nasal tip supporting structures. Aesthet Plast Surg 29:85–99
Plast Surg 30(2):159–168 26. Johnson CM Jr, Godin MS (1995) The tension nose: open structure
8. Gruber RP, Belek KA, Barzin A (2012) Commentary on: a com- rhinoplasty approach. Plast Reconstr Surg 95(1):43–51
plete subperichondrial dissection with management of the nasal 27. Denenberg S (2018). http://www.facialsurgery.com. http://www.

ligaments. Aesthet Surg J 32(5):575–577 facialsurgery.com/ClkoffTPgt3_2011_12_01mh.html
9. Çakır B, Oreroğlu AR, Doğgan T, Akan M (2012) Rhinoplasty: a 28. Ozmen S, Eryilmaz T, Sencan A, Cukurluoglu O, Uygur S, Ayhan S,
complete subperichondrial dissection with management of the nasal Atabay K (2009) Sliding alar cartilage (SAC) flap: a new technique
ligaments. Aesthet Surg J 32(5):564–574 for nasal tip surgery. Ann Plast Surg 63(5):480–485
10. Arslan E, Gencel E, Pekedis O (2012) Reverse nasal SMAS-
29. Dosanjh AS, Hsu C, Gruber RP (2010) The hemitransdomal suture
perichondrium flap to avoid supratip deformity in rhinoplasty. for narrowing the nasal tip. Ann Plast Surg 64(6):708–712
Aesthet Plast Surg 36(2):271–277 30. Pshenisnov KP (2015) Commentary on “comparison of various
11. Karacalar A, Korkmaz A, Içten N (2005) A perichondrial flap for rhinoplasty techniques and results of long-term”. Aesth Plast Surg
functional purposes in rhinoplasty. Aesthet Plast Surg 29(4):256–260 39:478–482
12. Cerkes N (2013) Concurrent elevation of the upper lateral carti- 31. Çakır B, Akan M (2019) Indications and techniques for increas-
lage perichondrium and nasal bone periosteum for management ing and decreasing tip projection in closed rhinoplasty. In: Chung
of dorsum: the perichondro-periosteal flap. Aesthet Surg J 33(6): KC et al (eds) Operative techniques in plastic surgery first, vol 1.
899–914 Wolters Kluwer, Philadelphia, PA, pp 276–282
13. Huizing EH, de Groot JAM (2015) Functional reconstructive nasal 32. Sheen JH, Sheen AP (eds) (1998) Aesthetic rhinoplasty, 2nd edn.
surgery. Thieme, Stuttgart Quality Medical, St. Louis
14. Bairati A, Comazzi M, Gioria M (1996) A comparative study
33. Daniel RK et al (2014) Rhinoplasty: the lateral crura-alar ring.
of perichondrial tissue in mammalian cartilages. Tissue Cell Aesthet Surg J 34(4):526–537
28(4):455–468 34. O’Halloran LR (2003) The lateral crural J-flap repair of nasal valve
15. Macé B (2008) Histologie. Omniscience, Paris collapse. Otolaryngol Head Neck Surg 128(5):640–649
16. Çakır B, Finocchi V, Tambasco D, Öreroğlu AR, Doğan T (2016) 35. Toriumi DM, Checcone MA (2009) New concepts in nasal tip con-
Osteoectomy in rhinoplasty: a new concept in nasal bones reposi- touring. Facial Plast Surg Clin North Am 17(1):55–90
tioning. Ann Plast Surg 76(6):622–628 36. Foda HM (2011) Alar base reduction: the boomerang-shaped exci-
17. Turgut G, Soydan AT, Baş L (2010) A new technique for creat- sion. Facial Plast Surg 27(2):225–233
ing spreader and septal extension grafts. Plast Reconstr Surg 37. Sheen JH, Sheen AP (eds) (1998) Aesthetic rhinoplasty, 2nd edn.
126(5):252–254 Quality Medical Publishing, St. Louis
18. Gryskiewicz JM (2005) Visible scars from percutaneous osteoto- 38. Millard R (1996) A rhinoplasty tetralogy: corrective, secondary,
mies. Plast Reconstr Surg 116(6):1771–1775 congenital, reconstructive. Little, Brown and Company, Boston
19. Orak F, Baghaki S (2013) Use of osseocartilaginous paste graft for 39. Tellioğlu AT, Özakpinar HR, Cakir B, Tekdemir I (2011) Importance
refinement of the nasal dorsum in rhinoplasty. Aesthetic Plast Surg of the levator labii alaeque nasi muscle in dorsal septal deviations. J
37(5):876–878 Craniofac Surg 22(2):446–449
20. Öreroğlu AR, Çakır B, Akan M (2014) Bone dust and diced carti- 40. Gubisch W (2006) Twenty-five years experience with extracorpo-
lage combined with blood glue: a practical technique for dorsum real septoplasty. Facial Plast Surg 22(4):230–239
enhancement. Aesthetic Plast Surg 38(1):90–94
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 787
B. Çakır, Aesthetic Septorhinoplasty, https://doi.org/10.1007/978-3-030-81861-6
788 References
41. Taştan E et al (2013) The oblique split method: a novel tech- cephalic malposition of lower lateral cartilage. Facial Plast Surg
nique for carving costal cartilage grafts. JAMA Facial Plast Surg 33(5):491–498
15(3):198–203
42. Erol OO (2000) The Turkish delight: a pliable graft for rhinoplasty.
Plast Reconstr Surg 105(6):2229–2241; discussion 2242–3
43. Ozmen S et al (2009) Sliding alar cartilage (SAC) flap: a new tech- Further Reading
nique for nasal tip surgery. Ann Plast Surg 63(5):480–485
44. Tellioglu AT, Cimen K (2007) Turn-in folding of the cephalic

