Individualizing Rhinoplasty Techniques: A Rhinoplasty Practice Blend of Endonasal and External Columellar Approaches

The Evolution of the Combined Use of Endonasal and External Columellar Approaches to Rhinoplasty

Over the past twenty years my experience of using a variety of eclectic techniques in

rhinoplasty performed primarily for the endonasal delivery flap approach has evolved

into a rhinoplasty practice using the external columellar approach in approximately forty

to fifty percent of cases to achieve the desired results. The concept of a graduated

approach to achieve a pleasing aesthetic result for the patient has been foremost in the

personal philosophy I have used over these twenty years. The evolving need to achieve

more refined results and prevent late complications has resulted in the increasing use of

the external columellar approach, which allows the opportunity to use certain grafting

techniques. This has been my personal philosophy that the least intervention in the

shortest operative time to achieve a satisfactory operative result and satisfy the goals of

the patient is foremost in my operative plan. However, the increasing opportunities to

use techniques to prevent what I have seen as late complications in endonasal rhinoplasty

have prompted me to utilize the open technique in a larger number of cases than

otherwise indicated in the primary evaluation of the patient. In reviewing my

approximately twenty years of experience, I have found that the two areas that most

commonly cause late problems in rhinoplasty using the endonasal delivery flap approach

are in the areas of the mid nasal pyramid and lateral alar sidewalls. It is paramount to

establish a structural foundation to the mid-nasal vault, which can prevent late inward

contraction of the upper lateral cartilages. Additionally, recognizing cephalic position of alar

cartilages and otherwise inherent weakness in the alar cartilages in the preoperative plan has led

to the increased use of alar batten and strut grafts to prevent external nasal valve collapse and the

im______ recurvature of the lateral nasal alar walls. Although both of these issues can be

corrected using the endonasal approach only, it is sometimes far easier to place structural grafts

through the external columellar approach.

Many philosophies in promoting external columellar approach to rhinoplasty have based their

sole purpose on maintaining integrity of support to the nasal tip and preventing later loss of tip

support. By using the external or open approach to rhinoplasty, other authors have maintained

that one is not interrupting tip-supporting mechanisms and tip support is of prime importance to

the overall aesthetic result. In fact, placing tip projection as a primary maneuver over profile-

plasty has been the order of motis operandi. It is my opinion that delivery flap approach to

endonasal rhinoplasty provides extremely satisfactory, if not superb maintenance of tip

projection and overall lobular and tip support. Allowing the profile to be set and the tip to be

adjusted according to the predicted and newly aligned profile has been a very excellent motis

operandi in my practice. It is not tip support or tip projection that has been the problem over the

long haul in endonasal rhinoplasty. Certainly, using the graduated approach to lobuloplasty, it

has always been preferable to use the external columellar approach to add structural grafting,

increasing the substantial amount of tip projection. In addition, when marked reduction of an

over projected nose is required, an open approach is, again, often easier to accomplish this

maintaining good symmetry and otherwise structural support.

These points will be emphasized in the graduated approach to the various problems one sees in

the preoperative condition in the tip and lobule. The nature of the mid-nasal vault and length of

the nasal bones will also dictate whether or not an external columellar approach is indicated

when otherwise an endonasal approach would be satisfactory to accomplish nasal tip plasty

goals.

Preoperative evaluation in rhinoplasty is paramount in determining the techniques that will be

required to achieve the aesthetic and functional results desired by the patient and predicted by the

surgeon. The consultation with the patient requires a detailed evaluation of the patient’s

concerns, desires and history related to their nose. Whether or not there has been significant

trauma to the nose and/or previous surgery is critical in determining the type of surgery that will

be required as well as the approach that may be dictated to accomplish those goals. The

preoperative nasal evaluation sheet is very helpful in documenting the aesthetic and physical

evaluation of the nose.

