Comprehensive Facial Rejuvenation: CHAPTER SEVEN: REJUVENATION OF THE AGING NOSE
CHAPTER SEVEN: REJUVENATION OF THE AGING NOSE
At first glance, a chapter dedicated to rhinoplasty in a book devoted to rejuvenation of the aging face appears misguided. However, the nose undergoes unmistakable signs of aging that should not be ignored by the aesthetic surgeon. As the eye and brow complex draws attention on direct gaze, the neck and chin complex are more acutely noted on lateral view. However, the central position and projection of the nose make it a feature that attracts scrutiny from both the frontal and profile perspectives. The elongated, crooked appearance that the aged nose assumes is particularly remarkable on lateral view and can undermine the surgically rejuvenated appearance of the remainder of the face. The protuberant, irregular proboscis that is the hallmark for rhinophyma may be disfiguring to the individual and worse yet may harbor occult basal cell carcinoma. With these general aesthetic considerations in mind, the facial plastic surgeon can judiciously determine when rhinoplasty may be warranted for the patient who displays the classic signs of the aging nose.Besides aesthetic concerns, the aging nose may prove to cripple the patient functionally as well. The inelastic, descended, mature nose exhibits less structural integrity than its younger counterpart and can obstruct nasal airflow substantially. Both the internal and external valves may be compromised by the weakened architecture. Further, the heavy soft-tissue envelope of the rhinophymatous nose may add considerable weight to the nose to compress both nasal valves further. The male patient often suffers from the ravages of nasal aging more so than the female due to the heavier, less angulated attitude that characterizes even the younger masculine nose. Also, rhinophyma appears to be a disease that afflicts the male patient almost exclusively. The mature male patient may therefore present more frequently to the physician for corrective surgery than the female due to these preponderant functional concerns. Along with ameliorating the functional deficits of the ptotic, unsupported nose, the surgeon will, per force, concurrently address some, or most, of the aesthetic attributes. Therefore, the aesthetic and functional dimensions are often inseparable entities; and this chapter will attempt to elucidate the surgical role for both conditions.
Although this chapter will dwell on the peculiar characteristics that define the aging nose, the authors will outline a rhinoplasty treatment strategy that may be more broadly applied to all situations. A ptotic tip is not exclusive to the aging nose, and many aesthetic flaws that mar a mature nose detract from the beauty of a more youthful nose. This proviso applies to the functional deficits that characterize the aging nose as well. The diligent rhinoplasty surgeon should tailor his or her surgical strategy to fit a particular patient’s nose but should approach all noses with a systematic policy. This philosophy that embraces simplicity, flexibility, and planning will be further detailed in the forthcoming section.
Preoperative Considerations: Patient Selection & Relevant Anatomy
Relevant Anatomy of the Aging Nose
Although the nose plays a central role in facial aesthetics, it remains chiefly a respiratory organ that warms, humidifies, and cleanses the ambient air upon inspiration. The primacy of nasal function should not escape the surgeon’s consideration when operating on this vital appendage: the responsibility to maintain nasal patency should inform even strictly aesthetic endeavors. Hence, the anatomy will be reviewed in terms of both the external aesthetic attributes and the internal functional underpinnings.
The nose is divided into three constituent elements: the lower flexible third (alar cartilages), the middle semi-flexible third (upper lateral cartilages), and the rigid upper third (the nasal bones) (Figure 7-1). The flared lower lateral, or alar, cartilages are winged, tapered structures that define the external nares and thereby the external nasal valve. More precisely, the external valve consists of the curved alar cartilage and the nasal floor to complete the circular, valvular ring (Figure 7-2). The integrity of the external nasal valve is commonly compromised by aggressive rhinoplasty but may be affected by numerous other factors, including congenital weakness, trauma, thermal injury, tumor, and aging. After rhinoplasty, the external valve may collapse either due to cartilaginous weakening (cephalic resection, domal division, and various incisions that weaken tip support) or soft-tissue retraction and scarring. Similarly, cartilaginous or soft-tissue weakness predispose toward valvular collapse in the aging nose. During the aging process, the soft tissue loses elasticity and the tissues become attenuated, both of which contribute to the inability to overcome gravitational force and to eventual tip ptosis. In addition, the cartilaginous structures of the nose lose some of their tensile strength and the ligamentous structures that bind the cartilages together (scroll, interdomal ligament, etc.) and that fasten the cartilage to the surrounding soft tissue (the minor tip-supporting mechanisms) experience some erosion to their strength. The increased sebaceous quality of the nasal tip, known in extreme as rhinophyma, adds weight to the nasal tip and may actually occlude the external naris. All of these factors lead to compromise of the external valve in the aging nose that may require surgical intervention to correct.
The internal nasal valve, also known as the limen vestibuli, is the major regulator of nasal airflow in the Caucasian nose. Mesorrhine and platyrrhine noses that typify the Asian and African noses, respectively, have a much broader cross-section in the region of the internal valve, and therefore they rarely suffer from internal nasal valve collapse. The nasal structures that comprise the internal valve include the caudal border of the upper lateral cartilage, the nasal septum and the anterior head of the inferior turbinate. The angle that is formed by the union of the nasal septum and the upper lateral cartilages should be a minimum of 10 to 15 degrees in order to ensure patency (Figure 7-3). A high septal deflection can impinge the upper lateral cartilage and thereby narrow the described angle. The weakening of the cartilaginous support that marks the aging nose can also contribute to internal valve collapse. Prior rhinoplasty can also detrimentally affect the internal valve, e.g., dorsal reduction will sever the upper lateral-septal union and may predispose toward valvular compromise. A bulbous anterior head of the inferior turbinate that may arise from allergy, infection, or tumor or may be a congenital structural anomaly can also lead to diminished airflow and increased turbulence. All of these structures should be carefully examined during the preoperative consultation (vide infra).
Rhinophyma represents a distinct clinical entity that can cause significant cosmetic and functional disturbance in the aging nose (See Case #1). Older men, in particular, are the primary victims of this deforming disease. The comic actor, W.C. Fields, sported perhaps the most notorious example of this elephantine nose. The increased sebaceous activity in the lower third of the nose occurs due to an idiopathic rise in sebaceous gland hypertrophy. Part of the mechanism by which this process may be triggered is attributed to proliferation of the bacterium, Demodex follicularis. Rhinophyma has been viewed as the end stage of acne rosacea, a dermatologic condition that afflicts the central oilier regions of the face. Topical tetracycline applied regularly during the incipient phase of this disease may control the spread and possibly reverse it. However, once the malady is in full bloom, medical management does little to efface this now impregnable entity. Of note, the oft-cited belief that rhinophyma originates from alcoholic intemperance is a fallacy that should not be propagated. As mentioned, correction of rhinophyma should address both the aesthetic and functional problems, which include the potential insidious presence of basal cell carcinoma. The most suspicious areas should be sent for pathological review either in the preoperative phase if highly suspicious to obtain insurance coverage or at minimum intraoperatively.