Çakir B (2016) Aesthetic septorhinoplasty. Springer, Heidelberg
portion of the lateral crus to support the alar rim in rhinoplasty.
Daniel RK, Palhazi P (2018) Rhinoplasty: an anatomical and clinical
Aesthetic Plast Surg 31(3):306–310
atlas. Springer, Heidelberg
45. Goksel A, Vladykina E (2017) Oblique turnover flap for reposition-
ing and flattening of the lateral crura: a novel technique to manage
Index
A Cone beam, 337, 341

Adjusting tip position, 211 Consultation, 4, 9, 56, 379, 687
Airway, 107–109, 129, 219, 220, 292, 302, 305, 687 Contour grafts, 89, 93, 424, 437, 530
Alar retraction, 391, 398, 651 Convex hump, 337
Alar rim resection, 184, 589 Convex lateral crura, 119, 397
Analysis, 70, 85, 141, 310 Convex shape, 108, 120, 488, 503
Anterior maxillary spine, 209, 225, 271, 272, 389, 451, 538, 620, 625 Cottle elevator, 217, 269, 271, 519, 662
Archiving, 14, 55 C’ point, 11, 63, 89, 90, 92, 386, 438–440, 539
Arkansas stones, 152 Crile retractor, 145
Arrhythmias, 208 C’ suture, 391, 438–440, 446, 447, 482, 539, 629, 677
Aufricht retractor, 238
Auto-rim flap, 55, 106, 108, 122, 141, 230, 231, 233, 391, 394,
397–401, 403, 406, 412, 417, 424, 503–505, 508, 628, 629, D
671, 672, 687, 689 Daniel, Rollin, 143, 210
Ayhan PPE forceps, 154 Daniel-Cakir elevator, 240
Dead space, 126
Deep inhalation, 93
B Deep inspiration, 100
Backups, 57 Definition, 13, 251, 253, 488, 520, 532, 533
Bone scissors, 147, 271, 280, 281, 311, 344, 350, 538, 630 Degussit, 152
Bone surface problems, 302 Deviated nose, 619–648
Bony hump, 256, 279, 336–338, 350 Dexketoprofene, 704
Boomerang shaped Peck graft, 531 Diced cartilage, 324, 655
Bruising, 158, 170, 302, 698, 700 Dissection of the Upper Lateral Cartilage Mucosa, 277–278
Bulbosity, 11, 20, 22, 106, 397 Dome divergence, 88
Dome equalization, 391, 432
Dome symmetry test, 426, 427, 628
C Dome triangles, 78–80, 84, 85, 88, 432, 434, 464, 530
Çakır 90 chisel, 293, 631, 650 Dorsal aesthetic lines, 8, 11, 12, 62, 129, 130, 132, 136–138, 183,
Çakır polygons, 76 310–312, 319, 336, 372, 678
Cartilage chips, 650, 652, 655 Dorsal bone polygon, 79, 128, 323
The cartilage edges, 70, 233 Dorsal bone resection, 280–283
Cartilage hump, 279, 319, 331 Dorsal cartilage polygon, 79, 126, 128, 129
Cartilage only dorsal preservation, 336, 337, 350, 372 Dorsal cartilage resection, 147, 278–280
Cartilage paste, 664 Dorsal fixation, 344, 353–355
Caudal edge of the lateral crus, 7, 93, 95, 97, 105, 395, 399, Dorsal preservation, 149, 228, 269, 335–339, 361, 365–369, 374, 377,
498, 504 427, 648
Caudal septum, 129, 208, 225–227, 271, 341, 379, 518, 546– Dorsal resection technique, 336
548, 554–556, 632, 671 Dorsum retractor, 145, 325
Cephalic dome suture, 84, 85, 97, 119, 123–125, 141, 391, 413, Drains, 696, 697, 700
415, 424, 428–431, 448, 461–463, 478, 480, 482, 505, Drawing, 61, 62, 70, 79, 85, 102, 127, 192, 273, 292, 311, 412, 438,
520, 629, 671, 676 489, 561, 568, 589
Cephalic malpositioning, 119
Cephalic resection, 95, 129, 264, 394, 397, 400, 406, 413, 414, 424,