When it involves the lobule, the preoperative analysis is critically important in determining the

“problem with the tip” and planning the appropriate approach and technical maneuver for the

aesthetic correction. One must determine whether or not the tip is bulbous, broad, wide, boxy,

bifid, trapezoid, twisted, asymmetrical, amorphous, infantile, over projected, under projected,

under rotated or over rotated. Evaluation of the tip is based on visual inspection, palpation and

photographic analysis. Palpating the nose determines the nature, volume strength and resiliency

of the lobular cartilages. This is critical to one’s surgical plan. One must determine the tip

support structures that are in place in this individual patient with special attention to the septum

and septal angle. The thickness of the skin envelope, whether it is quite thin and showing and

relief the definition of the strong alar cartilages or alternately that the skin is quite thick, hiding

otherwise soft lobular cartilages, is extremely important. Whether or not there are columellar

distortions, such as hanging, retracted, angulated or twisted columella. Evaluation of the base of

the columella at the nasal spine is important to determine whether or not the tip is over projected,

under projected, relating to an over prominent nasal spine, or is a pinched nose related to an

overgrowth of the nasal septum. Is a tip hanging from the nasal septal angle or is it supported on

its own right by the strength of the alar cartilages? Are the alar cartilages normally oriented or

are they more cephalically positioned, leaving the lateral nasal alar walls without cartilaginous

support? The nature and shape of the alar cartilages are extremely important as well – Are the

cartilages extremely convex, concave, rolled, flattened, wide or narrow? Are the alar cartilages

long, creating an under rotated nose with a relatively short medial crura? or Are the medial crural

feet short whereby the tip would lose significant support when released from the nasal septum?

These are all questions that are vital to determine at the time of the physical examination of the

patient.

The next critical area in determining the extent of surgery required and the approach that will be

necessary is the length of the nasal bones, the prominence of the nasal hump, and the width or

strength of the upper lateral cartilages. If a patient presents with a very large projecting nasal

hump and an overly narrow nasal pyramid, yet short nasal bones, there is a high probability of

inward contraction and late deformity of the mid nasal vault if the mid nasal vault is not

supported at the time of primary surgery. Evaluating the extent of the deviation of the nose and

how much the deviation of the septum relates to the deviation of the nasal pyramid and lobule is

critical to determine how much septal surgery is indicated to correct this and yet maintain mid

dorsal support. Is the septum so deviated that a caudal approach to the septoplasty is extremely

difficult and a dorsal approach would be much more efficacious in correcting the caudal septal

deformity?

Hs the patient had one or more previous nasal surgeries, creating significant scarification of the

soft tissue overlying the alar cartilages and lobule and hiding the amount of excisional surgery

performed on the structural integrity of the lobule from previous surgery? How much grafting

will be required to attain a newly supported and aesthetic result? This may require an external

columellar approach in order to adequately suture grafts in place and determine the extent of the

previous excisional surgery.

Finally, the extent of the need for augmentation of the nasal dorsum will dictate the type of

grafting material placed for any individual patient. The choice may involve autogenous cartilage

grafting using alternative operative sites such as ear conchal cartilage or rib cartilage and the

access or approach may be alternated between an endonasal or an external columellar approach.

If, however, autologous grafting is indicated, such as the use of GoreTex or Alloderm, one may

choose to use a separated external columellar incision from the dorsal graft to prevent any

chance of late graft exposure and infection.

Other factors that determine the need for a more aggressive approach and more visibility for

grafting is a markedly under projected or over projected nasal tip, a markedly over rotated or

under rotated nasal lobule, and a markedly asymmetrical nasal tip. These particular anatomical

variants are much more difficult to adequate assess and correct through the endonasal delivery

flap approach or other “closed” nasal procedures.

In general, the use of the external approach has increased as one recognizes the need for

increased use of grafting to not only correct the preexisting preoperative condition, but also to

prevent later aesthetic and functional problems related to surgical maneuvers performed in the

primary rhinoplasty. The increased use of spreader grafts to maintain mid nasal vault integrity

and the increased use of alar batten and strut grafts placed in the vestibular side of the alar

cartilages has increased the need to use the external columellar approach to properly place these

grafts, in my practice.