A Systematic Approach to Rhinoplasty
Although this chapter is devoted to the surgical management of the aging nose, the reader is encouraged to approach every rhinoplasty in a systematic fashion. This section will elucidate the authors’ philosophical approach to all rhinoplasty, which the reader can adapt to fit the circumstance at hand. The three cornerstones that define successful rhinoplasty surgery are simplicity, planning, and flexibility. Although these principles appear to be broadly conceived and ill defined, the reader is urged to review this section carefully and contemplate the guiding tenets outlined. After diligent study, the reader will hopefully come to realize the importance that these dictates exemplify.
The guiding principle of simplicity should always be recalled during the preparatory and execution phases of rhinoplasty. Simplicity entails undertaking rhinoplasty with the fewest steps necessary to achieve the aesthetic or functional goals. For instance, a patient who exhibits cephalic fullness to the lower lateral cartilages without notable bifidity should be an eligible candidate for a closed, non-delivery, transcartilaginous technique. The non-delivery technique affords the most expedient and targeted approach to the aesthetic deficit without undue, protracted operative dissection. In contrast, rhinoplasty surgery that entails major architectural destruction followed by extensive structural reconstitution should be condemned if conducted in an indiscriminate fashion. Not every nose justifies aggressive resection: prolonged surgical manipulation increases variability due to scar contracture over time that may transform a beautiful immediate result into a disaster down the road. The effect of skin “shrink wrapping” may reveal any minor flaws in surgical technique or even expose the outline of structural grafts that have been perfectly executed.
Categorically, plastic surgeons are perfectionists by inclination; and, for that reason, the targeted goal is consistently 100% in every rhinoplasty endeavor. However, if achievement of 100% entails 5 hours of surgery, then the ultimate result may fall far short of the intended mark due to the aforesaid variability that arises from radical surgery. The law of diminishing returns takes hold, as edema distorts anatomy and as the hemostatic effects of the local anesthetic dissipate after an hour and a half of operative time.
Instead, the surgeon should think systematically how he or she could arrive at the maximal aesthetic achievement with the minimal of surgical maneuvers. Accordingly, a realistic goal for surgery may be 90% rather than 100%. This is not to concede that 100% is not achievable but rather that it may not be preferable because by doing so the final result may approach 80%. These percentages are only presented to help instruct the rhinoplasty surgeon understand the principle of simplicity more precisely and clearly do not represent actual conceived numerical values.
Planning goes hand in hand with simplicity. In order to achieve the most straightforward, simplest strategy to every rhinoplasty endeavor, proper planning should begin from the first patient encounter. At the conclusion of the initial consultation, the surgeon should outline a plan for surgery that may involve as basic as a few marginal notes jotted down to a more elaborate and complete dictation. Either method of documentation is acceptable so long as the surgeon can readily refer to the proposed plan at the time of surgery and recall what should be done at that later date. With a hectic schedule, it is a wasteful and troubling exercise to begin afresh with surgical planning moments before the actual procedure. Using simplicity as a guide, the surgeon should deliberate seriously whether an external, transcolumellar incision is justifiable. The authors believe that open-structure rhinoplasty is a worthwhile venture in select cases but should not be undertaken in every circumstance. The external approach adds increased surgical dissection and operative time that may not be required. Conversely, difficult, revision cases may not be suitable to an endonasal approach due to the need for better visualization and for greater structural reconstitution. Letting the punishment fit the crime should dictate how much surgical dissection is necessary. The forthcoming section on operative considerations will present treatment strategies that are based on these guiding tenets of planning and simplicity.
Flexibility constitutes the final consideration that should inform every rhinoplasty effort. Although this principle really refers to intraoperative decision-making, it is mentioned in the preoperative section so that the reader can understand the three guiding tenets of simplicity, planning, and flexibility together. Despite the best efforts at planning an effective strategy, the vicissitudes that may arise during surgery occasionally justify a change in the course of action. This decision to undertake a different surgical tactic defines flexibility. The surgeon should not rigidly adhere to a preconceived plan if that plan begins to appear ill suited to the current situation at hand. For instance, placement of a columellar strut and a transdomal suture may be all that are required to correct a ptotic tip during intraoperative analysis, and the plan for a lateral-crural overlay may be justifiably abandoned given the perceived situation. With all three cornerstones in mind, the surgeon should be able to formulate a reliable, systematic strategy for every rhinoplasty and adapt that strategy according to individual constraints. Diligent study of long-term postoperative results will confirm or alter future surgical endeavors; and the successful rhinoplasty surgeon should remain a pupil for life.
The three elements of a proper preoperative evaluation include assessment of the psychological motivations and expectations, the history of the patient’s problem, and physical assessment of the aesthetic and functional features of the patient’s nose.
The psychological inquiry that is mandatory for every cosmetic consultation has been well outlined in Chapter 3. Nevertheless, rhinoplasty often carries with it more psychological overtones than routine, aging-face surgery and deserves special mention herein. Although rhinoplasty of the aging nose is primarily restorative, aesthetic enhancement beyond one’s former, youthful nasal shape may be requested. For example, a mild dorsal hump that is present at youth may become accentuated over time due to nasal-tip ptosis. The patient may desire not only correction of nasal ptosis but also removal of the hump altogether. Alternatively, the patient may request aesthetic tip refinement along with improvement of nasal function. As the nose is prominently situated in the center of the face, changing the aesthetic features of the nose may have significant psychological repercussions. Accordingly, the surgeon should decipher the exact aesthetic and functional goals that the patient desires and work to match those objectives after careful investigation of the underlying motivations and expectations.