473, 505, 671, 672, 677, 687 E
Çerkeş scissors, 228 The ellipse model, 417, 419, 430
C graft, 515, 540 Esson, Micheal, 210
Chondroblasts, 264, 265 External osteotomies, 152
Chondrocytes, 265 External valve, 99, 500, 504, 508
Collapse, 85, 100, 106, 129, 263, 287, 323, 347, 498 Extra columellar strut, 515, 543, 544
Columellar polygon, 90–92, 433, 434, 438, 440–442, 524, 629, 677 Extracorporeal correction, 273
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 789
B. Çakır, Aesthetic Septorhinoplasty, https://doi.org/10.1007/978-3-030-81861-6
790 Index
F L
Facet, 79, 89, 96 Landecker, Alan, 207
Facet polygon, 7, 79, 82, 84, 85, 92, 93, 95, 97, 105, 106, 141, 231, Lateral aesthetic lines, 62, 139–141, 305
391, 394, 395, 397–399, 401, 403, 405–407, 409, 430, 431, Lateral bone polygons, 79, 129
502, 508, 522, 612, 629, 672 Lateral crural caudal excess, 409, 687
Fat injection, 170, 171, 173, 176, 179, 184, 187, 193, 195, 200, 202, Lateral crural cephalic strut graft, 677
203, 512 Lateral crural preservation, 415
Fibrous perichondrium, 265 Lateral crural resection, 391, 413, 415, 472, 671
Figure-of-eight suture, 391, 432, 435, 442, 482 Lateral crural steal, 211, 213, 231, 386, 389–391, 397, 399, 413, 417,
Fine hooks, 149 420, 422, 424, 425, 428, 430, 448, 469, 471–473, 493, 494,
Fish-eye photos, 20, 26 628, 629, 675, 676
Fixing the silicone splints, 696 Lateral crural subperichondrial dissection, 233–237
Focus point, 22 Lateral crus, 82, 84, 92, 93, 95, 97, 99, 100, 105–110, 112–114, 119,
Footplate, 62, 90–92, 213, 232, 271, 387, 389, 390, 420, 120, 122, 123, 125, 126, 148, 149, 202, 230–233, 237, 243,
422, 424, 430, 433, 451, 469, 471, 515–518, 537, 253, 380, 386, 387, 389, 390, 394, 397–399, 401, 404,
568, 569 413–415, 417, 420, 424–426, 429, 431, 443, 457, 461,
polygon, 91 478–480, 487–490, 493, 496, 499, 501–505, 507, 508, 588,
setback, 386, 390, 420, 425 620, 629, 668, 671, 672, 675, 676, 690
Foot-prints, 14 polygon, 79, 93, 97, 123, 394, 506
Forehead fat grafting, 170 resting angle, 85, 93, 97, 100, 105, 123, 125, 141, 413
Forehead fat injection, 170, 182, 183, 187, 195 Lateral keystone dissection, 349, 350
4 mm chisel, 221, 271, 280, 281, 538 Lateral osteotomy, 150, 263, 285, 288–292, 350, 352, 360, 700
Lateral strut crural graft, 109, 652, 656, 659, 662, 684
Length, 448
G Libra graft, 130, 141, 311–319, 325, 326, 330, 331, 625, 632–634
Glabellar edema, 283 Light, 7, 14, 15, 22, 23, 27, 82, 87, 114, 128, 130, 154, 210, 211, 397,
Göde, Sercan, 215 406, 587
Gottschalk, Howard, 153 Lighting, 14, 16, 20, 22, 23, 130, 210–211, 420, 488, 501
Greenstick fracture, 301, 352, 625 Limited dissection, 302, 376
Gubisch, 208 Lobule projection (LP), 448, 469–473, 533, 558
Lobule stabilization suture, 391
Local anesthetıc ınfıltratıon, 205–213
H Long lateral crura, 106, 116, 478, 687
Hanging columella, 431, 444, 548, 651, 671, 672, 676, 684 Loop suture, 316, 391, 432, 434–438, 462, 627, 677
Headlamp, 154, 211 Low septal strip, 269, 336, 339–353, 356, 360, 361, 373, 648