Following the initial consultation during which the historical and physical evaluation of the

patient has been obtained and documented, the patient is brought into the photographic area

where a series of standard preoperative photographs are obtained. Photos taken for computer

imaging analysis are obtained simultaneously to increase the communication about the

preoperative plan with the patient. The same excellent standardized lighting and background are

used for both the digital photography of the preoperative standard views for rhinoplasty as well

as for use of computer imaging alterations. I find it extremely helpful in the evaluation as well

as educational part of the consultation with the patient to perform video imaging and computer

simulation of the aesthetic results that I predict can be accomplished with any given individual

patient. This has occasionally caused a patient to elect not to have surgery due to the fact that the

predicted results are not as dramatic as they desire or hoped to achieve with the amount of effort

and expense involved to undergo the procedure. It is vitally important to any cosmetic procedure

that the patient is committed, not only to the extent of postoperative recovery, but also to the cost

involved in having the procedure. An unrealistic expectation as to the results sets up the

opportunity for an unhappy patient with an otherwise satisfactory operative result. Computer

imaging enhances the communication with the patient about the expected results and the

potential results achievable well beyond any examination in front of a mirror or drawing or

otherwise standard photographs. One can actually learn from the patient their desires about

profile relationships, which may or may not mirror exactly the surgeon’s preference. It is also

important to be extremely honest and accurate regarding the corrections that can be made on the

computer image in relationship to the preoperative condition of the patient and the abilities of

our surgical techniques to accomplish an “ideal” aesthetic result. Given that limitation and the

fact that each patient has signed a waiver stating they understand this is a predictive illustration

and not a guarantee as to the exact replication of the aesthetic result surgically has been

extremely positive adjunct to the consultative process in my practice over the past seventeen

years that I have been using it. At the least, it allays the fears of any given patient that they will

not look like themselves once the nose is altered, even though they strongly desire modification

and improvement in their nasal appearance.

The preoperative preparation for a patient involves the identification of any bleeding, diastases,

or abnormalities and assuring that they are in satisfactory health status to undergo anesthesia. A

CBC, PT, PTT and platelet count are obtained on all patients. If the patient is over forty years of

age, we require an electrocardiogram as a minimum assessment of their cardiac performance.

All nasal surgery can be performed as an outpatient in an ambulatory surgical setting. The most

common anesthetic for nasal surgery is monitored anesthesia controlled sedation technique. The

patient is usually not intubated with an endotracheal tube and is administered anesthesia through

an intravenous combination of sedatives and narcotics. Their breathing, oxygen saturation,

blood pressure and cardiac activity are monitored continuously. However, increasing use of

general inhalation anesthetics which are short acting have minimum incidence of nausea has

been used in our practice. Although the use of propofol intravenous sedation has been

successful, this has been replaced due to lesser cost factors related to using the newer inhalation

anesthetics. If a patient is under twenty years of age, we have found that sedation anesthetics are

variable in their effectiveness to maintain a quiet and comfortable patient for the procedure.

Almost routinely, general anesthesia is used for the younger age group rhinoplasty patient.

Controlling the airway and administering O2, minimizing any swallowing of blood during the

procedure has been accomplished through the use either of endotracheal intubation or pharyngeal

intubation and the use of a LMA tube.

Each patient is topically anesthetized in the preoperative area with Afrin or Diclone nasal spray

to begin vasoconstriction. Once in the operating area and after having undergone the initial

induction of anesthesia, cocaine 4% on 1x3 cottonoids is used for topical vasoconstriction and

anesthesia. The nose is then infiltrated externally and internally completely with about 6-cc to 7-

cc of Xylocaine 1% or 2% with 1:100,000 epinephrine and 1:50,000 epinephrine; 1:50,000

epinephrine has been found to be very safe as long as the patient is monitored and provides a

significant degree of increased vasoconstriction throughout the procedure.