As mentioned, the male patient often suffers the effects of nasal aging (ptosis and/or rhinophyma) more acutely than his female counterpart. Unfortunately, men may exhibit a more profound psychological dilemma when electing aesthetic or functional rhinoplasty. Studies have revealed that men are less tolerant of change to their physical facial features. This fact is particularly true for the more mature male patient who already has developed a rather static self-image, as opposed to the more mutable self-perception of the adolescent male. While women can easily adapt to their newly shaped visage, men gaze into their reflected image and see an altogether foreign expression. Furthermore, the altered nose proves to be most troublesome aspect of the face for men to accept. Freudian connotations have been made of the nasal appendage mimicking a phallus and surgical correction of which is commensurate with castration. This analogy may strike the reader as grossly absurd; however, significant nasal reduction may be viewed as a form of emasculation, as the strong nasal profile is a hallmark of masculinity. Besides the aesthetic patient, the functional male rhinoplasty patient may prove equally frustrating. The classic, “engineer”-minded individual approaches the physician, often clutching in tow elaborate, self-executed diagrams that attempt to instruct the physician how best to alleviate the nasal impairment. Typically, these illustrations serve to impart little substantive information but only to underscore the fixated frame of mind that the patient is exhibiting. Most often, this type of patient has already journeyed tirelessly to find the elusive surgeon who will address his every complaint. The plastic surgeon should always be attentive during the preoperative phase to determine not only which patient should be operated upon but, more importantly, which one should not.
A thorough and complete history should be taken to ascertain the patient’s aesthetic and functional concerns. The details of good history taking should already be well understood by the physician. Nevertheless, a few salient points that are particular to rhinoplasty will be mentioned herein. The psychological motivation for aesthetic improvement has already been addressed in the previous section and will not be reiterated. Apart from psychological issues, the surgeon must endeavor to determine exactly what aesthetic flaws concern the patient. The consultation process should reflect the progressive union of the patient’s desires with the educated opinion of the surgeon. Aesthetic goals that may compromise nasal function should be tempered appropriately. For instance, overly narrowing the nose may not be achievable given poor elasticity or already impaired nasal airflow. A crooked nose is a very difficult entity to correct fully, and the surgeon should declare the limitations of surgical intervention to establish realistic expectations. Past history that should be elucidated include prior trauma, nasal and sinus surgery (both aesthetic and functional), allergy and sinus disease, and other related systemic illnesses. The precise nature and extent of prior surgery should be delineated so that planning for the current endeavor can be maximized. Previous operative dictations can be helpful but oftentimes may be misleading or vague. Therefore, an in-depth history and attentive physical examination may serve as a next best proxy for this lack of knowledge.
For functional complaints, the surgeon should probe the exact circumstances when the nasal impairment occurs or is exacerbated. If the nasal obstruction arises only temporarily, then surgical intervention may not be justified and medical therapy may be warranted instead. If allergy or other medical conditions can be ruled out, then precise localization of the nasal impairment is often uncovered during the physical examination.
Nasal aesthetic and functional flaws may be most clearly ascertained with a thorough physical examination. Most of the physical examination may be completed during the initial portion of the consultation in which the patient reports the aesthetic problems that trouble him or her. The physical examination, therefore, may be integrated into the dialogue with the patient and any remaining aspects of the examination that were not formally covered early on are evaluated at this point. First, the nose is inspected for symmetry and for compliance with aesthetic guidelines.
Ideal nasal and facial aesthetic proportions have been widely reported. However, a brief review will be included herein. The nasal length (from glabella to nasal tip) should occupy approximately one third of the total vertical height of the face. The upper one third of the face should extend from the hairline to the glabella, and the lower one third should cover the distance from the bottom of the nose to the lower aspect of the chin, or menton (Figure 7-4A). As the patient matures, the nose will elongate due to gravity and to loss of elasticity so that the nose will come to occupy greater than one third of the vertical facial height. Similarly, the lower third of the face shortens due to the encroachment of the longer nose over the upper lip. As the male patient matures, the loss of frontal hair translates into a longer upper one third of the face (Figure 7-4B). However, as the chapter on hair restoration has detailed, the upper third of the face should not be shortened to the golden one-third distance to avoid a prepubescent appearance of the hairline. Horizontally, the nasal width should equal that of an eye, forming one fifth of the total distance across the face. The distance from the lateral canthus to the lateral aspect of the flared ear should occupy the remaining fifth of the face (Figure 7-4C). Aging does little to impact upon the proportion of the horizontally divided face.
On profile view, nasal projection has been defined by many formulae. A simple method that has proven clinically reliable is the one described by Goode: the distance from the alar-facial groove to the nasal tip should equal to 0.55 to 0.60 of the distance from the nasion to the alar-facial groove (Figure 7-5). Generally speaking, the male nose can tolerate a greater degree of projection than that of the female. The rotation of the nose defined by the columellar-labial angle should be more perpendicular for the male, approximately at 90 to 95o; whereas the ideal female rotation rests between 95 to 105o (Figure 7-6A, B). As the patient matures, this angle becomes more acute, and restorative surgery should aim to return the nose to the ideal attitude. The nasofrontal angle is narrower for the male, ranging ideally between 115 to 120o owing to the heavier male brow and is more open for the female, situated between 120 to 130o (Figure 7-6A, B). On profile, the male nose can tolerate a slight dorsal convexity, or hump, whereas the female nose should be relatively straight in contour. A slight supratip break, or depression, is a favorable aesthetic attribute for the female but is not so for the male. A double-break contour of the columella-lobule region is a natural and pleasing configuration that should be maintained or improved with surgery. Finally, the alar-columellar relationship should be such that a perfect oval shape of the nostril is viewed laterally with the distance from the ala to the columella approximating 1 to 2 mm (Figure 7-7). An entire book can be dedicated to the description of ideal aesthetic values, but this brief review should serve as a basic framework with which the rhinoplasty surgeon can assess the patient’s nasal features.
After the nasal anatomy has been visually studied, the surgeon should evaluate the nasal soft tissues by palpation. The nasal tip should be depressed with a finger and released to determine tip recoil (Figure 7-8A). If the lower lateral cartilages splay easily under pressure and do not spring back to their normal configuration after release, then surgery should be tailored to reflect the weaker condition of the cartilages. For instance, significant trimming of the lower lateral cartilages should be avoided in these circumstances. The skin thickness should also be appreciated, as thin skin may expose any surgical imperfections over time and thick skin may camouflage the surgical result (Figure 7-8B). Therefore, medium-thick skin is ideal for rhinoplasty. The length of the nasal bones should also be palpated, as short bones predispose toward an inverted-V deformity (Figure 7-8C). This complication appears as a cutaneous, inverted-V depression between the nasal bones and upper lateral cartilages, as the middle vault collapses due to lack of bony support after surgical manipulation. In these cases, osteotomies may need to be avoided or spreader grafts placed to buttress the upper lateral cartilages (the middle vault) against inward collapse. Any bony irregularities should also be studiously palpated and recorded.