Hemitransfixion incision, 225, 554 L-septoplasty, 269, 625
High-low-high osteotomy, 287
High septal strip, 336, 339, 340, 344–351, 354, 370, 372
Horizontal mattress suture, 85, 273, 316, 442, 506, 557 M
100 mm macro lens, 4, 14, 15, 20 Macintosh, 36, 38
Magnetic instrument mat, 144
Marginal incision, 225, 551
I Mass polygons, 79, 97
Illusion, 15, 119, 192, 487 Maxillary spine resection, 470, 538
Imaging, 9, 27, 31, 32, 35, 36, 43, 44, 46–48, 52, 341 ṃÇakır 90 chisel, 263
Increasing dome definition, 520–521 Medial crura, 82, 89, 90, 126, 235, 253, 424, 433, 434, 437, 440, 441,
Inflammation, 159, 165, 166, 263 447, 456, 548, 554, 628, 671
Infracartilaginous incision, 229, 230, 550 Medial crural overlap, 213, 391, 424, 443–453, 456–458, 461–465,
In-fracture, 43, 221, 289, 297, 301, 302, 309 471, 472, 481, 494, 506
Infralobular polygon, 79, 89, 90, 93, 520, 521 Mucosal bleeding, 209
Infralobule, 448 Mucosal laceration, 146, 355
caudal contour grafts, 524, 526
length, 386
Injection points, 208–210 N
Intercartilaginous incision, 225, 287, 550, 634 Narrow nasal base, 337
Interdomal triangle, 78, 86, 89 Nasal cartilages, 15, 70, 264, 623
Internal valve, 99, 126, 129, 209, 225, 264, 277, 278, 301, 302, 318, Nasal packings, 205
424, 473, 549 Nasal speculum, 144
Intraoperative photographs, 15 Needle holder, 146, 354
Inverted-V deformity, 301 Nose tip cartilages, 99, 141
Işık, Selçuk, 170 Nostril apex projection (NAP), 420, 469–473, 515, 537–540
ISO setting, 22
O
K Oblique split rib grafts, 656
Keystone area, 127, 130, 237, 311, 350, 360 Open roof, 128, 285–288, 298, 300–302, 338, 350
Index 791
Oral isotretinoin, 159, 160, 165 Scoring, 106, 124, 346, 625, 632, 648, 652
treatment, 159, 160, 165 Scroll facet, 123–125, 141, 507
Osseocartilaginous dorsal preservation, 336, 350–353 Scroll ligament, 126, 225, 229, 235, 243, 264, 361, 471, 549–551,
Ostectomy technique, 291, 293–295, 301, 309, 325 553, 648
Osteotomy of the radix, 353 Scroll line, 8, 97, 126, 488, 509
Oxymetazoline, 704 Scroll repair, 550, 551
Sculpture, 61, 68, 76, 79
Septal angle, 99, 126, 127, 141, 209, 225, 228–230, 247, 248, 250,
P 254, 277, 316, 353, 379, 389, 432, 531, 546, 547, 552, 553,
Palhazi, Peter, 222 557, 558, 622, 667
Parenthesis tip, 119, 379, 487 Septal extension graft, 471, 473, 548
Patient position, 206 Septoplasty, 205, 267–275, 341, 556, 625–628, 648
Perichondrial graft, 660, 662 Septum scissors, 147, 345, 355
Perichondrium, 89, 90, 108, 119, 126, 146, 148, 209, 220, 226–229, Sesamoid cartilage, 235, 243, 264, 443, 549
233–236, 238, 240–245, 247, 254, 255, 263–266, 268, 269, Setting the dorsal height, 285
277, 311, 347, 348, 350, 434, 470, 532, 539, 546–549, 555, Shield grafts, 77, 78, 532, 660
557, 625, 656, 662, 668 Shutter speed, 22
Periosteal dissection, 148, 237–241, 256 Skin care, 158
Permanent pigmentation, 152 SLR camera, 14
Perpendicular plate of ethmoid bone (PPE), 154, 209, 269, 272, 338, SMAS, 89, 245, 248, 263–265, 442, 550
339, 341, 342, 344, 347, 351, 353 Soft box, 14, 22, 23
