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The Facial Plastic Surgery Center
Dr William Portuese - Board Certified Facial Plastic Surgeon

Surgical Options in Fixing Nose Issues


Dorsal Surgery

Surgical Techniques


Dorsal Surgery Septoplasty The area in red represents the septum. When the septum is crooked or deviated, it must be straightened to permit functional breathing. This also represents the area of cartilage and bone that is the internal portion of the nose, which can be used for dorsal augmentation to build up the bridge or sidewalls of the nose used in structural cartilage grafting for a rhinoplasty.

Normal Anatomy

Dorsal Surgery Underneath the skin envelope of the nose, the upper portion of the nose consists of two paired nasal bones which form the solid bridge of the nose attached to the forehead. Below that are triangular cartilages called the upper lateral cartilages that attach to the nasal bones. Below that is the more flexible portion of the nose made up of the lower lateral tip cartilages which composes the shape and structure of the nasal tip. The nasal septum is composed of both septal cartilage in the front of the nose, and the top and bottom portions of the septum are composed of ethmoid bone and vomer bone.

Dorsal Surgery – Reduction

Dorsal Surgery The area shaded in red shows the area of the bridge where a bump would be present. It is removed to further refine the dorsal aesthetic line or also known as a hump reduction in the nose.

Dorsal Surgery – Augmentation Dorsal Onlay Septal Cartilage

Dorsal Surgery The green area represents an area of cartilage augmentation to build up the bridge when the bridge itself is too low or been previously resected or is ski-sloped and needs to be built back up. Typically the cartilage is harvested from the internal portion of the nasal septum or ear cartilage is also used. Occasionally patients require a synthetic implant to achieve the desired results.

Dorsal Surgery – Augmentation Radix Graft Crushed

Dorsal Surgery The area in green represents a small cartilage graft that is placed at the top portion of the nasal dorsum called the radix. When the bridge of the nose has an area of depression, a graft is used to build up and lengthen the nasal bridge. Additionally this procedure augments the shallow takeoff root of the nose from the forehead.

Dorsal Surgery: Augmentation Lateral Nasal Wall Grafts Crushed

Dorsal Surgery The green areas represent cartilage grafts that are placed over the nasal bone or upper lateral cartilage area to bolster the strength and augment the sidewalls of the nose during a rhinoplasty.

Tip Surgery – Claudal Septum Resection Slanted

Dorsal Surgery The area in red shows the resection of cartilage that is done where there is a deviated septum and where the portion of the base of the nose is warped and blocking the airway. It is also done to trim off excess columellar show when the columella is hanging down too far below the nostril rim. This can be both cartilage and skin, it can be trimmed, and is frequently done during a rhinoplasty procedure.

Tip Surgery – Columellar Strut Floating With Sutures

Dorsal Surgery On occasion when there is loss of tip projection or support in the tip, a cartilaginous columellar strut is fashioned from septal cartilage and positioned underneath the tip to give more projection and strength to the nasal tip.

Tip Surgery – Lateral Crural Cephalic Removal

Lateral Crural Cephalic Removal The area in red shows the most common area of cartilage that is trimmed and removed to feminize, refine, and reshape a bulbous tip. This is a very common procedure during the tip component surgery of a rhinoplasty.

Tip Surgery: Tip Sutures Lateral Crural Spanning

Tip Sutures Lateral Crural Spanning The area in black across the nasal tip shows the area of the lower lateral tip cartilages that are sewn together to reduce a bulbous nose or a wide tip. These are sutures that are placed to refine and feminize a wide, flaring, boxy tip. Cephalic trim of the lower lateral cartilages can also be performed at the same time.

Tip Surgery: Tip Grafts Champagne Graft

Tip Grafts Champagne Graft The area in green shows small cartilage grafts placed in the tip to create further tip projection. This also helps with tip defining points and is sometimes used to give a better appearance to the tip.

Tip Surgery: Alar Base Resection Into Vestibule

Tip Surgery The area in red shows the area of the skin of the nostrils that is removed and resected for wide, flaring nostrils. Sutures are placed in the natural crease and typically disappear after the incisions are well healed.

Osteotomies Medial and Lateral

Osteotomies Medial and Lateral The red lines represent the areas where the nasal bones are narrowed during rhinoplasty. This is when the nose is re-broken and reset narrower after it has been fractured or reduced in size to narrow the width of a wide nasal bridge.

Spreader grafts

Spreader grafts Spreader grafts can lengthen a short nose, but are most frequently used to correct a twisted or pinched nose. These grafts serve to widen the mid-third of the nose and improve airflow dynamics with in the nose. Composed of cartilage from the nasal septum, the spreader grafts are typically 1-inch in length and 3 mm wide. If there is an insufficient amount of septal cartilage to construct a spreader graft, ear cartilage is an acceptable alternative. Grafts can be bilateral or unilateral, and are placed endonasally. Through a closed approach they are positioned between the perichondrium of the septum and the upper lateral cartilages to make the upper lateral cartilages less concave. Bilateral spreader grafts are typically used for a very pinched nose where widening is needed at the mid-third of the nose. Unilateral spreader grafts are used when an upper lateral cartilage has been fractured off the nasal bone on one side and simply needs to be pushed outward to correct the concaved and twisted cartilage.

Alar rim grafts

Alar rim grafts Alar rim grafts are used to strengthen the alar rim, help with valve collapse and correct contour irregularities of the tip. Composed of septal cartilage, the grafts are sculpted into a convex shape thereby increasing rigidity and convexity to prevent nostril collapse during inspiration. Through a closed (endonasal) approach, these grafts are placed on one side or both sides of the alar rim on the inside of the vestibule to counteract a pinched nostril appearance. Carved to be convex in shape, these grafts give convexity to the alar rim and prevent nostril collapse or inward migration upon deep inspiration.

Composite grafts

Composite grafts Composite grafts are used to correct alar flare or a retracted alar rim and notching. These grafts are unique because they are composed of both skin and cartilage harvested from the ear and their primary purpose is to pull down a retracted alar rim, especially when notching is present. They are placed just on the inside of the nose at the alar rim, which expands the internal nasal vestibule creating a downward expansion of the alar rim and a better alar-columellar relationship.

Alar baton grafts

Alar baton grafts Alar baton grafts are also known as lateral crural strut grafts and help with alar retraction and a concaved cartilaginous tip. Composed of septal cartilage, they bolster and strengthen the lower lateral cartilages of the nasal tip to reduce a “pinched-nose” appearance. These grafts are placed in a very precise pocket on the undersurface of the lower lateral cartilage.

Premaxillary grafts

Premaxillary grafts A premaxillary graft is used to improve the projection of the entire base of the nose. This graft is made of either septal or ear cartilage and augments the base of the nose beneath the nasal tip. The graft is placed above the periosteum at the piriform aperture just above the upper incisor tooth roots.

Columellar plumping grafts

Columellar plumping grafts Columellar plumping grafts are used when the nasolabial angle is quite low and retracted. Either septal or ear cartilage is used to fashion these grafts. They are inserted into the lip junction at the columellar base to augment and build up that area.

Cap grafts

Cap grafts Cap grafts are used when more projection or softening of the nasal tip is desired. It is a particularly useful if one is trying to decrease the bifidity or cleft of the nasal tip. The cap graft will create more projection to a flat nasal tip and minimize incongruences of the tip cartilages. The graft is composed of nasal cartilage and is placed over the dome area of the lower lateral cartilages.

Washington Ambulatory Surgery Center Association Washington State Medical Association American Academy of Facial Plastic and Reconstructive Surgery Real Self