After all of these external landmarks and structures have been adequately assessed, the surgeon should then turn his or her attention to the internal aspect of the nose. If the patient reports nasal obstruction, the surgeon should begin the nasal examination by observing the patency of the external nasal valve. Without touching the patient’s nose or inserting a nasal speculum, the surgeon should observe the nares in repose and in dynamic contraction during quiet respiration. At rest, the external valve may already appear to be compromised by virtue of a narrowed nostril aperture. Alternatively, the external valve may appear to collapse only with inspiration due to weak lateral alar support. If either condition is noted, then a cotton-tip applicator can be used to stent the nostril open to determine if this action alleviates the nasal obstruction. A finger that is positioned just lateral to the ala on the cheek skin can be used to distract the cheek laterally and thereby open the nostril. If these techniques improve symptomatic nasal airflow, then external nasal valve collapse is present. For the aging nose, the external valve may be reduced by nasal-tip ptosis. Therefore, lifting the nasal tip back to a more upright position may eliminate nasal congestion that corroborates external valvular compromise. The following section will describe methods to address external-valvular problems.
Next, the internal nasal cavity should be inspected for signs of septal, turbinate, or internal valvular compromise. A nasal speculum can be placed to widen the nasal aperture for better visualization of the internal anatomy, and a headlight will provide proper illumination. The septum should be checked for deviation, and a comparative view of both nasal cavities may render more accurate assessment as to the presence of a septal deflection. A high septal deflection located at the junction of the upper lateral cartilage and septum should be carefully studied, as this narrowed passage may be related to internal valve restriction. As mentioned, the anterior head of the inferior turbinate is also a constituent element of the internal nasal valve, and enlargement of this tissue may restrict nasal airflow. Erythematous, purulent turbinates suggest a bacterial etiology for the inflammation, whereas pale to violaceous and edematous mucosa may indicate an allergic source. After anterior rhinoscopy has been concluded, the nasal speculum should be removed. Then, if internal valve collapse is entertained, a cotton-tip applicator should be gently inserted into the nose to stent the upper lateral cartilage away from the septum. The applicator tip should be applied against the upper lateral cartilage near the septal-upper lateral cartilage junction (Figure 7-9A). If the patient is equivocal about the improvement, then the contralateral side should be tested in a similar fashion to offer the patient a comparative perspective. Finally, the cheek should be distracted immediately lateral to the upper lateral cartilage very gently to determine if there is any improvement with this technique (Cottle maneuver) (Figure 7-9B). This method carries value only if the finger distracts the upper lateral cartilage (at the internal nasal valve) and not the nostril (i.e., the external nasal valve.) Similarly, the external valve can be stented open either with a cotton-tip applicator, nasal speculum, or finger distraction against the cheek. The following section on surgical technique will elaborate on correction of internal valvular collapse.
Intraoperative Considerations: Technique & Salient Technical Points
Instrumentation/Equipment for Rhinoplasty
10 cc syringe, 27-gauge (1 1/4 inch long) needle with 1% lidocaine and 1:50,000 epinephrine
Bowl with 4 long nasal pledgets soaked in equal parts of oxymetazoline &
Surgical marking pen
Nasal Tray which includes
Large Rubin elevators
Medium Rubin elevator
Unguarded 2 mm osteotome
Unguarded 3 mm osteotome
Dissection block (for graft carving)
Medium Debakey forceps
Fine, toothed forceps
4-0 chromic suture, PS-4 (P-24)? needle
5-0 chromic suture, P-13 needle
7-0 prolene or nylon, P-1 (P-10) needle (for skin closure or external incision)
4-0 polydioxanone, PS-3 (PRE-3) [PC-34] needle (suture for graft fixation
and for suturing cartilage)
10 cc syringe, 27-gauge (1 1/4 inch long) needle with
1% lidocaine and 1:50,000 epinephrine
Cotton tip applicators
4 x 4 gauze
Bowl of saline
Bowl of hydrogen peroxide
No.15c blades (3)
Telfa (cut into 2 strips 3/4″ long)
Eyepad cut into half (as a nasal tip dressing)
Brown Micropore tape for the dorsum
Bacitracin ointment in 5 cc syringe
4 x 4 gauze
Instrumentation/Equipment for Rhinophyma Resection
27-gauge (1 1/4 inch long) needle with 1% lidocaine and 1:50,000 epinephrine
Surgical marking pen
4 x 4 gauze
No.10 blade (3)
CO2 laser (or thrombin spray and monopolar electrocautery)
27-gauge (1 1/4 inch long) needle with 1% lidocaine and 1:50,000 epinephrine)
4 x 4 gauze
Eyepad cut into half (for nasal tip dressing)
A. Aesthetic & Functional Rhinoplasty of the Aging Nose
Rhinoplasty is a vast and complicated subject that would require several volumes of writing to do it justice. Although the previous section outlined a general approach to rhinoplasty, this section on intraoperative management will only detail the surgical maneuvers relevant to correction of the aging nose (both functional and aesthetic). The preoperative section presented broader themes in order provide the reader with a framework with which to approach rhinoplasty according to the authors’ philosophy. This section will remain true to the objective of this book, i.e., surgery for facial rejuvenation. If the reader requires more in-depth knowledge about rhinoplasty, he or she is referred to Eugene Tardy’s masterpiece, Rhinoplasty: The Art and The Science , or Jack Sheen’s illustrious text, Aesthetic Rhinoplasty , for greater detail. Interestingly, even texts that are dedicated to rhinoplasty often fail to include a chapter that specifically outlines a treatment strategy for the aging nose. Certainly, rhinophyma resection is considered too outr for inclusion within the subject of most rhinoplasty textbooks. This chapter will hopefully add a rational and embracive treatment strategy for the aging nose to the existing body of literature.