Photography, 4, 9, 14, 22, 27, 43, 44, 46–48, 52, 56, 587, 687 Soft tissue pillow, 247
angles, 9–14 Space polygons, 79, 89, 90
Photoshop, 27, 41, 43, 87, 211, 419, 443, 470 Spreader graft, 127, 128, 273, 311, 318, 319, 325, 424, 473, 524, 632,
analysis, 213 652, 661, 662, 678
Pinched nose, 93, 651, 652, 671, 687, 697 Stabilization of the nasal tip, 545–558
deformity, 93, 499, 687, 689, 690 Stretching the lateral crus, 109
Pitanguy ligament, 126, 141, 225–227, 242–244, 247–252, 255, 264, Strut graft, 89, 100, 109, 250, 342, 346, 391, 424, 433–442, 463, 471,
341, 376, 432, 436, 437, 509, 515, 524, 531, 546, 548, 549, 482, 506, 533, 543, 544, 629, 659, 677
552–554, 558, 629 Subperichondrial dissection, 108, 119, 120, 127, 143, 145, 209,
Plunging nasal tip, 389 233–237, 241–242, 244, 253, 255, 263–266, 429, 548, 552,
Polygon, 13, 61, 68, 69, 76, 79, 80, 85, 88, 90, 93, 96, 99, 100, 105, 625, 690
107, 112, 119, 124–127, 130, 134, 139, 141, 242, 299, 310, in open approach, 253–263
317, 326, 330, 331, 379, 397, 399, 422, 432–435, 438, 440, Sub-SMAS dissection, 244, 263, 264, 350
442, 449, 451, 452, 457, 482, 494, 495, 502, 505, 507, 515, Superficial SMAS, 90, 242, 244, 253, 434, 441, 553
522, 524, 553, 660 Supraalar groove, 488, 490, 496–498
Posterior strut technique, 227, 267, 515, 554 Supra-tip breakpoint, 176
Post-operative order, 704 Supratip depression, 347
Premaxillary augmentation, 471 Supratip graft, 515
Prescription after rhinoplasty, 704 Surgical lights, 210
Pressure of the intubation tube, 206 Swinging door septoplasty, 336, 648
Preventing alar retraction, 672
Pseudo-cephalic malposition, 490, 491, 494
Pulse and blood pressure, 207 T
Taping and splinting, 210, 697
Taştan’s, Eren, 153
R Taştan-Çakır saws, 153
Radiofrequency, 215, 220, 221 Tellioğlu, Ali Teoman, 210
Radix reduction, 149 Test dome symmetry, 429
Rasp, 129, 148, 149, 280, 283, 291, 293, 300, 350, 630 Thick and long nasal bones, 338
Recording program, 55 Tip breakpoints, 77, 79
Recurrent hump, 338, 376 Tip camouflage, 515, 543
Re-drape problems, 302–305 Tip grafts, 241, 389, 390, 417, 420, 464, 471, 515, 524, 531, 660, 687,
Repairing the superficial SMAS, 553–554 689
Repositioning, 119, 120, 123, 387, 487, 488, 493, 576 Ti point, 79, 86, 88, 428, 524, 530
Respiration, 99 Tip projection (TP), 43, 390, 406, 420, 424, 430, 444, 451, 469–473,
Revision surgery, 159, 250, 305, 307, 338, 437, 512, 671 512, 530, 546
Rib cartilage, 650, 656, 662, 664, 704 Tip rotation, 129, 415, 420, 469–473, 493, 554
Rim grafts, 88, 93, 97, 100, 150, 397, 399, 431, 499, 507, 515, 544 Tip shadows, 183
Rongeur, 150, 344, 347, 349, 352, 538 Topographic problems, 129
Ropivacaine, 208 Transdomal suture, 84, 85, 93, 95, 125, 428, 431, 515, 520, 521
Transfixion incision, 225–227, 267, 272, 341, 516, 517, 546, 551, 554
Transparent tape, 210
S Transverse osteotomy, 153, 287, 290–291, 298, 300, 338, 348,
Saban, Yves, 222 351, 352
Scar, 62, 266, 423, 554, 555, 560, 563, 566, 568, 575, 616 Ts point, 79, 86, 88, 530
792 Index
Turbinate, 215, 216, 218–221, 339, 341 W