Access Incisions

Incisional access to the patient is, of course, dictated on whether the decision was made to

approach a nasal surgical procedure endonasally or with an external columellar incision. The

endonasal delivery flap approach is performed in the majority of cases, but there are occasions

where a retrograde or transcartilaginous approach is used in increasing numbers of cases where

an external columellar approach is used. The access incisions for delivery of the alar cartilages

involve bilateral marginal and intercartilaginous incisions. The intercartilaginous incision at the

lymen vestibularly is connected with a high septal transfixion incision. The septal transfixion

incision is carried down inferiorly if deprojection is desired. These parallel incisions are used to

deliver a bipedical congro cutaneous flap. I do agree the approach is particularly valuable and

useful in the primary nasal procedure where no undermining has been performed previously over

the alar cartilages. Once scar tissue adherence has occurred, it is very difficult to do a delivery

approach and an external columellar incision may be required just on the basis of the amount of

scar tissue and ciccatrixial contraction to the cartilages themselves from the overlying skin and

soft tissue. In the event an external columellar incision is indicated, I prefer an inverted (V)

columellar incision. This is in the ?Reathey? form and it is placed at the junction of the

columellar, between the lower three-thirds and the upper one-third of the lobule. It is connected

carefully to marginal lateral medial crural and marginal lateral crural incisions.

Indications For An External Columellar Incisional Approach to Rhinoplasty

Throughout my practice, it has been customary that I have primarily done secondary revisional

nasal surgery through the external columellar approach. There are certain cases where small

pocket grafting and minimum revision procedures are indicated and an endonasal approach can

be useful without opening the nose to completely correct the preexisting problems.

Whenever a patient requires significant tip grafting for under projection, an overly shortened

nose, alar collapse or an asymmetrical tip, I have used the external columellar approach.

Significant over projection has also been an indication for an external columellar approach to

maintain structural integrity of the lobule as it is markedly reduced. Soft nasal lobular cartilages

of the infantile type were lacking any real adherent support has dictated an external columellar

approach to add structural grafting. Finally, the indications have increased significantly late in

the last five to eight years with the increased use of spreader grafts in the mid nasal vault and the

increasing use of alar batten and strut grafts for lateral alar collapse and cephalic position of the

alar cartilages. There have been occasional cases where the significant deformity of the nasal

septum and significant columellar deviations have dictated an external approach to untwist these

deviations and actually approach the septum properly.

Finally, I have found on occasion that, despite making preoperative plan to approach the nose

and nasal lobule with an endonasal delivery flap approach, it has been necessary in the middle of

the operation to convert to an external columellar incision and open the nose completely in order

to correct the asymmetries or anatomical variants that have been discovered when it was

otherwise not possible to achieve the desired aesthetic result with good symmetry and predictive

outcome otherwise.

There are a few indications in my practice, in approximately three to five percent of cases,

whereby the inherent nature of the tip, infratip lobule and facette area has dictated no surgical

intervention and only minor modification of the cephalic portion of the alar cartilages has been

required. These cases would lend themselves very nicely to either retrograde approach or a

modification of the transcartilaginous approach to trim the cephalic margin of the alar cartilages

and otherwise not disturb and undermine nasal tip skin. One such case is shown in the

accompanying illustration.

It is important to determine the order of procedures in any rhinoplastic surgical operation. One

procedure may preceed and be in a specific order for an otherwise harmonious result. A

predictive plan is vitally important to achieve the entire result planned as well as to keep the

efficiency of the operating time down.

The order of procedure in the endonasal delivery flap approach to rhinoplasty is as follows: (1)

access incisions, (2) deliver the alar cartilages, (3) trim cephalic margins of alar cartilages as

indicated, removing the dorsal profile component of the alar cartilages, (4) shorten the caudal

septum, if appropriate, (5) perform septoplasty and/or harvest septal cartilage for grafting

purposes, (6) expose the dorsum and perform profile plasty, (7) place spreader grafts, if indicated

(even in the endonasal approach), (8) perform single and double dome suturing as indicated in

graduated fashion with final tip modification, (9) place alar batten grafts, if required (even

through the endonasal approach), (10) place columellar strut and stabilize the medial crura, (11)

perform medial, followed by lateral, osteotomies, (12) placement of onlay or radix grafts in the

nasal dorsum, (13) close intranasal incisions- both intercartilaginous and columellar, (14) at this

time, in an endonasal approach, place infratip lobular or soft tissue tip grafts or morselized

plumping grafts, as indicated, (15) alar base narrowing, (16) apply dressings with Surgicel under

domes.