Surgical Maneuvers: Correction of the Ptotic Nose
Septal Angle Resection
Resection of the septal angle, or antero-inferior margin of the septum, is an effective method of elevation of an under-rotated nose in the younger patient. However, this simple strategy may not work as well for the aging nose. This maneuver is predicated on the elasticity of the nose that will allow the soft tissue to retract over the resected angle – a state that may not exist in the mature nose. Septal angle resection may still constitute a viable technique in the following two conditions. If sufficient elasticity is still noted in the nose, then septal angle resection can be attempted in conjunction with other restorative maneuvers. Because the nose is ptotic usually due to loss of elasticity, this technique often does not work alone or at all. If the septum appears to be very long and the tip resists upward transposition with digital pressure, then appropriate angle resection may be indicated in this circumstance to permit freedom of the nasal tip to ride upwards.
Septal angle resection may be undertaken through an external or endonasal approach, with the latter being preferred for its simplicity and direct access. A near complete transfixion incision is undertaken to expose the caudal margin of the septum.? As a technical point, it is easier to incise the mucosa directly over the septal cartilage (about 1 mm cephalad to its caudal border) so that the plane of dissection can be easily established for septoplasty. Then, in order to expose the septal angle, fine curved scissors are used to retrodissect the mucosa off of the caudal border of the septum to expose the antero-inferior margin, or angle. A No.15 blade can then be used to transect a triangular wedge off of the caudal septum with its base along the anterior border so that the nasal tip will then be transposed superiorly (Figure 7-10 A, B).
According to Anderson’s tripod theory, lengthening of the central leg (the medial crura) or shortening of the lateral legs (the lateral crura) will rotate the nose upwards (Figure 7-11). As the nose ages, the central tripod limb, i.e., the medial crura, loses support, and the nose rotates downward. To counterbalance the force of gravity, a columellar strut should be placed in most, if not all, cases of nasal tip ptosis, especially considering that the rhinoplasty surgery alone causes loss of tip support. Even in standard rhinoplasty cases in which nasal ptosis does not exist, the columellar strut can serve a useful function to prevent future tip ptosis. A good rule to follow is that if one thinks that a columellar strut may be beneficial, then it should be placed. The ease of surgical placement justifies its role in the majority of rhinoplasty cases, and it represents the minimum surgical maneuver for the ptotic nose. A columellar strut may be used alone only if very mild tip ptosis is present, i.e., the columellar-labial angle does not exceed 20o downward from the desired position and if tissue integrity is not excessively flaccid. After placing and securing the columellar strut, the new columellar-labial angle should be verified and tip resilience palpated to determine whether additional steps should be carried out to raise the tip further. The nose will descend approximately 10o over time due to a mild loss of structural support, and slight overcorrection is warranted.
In accordance with simplicity, the endonasal approach is favored if the nose does not need to be opened for any another reason. Septal cartilage serves as a better donor material, as it is more rigid and straighter than auricular cartilage and thereby acts as a more effective buttress. However, if septal cartilage is deficient, then auricular cartilage may be used instead. In order to increase the tensile strength of conchal cartilage, the portion of cartilage should be harvested with twice the width (approximately 4 mm) and transected along its length through the entire thickness while retaining one perichondrial surface intact. The strut is then folded onto itself pedicled on the perichondrium in order to increase the rigidity of the cartilage. Prior to insertion, the folded cartilage should be secured with 5-0 chromic suture in a mattress configuration to prevent the cartilage segments from unfolding (Figure 7-12).
Via the endonasal approach, the columella should be accessed via a a separate incision contralateral to that used to access the septum during septoplasty. A 3-mm vertical (i.e., running perpendicular to the orientation of a transfixion-style incision) incision is made just caudal to the caudal septal border midway between the septal angle and the nasal spine. Fine curved scissors are used to dissect a pocket between the medial crura up toward the nasal tip and down toward the nasal spine. The pocket stops short of the actual nasal spine in order to avoid the strut from clicking on the bony prominence during animated expression. The columellar strut is then inserted into this pocket through the aforementioned 3-mm stab incision and secured into place via the pocket principle, as suture fixation is unnecessary (Figure 7-13). Of note, the strut should theoretically be ensconced between the limbs of the medial crura but in actuality is typically situated slightly higher bordered by the caudal septal border superiorly and the medial crura inferiorly. In the external approach, the columellar strut is placed by dissecting a pocket starting from the anterior aspect of the medial crura between the domes down toward the spine. After securing the graft in position, any excess that remains beyond the domes should be transected. As mentioned, tip position and support should be confirmed before completion of the operation.
Lateral Crural Overlay
The lateral crural overlay technique represents a more radical solution to nasal tip ptosis and is indicated in cases in which the nasal tip is moderately to severely ptotic. This technique relies on the principle of shortening the lateral limbs of the tripod to effect rotation of the nasal tip upward (Figure 7-14). Although this technique can be carried out via the endonasal approach, it is not recommended, as proper visualization, ease of surgery, and accurate assessment of symmetry and height all mandate use of the external approach. The lateral crural overlay technique can correct even the most significant downturn of the nose. Furthermore, the degree of rotation can be adjusted by overlapping the cartilaginous segments to the desired extent. This technique readily addresses the lateral limbs of the tripod (i.e., the lateral crura) and works effectively when combined with other ancillary surgical maneuvers that help buttress the medial, central limb, e.g., a columellar strut.
First, an inverted-V incision is marked at the mid-columellar aspect. After local anesthesia is administered, the skin/soft tissue envelope is opened along the supraperichondrial, sub-SMAS plane until the nasal tip is fully exposed . Dissection should be carried out toward the pyriform aperture, as the full length of the lateral crura should be in view for lateral crural overlay. The extent of dissection laterally may be slightly more than what is required for simple nasal-tip surgery. A columellar strut may be placed at this time via the external approach and secured in place. By strengthening the central limb (the columella) and shortening the lateral limbs (the lateral crura), the nose can be rotated and maintained in that position for the greatest duration.
Sharp, angled Converse scissors should then be used to undermine several millimeters of vestibular skin away from the overlying lateral crus at approximately one-third the distance from the pyriform aperture to the dome, i.e., nearer the pyriform aperture (Figure 7-15).? A No.15 blade should then be used to transect the lateral crus completely in a vertical fashion without injuring the underlying vestibular skin. The medial edge of the transected lateral crus can then be brought to lie over the lateral edge and secured in place with a buried, horizontal mattress suture of 5-0 polydioxanone. As mentioned, the amount of nasal elevation desired will dictate the degree of overlap. The contralateral side is approached in the same fashion. Even with marked tip ptosis, the amount of cartilage overlap should be approximately 1 to 2 mm at a maximum during the initial attempt because of the significant degree of rotation that this surgical maneuver offers.