bone, 220, 221 WASA segment, 347
SMR, 153, 215–223 Webster’s bone triangle, 139
2 mm chisel, 217, 263 Webster triangle out-fracture, 221
Weil-Blakesley thru-cut forceps, 217
Wide bony dorsum, 337
U Wide lateral crura, 106, 662
Unsuccessful osteotomy, 302 Windows, 36, 38
Upper lateral cartilage (ULC), 79, 97, 99, 126, 128, 129, 148, 225, Wrong resting angle, 119, 487
228, 229, 237, 254, 266, 277–279, 282, 314, 317, 318, 336,
340, 341, 349, 376, 387, 389, 394, 398, 413, 415, 473, 497,
549–551, 620, 622–624, 631–634, 668, 671, 672, 675
X
Xylometazoline nasal spray, 205
V
Vertical compression test, 99, 100
Vertical scroll reinsertion, 549–552 Y
Vomer, 154, 272, 339–341, 379, 387, 424, 648 Yaremchuk, 187

Barış Çakır - Aesthetic Septorhinoplasty-Springer (2021) PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Barış Çakır - Aesthetic Septorhinoplasty-Springer (2021) PDF

Uploaded by

Copyright:

Available Formats

Barış

Editing and translation by Bülent Genç

ISBN 978-3-030-81860-9 ISBN 978-3-030-81861-6 (eBook)

Newport Beach, CA, USA Rollin K. Daniel

Istanbul, Turkey Bülent Genç

About the Second Edition

Part I Before Surgery

12.10.13 Complications: Case #1��������������������������������������������������������������������� 374

18.3.2 Expanding the Interdomal and Infralobular Polygons��������������������������� 521

Documentation of patient information is very important

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 3

The parabolic dorsal aesthetic lines stand out in the case

Please notice the relationship between the lateral supratip

You should employ a photographic standard. The more

1.1.2 Photography Angles

Both ears should be equally visible in the frontal view. The

Photos when smiling give an idea about muscle activity.