Transcutaneous Nasal Elevation
The above surgical techniques serve as reliable methods to address nasal tip ptosis in the overwhelming majority of cases. However, in the recalcitrant case, a more radical option may be elected. The nose can be lifted upward via excision of a wedge of skin at the nasal root and suspended upward to the new level (Figure 7-16). Clearly, this technique should be reserved for the patient who is more advanced in age and who desires to undergo an expedient method to correct his or her nasal ptosis. Although the blood supply to the nose emanates principally from vessels that reside lateral to the pyriform aperture, a transcolumellar incision may be safely combined with this extensive incision superiorly without jeopardy to the vascularity of the skin flap.
The patient should be asked to depress the brow and raise the nose in a snarl so that the deeper rhytids can be ascertained. A fusiform line that extends across the nasal root, or nasion, should be drawn that is centered over the midline and that extends just lateral to the nasal width. Forceps should be used to grasp the skin and soft-tissue to determine how wide the fusiform incision should be in order to effect nasal tip elevation. Dissection is taken down to the periosteum, and the skin island is removed and discarded. Undermining should be undertaken only below the inferior wound edge to mobilize the tissues for elevation. Generally speaking, dissection is usually taken down in a sub-SMAS plane until sufficient tissue mobilization becomes apparent: wide undermining is typically necessary to achieve this goal. 4-0 polydioxanone is used to suspend the inferior flap through the periosteum and soft-tissue of the upper flap until the desired nasal height is achieved. After the desired nasal tip position is attained, the skin is closed with a running 6-0 nylon suture. If the patient has concomitant nasal obstruction, the procedure should be carried out with minimal sedation so that the patient can report whether elevation of the tip has provided subjective nasal airflow improvement. Although a cutaneous incision in a highly conspicuous location like the nasal dorsum may seem a rather poor decision, this incision has healed uniformly well in the patients who have undergone this procedure in the authors’ practices.
Surgical Maneuvers: Correction of Valvular Collapse
If the patient presents with a ptotic nasal tip, he or she may have external and possibly even internal nasal valve collapse. Accordingly, correction of the ptotic nasal tip may ameliorate or eliminate the associated nasal obstruction. If not, then the following maneuvers may need to be undertaken to address internal and external valvular collapse, respectively. Assuming knowledge of fundamental nasal surgery, basic septoplasty and turbinoplasty techniques will not be reviewed. Further, scarred or deficient anatomy that results from prior trauma or surgery and that leads to valvular compromise fall outside the subject of this chapter.
A spreader graft may be placed either through an external or endonasal approach (Figure 7-17). However, the internal valve can be stented more effectively through the internal approach. As Toriumi reported, the cantilever effect on the internal valve is only achievable via an endonasal approach; and therefore, this method is preferred (Figure 7-18 A, B). The endonasal approach for spreader-graft placement is easy to perform and can be done in 10 to 15 minutes with the patient under minimal sedation. By doing so, the patient can report subjective improvement immediately after graft insertion and thereby confirm success of the operation.
After the septum has been anesthetized, a No. 15 blade is used to make a 2 to 3 mm incision along the dorsal aspect of the septum approximately 2 to 3 mm cephalad to the caudal septal border. A Freer or Cottle elevator is used to dissect a narrow subperichondrial pocket as wide as the elevator tip until the midportion of the upper lateral cartilage is reached (Figure 17-19A). As the pocket remains narrow and high along the septum, the elevator should be nudged forward slowly rather than swept up and down in a broad path. When the pocket has been completed, the elevator tip is pressed against the upper lateral-septal junction and pulled back forcibly along this junction to ensure that the graft will be placed as high as possible at the upper lateral-septal interface. However, the surgeon should be careful not to sever the connection between the septum and the upper lateral cartilage otherwise no cantilever effect can be obtained. By placing the graft tightly within this recess, the upper lateral cartilage can be properly cantilevered outward to open the internal valve (Figure 17-19B). The contralateral side is carried out in the exact same method prior to harvesting the graft material. By creating the recipient site first, the dissected pocket will have achieved complete hemostasis by the time the graft is ready to be inserted.
If the grafting material is to be derived from the septum, then septoplasty should be performed at this time. It is imperative that the septoplasty be conducted in a separate, discrete pocket that does not communicate with the higher graft pocket described above. If the two pockets are joined by accident, then a mattress suture can be placed to fixate the graft in place. However, this is far from ideal, as the graft is less securely positioned and the task of placing a suture very high cephalically is not an easy proposition. If the graft cannot be adequately sutured into position, then the nose may be opened to permit increased visualization and external suture fixation.
After the graft is harvested, two rectangular pieces of cartilage (one for each side of the nose) should be created that measure approximately 2 to 2.5 mm x 20 x 25 mm in size. The spreader grafts should be taken from the thickest portion of septal cartilage, which is typically situated along the posterior bony-cartilaginous junction. The thicker cartilage can more effectively stent the nasal valve open. A fine, toothed forceps can be used to insert the graft into the narrow pocket under direct visualization. Oftentimes, if the graft is placed correctly, the upper lateral cartilage can be observed to move laterally under the pressure of the spreader graft. If the patient is under lighter sedation, then he or she should be asked to comment upon the nasal improvement to ascertain whether a thicker graft is needed. At times, a double layer of septal cartilage may be required if the patient still presents with nasal obstruction after graft insertion. However, it is more difficult to place a double-layered graft into the tight, cephalic pocket. After the graft is inserted, the incision can be closed with a simple mucosal suture or a through-and-through mattress to close both incisions at the same time.
Alar Batten Graft
Like the spreader graft, the alar batten graft can be placed via the endonasal approach, which affords the simplest and fastest method to improve external valve collapse. Also similar to internal spreader graft placement, the pocket should be created first to permit maximal hemostasis before graft insertion. An abbreviated, 4-mm incision should be made along the caudal aspect of the lower crus just lateral to the vestibular dome (Figure 7-20A). A fine pair of sharp scissors should be used to dissect a pocket over (i.e., superficial to) the lateral crus toward the pyriform aperture. The tendency is to dissect a pocket angled too superiorly. Therefore, the surgeon should make a conscientious effort to turn the wrist laterally toward the pyriform aperture. The pocket is created so that the graft will be situated partly over the lateral crus and partly over the soft tissue that lies inferiorly and that is devoid of cartilage (Figure 7-20B). Further, the pocket should be dissected all the way to the pyriform aperture.