Aligning the nasal tip with the cheek contour is an easy

In the side view, facial profile is evaluated. The C point

Photographs while smiling show nasal tip dynamics.

The nose should play along with facial gestures. Dorsal

My art teacher once asked me why some operated noses

1.2 The Photography System

Obtain an intermediate-level SLR camera. A proper lens

1.2.1 Intraoperative Photographs

I have been taking photos of the structure of nasal cartilages

1.2.2 Light Illusions

The positions of the lights, the patient, and you should be

This is another example where the only difference is the

Below you can see the preoperative and postoperative

1.3 Camera Settings 1.3.1 Focus Settings

1.3.2 ISO 1.3.6 Color Settings

1.3.3 Shutter Speed

It shows how long the diaphragm stays open. If the shutter

are big in photos. You should know what a fish-eye problem

1.3.9 Video Camera 1.4 Imaging

Open the file.

Choose the nose with Rectangular mask.

Open the Liquify filter.

Design a nose that fits the face.

Practice it a few times and correct it over and over again.

Work on tip details.

You can use smaller masks for working in detail.

In the following photograph, two layers are formed. In

Add “plan” to the name filename and save.

1.5  he Importance of Photography

noses that you find beautiful by 90° and examine them.

As I am left-handed, I stay on the left of the patient to

Do not start operating without imaging. I never operate

Same patient’s 3-year post-op photographs.

Make regular backups. The photo archive of a plastic sur-

You cannot perform a good surgery unless you draw the

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 59

2.1 Exercises During rhinoplasty courses in Turkey, we organize

2.1.1 Sketch from the Front

• The nose tip consists of three circles. The middle circle

Draw the nostril sill to understand its anatomy well. See

• Investigate the fusiform structure that the nose dorsum

2.1.2 Sketch from the Side

• Determine the length and height of the nose. Determine

2.1.3 Sketch from Above and Below

It is also important to draw the nose from top and bottom. If

Following page: A sculpture made from polygons.

Newport Beach, CA, USA Rollin K. Daniel

Istanbul, Turkey Bülent Genç

Part I Before Surgery

12.10.13 Complications: Case #1�� 374

18.3.2 Expanding the Interdomal and Infralobular Polygons�� 521

1.1.2 Photography Angles

1.2 The Photography System

1.2.1 Intraoperative Photographs

1.2.2 Light Illusions

1.3 Camera Settings 1.3.1 Focus Settings

1.3.2 ISO 1.3.6 Color Settings

1.3.3 Shutter Speed

1.3.9 Video Camera 1.4 Imaging

1.5 he Importance of Photography

2.1 Exercises During rhinoplasty courses in Turkey, we organize

2.1.1 Sketch from the Front

2.1.2 Sketch from the Side

2.1.3 Sketch from Above and Below

2.2 Analysis of Patient Photographs

3.1 Infratip Triangle

3.3 What Is a Facet? 3.6 Tip Breakpoints

3.4 The Non-mobile Nose

3.5 The Mobile Tip Area

3.5.1 Mass Polygons

3.5.2 Space Polygons

3.8 Interdomal Triangle

3.14.2 Incorrect Resting Angle and Its Effect

3.14.5 Convex Lateral Crura

3.15 Scroll Facet

3.17 Dorsal Cartilage Polygon

3.16 Scroll Line

3.18 Dorsal Bone Polygon

3.19 Upper Lateral Cartilage Polygons

3.21 Dorsal Aesthetic Lines