Septal or auricular cartilage should then be harvested as grafting material. Although auricular cartilage reproduces the natural curvature of the lateral crus, it lacks the tensile strength needed to stent the external valve sufficiently. Therefore, septal cartilage is much preferred as an alar batten graft. The graft should then be carved such that the dimensions will fit the proposed pocket. Typically, a graft size of 3 to 4 x 15 to 20 mm is acceptable. The lateral end of the graft should have a small V wedge removed, such that the graft will be firmly anchored into the soft-tissue near the pyriform aperture like a tent-pole. The most technically difficult aspect of this procedure is graft insertion and may require several attempts even in the most experienced hands. A precise, fine-toothed forceps that extends over the entire length of the graft should be used to insert the graft into the pocket: the forceps held in this fashion will serve to protect the graft from buckling or tearing and to guide the graft properly into the pocket. It is imperative that the graft extends all the way to the pyriform aperture. If the graft falls short of this distance, it will merely contribute to the weight of the ala and exacerbate, rather than relieve, external valve collapse. A graft that reaches the pyriform aperture will act like a Romanesque buttress to add rigidity and lend support to the external valve. The endonasal approach is preferred so that the patient can remain under minimal sedation and can report the improvement in nasal obstruction immediately after graft placement. The entire procedure should be relatively quick, like internal spreader graft insertion. The incision can then be closed with a single absorbable 5-0 chromic suture.
B. Correction of Rhinophyma
Rhinophyma is a disfiguring disease, and treatment of which can be a very rewarding experience for the surgeon and patient alike. Success can be ensured if the surgeon follows a few basic guidelines that will be enumerated. Although rhinophyma afflicts the nose, correction of this disease is more a task of dermatologic surgery than rhinoplasty. The philosophical approach in which a combination of resurfacing techniques is used has been highlighted in Chapter 9. However, this chapter will deal more in depth with the precise method of treatment and explain how to avert disaster if the reader subscribes to the conservative strategy outlined.
Because this surgery can be quite hemorrhagic, general endotracheal anesthesia is preferred for patient comfort, compliance, and airway control. However, intravenous sedation can be used without undue concern. After the patient has been properly anesthetized, 1% lidocaine with 1:50,000 epinephrine should be infiltrated endonasally along nasal bones, the nasal tip and alae. Minimization of local anesthetic in the superficial tissue planes can obscure the intended area of resection. Therefore, transmucosal infiltration of the anesthetic will prevent cutaneous tissue distortion but promote adequate hemostasis. After ten minutes are allowed to elapse, actual surgery can safely commence.
First, a Bard-Parker No.10 blade is used to trim the excessive tissue off the nose (Figure 7-21). Usually, significant hemorrhage is encountered at this point. It is very important that the blade be angled parallel with the skin surface, as tangential dissection may leave large divots that may be difficult to camouflage (Figure 7-22). In order to aid resection near the alae, a moistened 4 x 4 gauze can be opened and inserted into each nostril to absorb excessive blood and to serve as a platform for dissection. Dissection should proceed in an orderly, systematic sequence following the nasal subunits: nasal dorsum, sidewalls, alae, tip, and columella. It is important that the surgeon continue symmetrically as well so that each nasal sidewall and ala is completed in a successive fashion, verifying accurate symmetry by both visual assessment and palpation. For instance, alar thickness can be assessed by removing the gauze and pinching the ala between two fingers to determine the remaining thickness. Compared with all other aspects of the nose, it is imperative that the surgeon not overthin the nasal alae. The tendency toward scar contracture is much higher in the alae, as no cartilaginous support exists in their inferior aspect. The authors have corrected several cases of subsequent external valve collapse in patients who had their surgery performed elsewhere by less experienced hands. At this point, it is worth stating a very important point about the rationale for surgical technique: the use of a cold-knife technique should be the principal method by which rhinophymatous resection is undertaken. Laser and/or cautery techniques cause excessive thermal injury and may leave the nasal tissue atrophied, attenuated, and uneven. Thermal injury is particularly problematic for the nasal alae, as the risk of scarification and contracture are amplified. Several No.10 blades should be kept ready for use, as repeated tissue transection quickly dulls the edge. The endpoint for tissue removal can be determined by examining the nose on profile when the normal contour and height are reestablished. Clearly, some underlying dermis must be retained to provide a source for epidermal regeneration. Typically, the novice surgeon will mistake the transected sebaceous tissue as adipose and fear that he or she has gone too deep. However, sebaceous glands are more compact and whiter than adipose, and the two can be easily distinguished after some scrutiny.
Cold-knife dissection offers a rapid method of reducing tissue bulk down to a favorable height and general contour. However, the remaining tissue will not appear even in nature because the tissue left in the wake of the knife blade is still crudely carved, despite the most rigorous attention. Therefore, a dermabrader must be used to refine the contour and to ensure a smooth and even terrain (Figure 7-23). However, the use of a dermabrader alone for the entire procedure without initial cold-knife excision is a tedious, time-consuming, and inefficient affair. The reader is reminded that a portion of the nasal tissue removed with the knife should be sent for pathological review if it appears excessively irregular or exuberant in nature, as basal cell carcinoma may be present within the tissue. The preferred type of dermabrader is a wire brush rather than a diamond fraise.? Fortunately, dermabrasion for rhinophyma is much more forgiving and technically less demanding than for standard cutaneous resurfacing.
A finger should be passed over the nose to determine where the irregularities reside and thereby guide dermabrasion. Oftentimes, irregularities will only be palpated rather than seen because the subtle contour differences may not be appreciated by the naked eye. Again, the ala should be gently handled. As the ala represents the most freely mobile tissue, the dermabrader should be delicately used near or on the ala. The direction of the dermabrader should always be directed toward the free alar margin, i.e., superiorly to inferiorly, to avoid inadvertent ensnarement of the edge by the dermabrader wheel.
After the entire surface has been adequately dermabraded, any remaining hemorrhagic points can be effectively cauterized with a CO2 laser. The CO2 laser should be used sparingly to seal any major bleeding and to pass lightly over the entire nasal surface to increase hemostasis and to effect some mild tissue tightening. The caveat that thermal injury is an unfavorable element should be recalled, and laser technology should be used only at the conclusion of the case for the above stated reasons rather than as an instrument for tissue ablation. Alternatively, if a laser is unavailable, then selective cautery can be used for any major sites of bleeding (Figure 7-24A) and thrombin adhesive applied liberally to enhance hemostasis further (Figure 7-24B).
At the conclusion of the procedure, liberal application of Bacitracin ointment should be applied and continued for 2 weeks until complete epithelialization has occurred in order to maintain a moist environment that will expedite epithelial regeneration. Of note, the abnormal rhinophymatous tissue will require a longer time to complete epithelialization than after skin resurfacing of normal skin areas. Therefore, the antibiotic ointment is maintained for the longer two-week period required for completed epithelialization. Light Xeroform gauze is applied to the resurfaced areas of the nose and left intact for the first two postoperative weeks as a biologic dressing (Figure 7-25). This covering serves to minimize bleeding and to camouflage the unsightly appearance of the resurfaced nose.
Salient Technical Points
Correction of the Ptotic Nose
1. Septal angle resection provides limited benefit to nasal elevation in the aging nose. An incision should be made 1 to 2 mm cephalad to the caudal septal border rather than on the mucosa inferior to the septal border, as determination of the septal dissection plane (for septoplasty) is much more difficult if the incision is made in the standard transfixion position. A fine pair of sharp scissors should then be used to retrodissect the cartilaginous septal angle from the surrounding tissue.
2. A columellar strut should represent the minimum necessary to correct a ptotic nose and can be effectively combined with other techniques to achieve maximal nasal elevation and to maintain longevity of the result. An endonasal technique is preferred for simplicity and direct access.
3. Lateral crural overlay represents the workhorse technique to correct moderate to severe nasal-tip ptosis. An external approach is advocated in order to enhance visualization and assessment and to facilitate ease of surgical dissection and suture fixation. The lateral crus should be transected approximately one-third the distance from the pyriform aperture to the nasal tip, nearer to the pyriform aperture; and only 1 to 2 mm of cartilage should be overlapped for the initial attempt, as significant tissue rotation occurs even with minimal tissue overlap.
4. Transcutaneous nasal elevation should be reserved for the more mature patient who desires an expedient but effective method for severe nasal tip ptosis. Although this technique may appear to stand contrary to aesthetic principles, the scar tends to heal exceptionally well and has not been a conspicuous entity in the patients who have undergone this procedure. The fusiform excision should be centered over the mid-nasion and dissection should be carried out only under the inferior wound edge until the nasal tip is adequately mobilized for elevation. Periosteal fixation sutures retain the nose in the desired height.
Correction of Nasal Valve Collapse
1. The spreader graft alleviates internal valve collapse and achieves the most dynamic expansion of the valvular region via the endonasal approach. The closed technique also permits a rapid and simple method for graft insertion in which the patient can report symptoms of nasal improvement when light sedation is used. The pocket should be made first before graft harvesting in order to permit time for hemostasis to be achieved. The pocket also should be created high along the dorsal aspect of the septum approximately the width of the elevator tip by nudging the elevator forward rather than a sweeping motion. And the pocket should be made as high as possible by pulling the elevator back along the upper lateral-septal junction. The thickest portion of septal cartilage located at the posterior bony-cartilaginous junction will facilitate the most cantilever action of the upper lateral cartilage.
2. The alar batten graft is intended for correction of external valve collapse. An endonasal approach is preferable for the ease and rapidity of the surgery. Septal cartilage should be used if possible in order to achieve the requisite rigidity to maintain valvular patency. Also, the cartilage must be inserted all the way to the pyriform aperture so that the cartilage provides a buttress effect rather than contributing to additional weight of the ala if it is too short. The pocket should be created in a supraperichondrial sub-SMAS plane superficial to the lateral crus, aiming the scissors laterally toward the pyriform aperture.
Correction of Rhinophyma
1. A No.10 blade should be used to remove the large majority of the bulbous excess before wire-brush dermabrasion is used to refine the nasal contour. Thermal injury is avoided by using this combined cold technique.
2. The affected nasal regions should be approached in a systematic sequence advancing from subunit to subunit and working in a symmetrical fashion. The ala should be cautiously approached so that adequate tissue is preserved to avoid unfavorable scar contracture and external valve compromise. The dermabrader should always be directed toward the alar margin to avoid ensnarement of the alar edge.
3. Careful palpation of any irregular contour should guide dermabrasion. CO2 laser or selective cautery can be used to achieve more complete hemostasis before completion of the procedure.
4. Liberal Bacitracin ointment should be applied and continued to maintain a moist environment, and Xeroform gauze should be left in place for a two-week period until complete re-epithelialization has occurred.
Postoperative Considerations: Care, Follow-up, & Complications
A. Postoperative Care & Follow-up
Postoperative Care for Rhinoplasty
Nasal postoperative care is a rather straightforward affair, but certain subtleties should be underscored so that the most favorable result is ensured. The patient should refrain from any vigorous activity and should not bend over or place undue pressure with valsalva maneuvers or other stressors. Unlike other surgery, ice is not applied to the nose if a nasal splint is in place so that the precipitation from the ice pack will not loosen the nasal splint. As with all facial surgery, the patient should prop his or her head up and sleep in an inclined position to minimize collected edema. On the morning of the first postoperative day, the patient is instructed to remove the nasal Telfa tampons but to continue with nasal tip dressings until all sero-sanguinous discharge has abated. If a nasal splint or adhesive is present, then the patient should also not shower or immerse the head otherwise both will be liable to come unfastened. On the morning of the 7th postoperative day, the patient should take a steam shower to loosen or remove the nasal splint and/or adhesive. When the patient arrives at the surgeon’s office, the nasal splint and adhesive should be easy to remove or have already fallen off. Any external incisional sutures should also be removed at this time, and gentle cleaning of internal debris and clot should be performed with a cotton-tip applicator soaked in peroxide solution.
Photographic documentation (only lateral and frontal views) should be obtained at the one-week visit for medico-legal purposes: if the patient should sustain injury to the nose thereafter a record will be present to attest to its state in the immediate postoperative period. Photographs are then taken at 1 month, 6 months, and1 year postoperatively, and then yearly thereafter. Patients should never be discharged but encouraged to return for visits. As mentioned earlier, the surgeon should always be a diligent student of his or her work in a formal manner. Rather than a casual glance at the patient’s nose, the surgeon should study the comparative pre- and postoperative views critically on a yearly basis at a very minimum. Only after careful scrutiny of all previous work will a surgeon improve his skills. The rational, systematic approach that has been advocated above has been culled from meticulous and repeated study of postoperative results. The authors contend that indiscriminate external rhinoplasty with major structural grafting will lead to unpredictable results 5 to 10 years later.