The order of approach using an external columellar incision is only slightly different in that,

depending on the need for tip projection enhancement or reduction, it is imperative to set the

nasal dorsum to the appropriate level, then perform the final tip maneuvers with sutured on grafts

and/or lobular reduction to fit the appropriate profile relationship. It is also imperative to place

spreader grafts prior to lobuloplasty. It may be required to perform medial osteotomies prior to

spreader graft placement and lateral osteotomies later on.

It is important to know at this juncture that my philosophy on tip support mechanisms is crucial

to the predicted outcome of the long term nasal tip projection and support. Although it is true

that many of the incisions required for access to endonasal delivery flap approach weaken the

support of the nasal lobule and what otherwise would decrease tip projection restructuring the

nasal lobule with the double dome suturing technique and resuturing the incisions as well as

providing strutting support to the columella, more than compensate for the loss of support from

the incisions alone. It has always been my philosophy that, if it is required to interrupt any of the

tip supporting mechanisms in order to accomplish the functional aesthetic result, one should do

this and just realize that reconstructing or compensating for this loss of support is equally

required. It is not inherently the nature of the approach of the operation that is dictated by

whether or not the supporting mechanisms are interrupted, but is it what one needs to accomplish

in final result that dictates the approach.

Approach to the Septum

My approach to the septum is either through a hemi transfixion incision or through one side of a

high septal transfixion incision extending into a hemi transfixion incision. Occasionally, when I

perform a complete transfixion incision for reasons of tip deprojection, one can choose either

side for the approach to the septum. Generally, I approach the septum on the side of the

deviation or large spurring, but I do not hesitate to elevate both sides of the caudal septum or

septal cartilage if there is significant deviation requiring bilateral flap elevation. The

mucoperichondrium is elevated initially through the use of sharp dissection using curved Iris

scissors and a dental amalgam packer to score and slide underneath the mucoperichondrium in a

matter of a few seconds. A combination of, primarily, blunt and some sharp dissection is then

used to sweep and elevate the mucoperichondrium, exposing the deformity of the septum and/or

allowing access to obtaining harvest grafting for rhinoplasty reconstructive procedures. The

nose is never packed. For reasons of mucoperichondrial flap repositioning, a mattress suture of

4-0 plain catgut on a short Keith needle is used in a mattressing fashion to reappoximate the

mucoperichondrial flaps and prevent hematoma. It is my philosophy that positioning the

turbinates laterally and/or turbinate reduction is of critical importance in maintaining airway,

particularly when reducing the overall size of the nasal pyramid. Submucous outfracture of the

nasal turbinates is a frequent procedure performed in primary rhinoplasty. Occasionally, a small

amount of reduction in the mucosal aspect of the turbinate is required using a submucous

electrical cauterization technique. When significant airway improvement is required for reasons

of turbinate hypertrophy and allergic rhinitis, direct partial turbinectomies are preformed. This is

a combination of removing one-third to sometimes one-half of the excess and hypertrophied

redundant portion of both the mucosal and bony portion of the inferior turbinate. When this is

performed, fingercot packing is placed in the nasal passage at the end of the operation to prevent

synechia from forming to to the septum. This fingercot packing, involving a finger of a latex

glove and a 1x3 cottonoid impregnated with Bacitracin ointment, is placed in the nasal passage

between the lower edge of the turbinate and the septum and sutured in the nasal vestibule. It is

removed at four days postoperatively.

Profile Plasty

Prior to performing the true modifications to the nasal lobule, but after the cephalic margin of the

lower lateral cartilages has been trimmed appropriately, profile plasty is performed. Over the

years, reduction of the nasal profile has been more and more conservative based, not only on the

aesthetic desires of the individual patient but also the aesthetic goals that I have personally

desired to achieve. These aesthetics are dictated both by our own personal ideas of harmonious

balance of the profile to the overall facial profile and with the trends in society and the concept

of beauty within our society. Besides the aesthetic goals that both the patient and the doctor

desire, conservative reduction of the nasal profile has proven to be a much more stable and

predictive procedure for long term results in rhinoplasty. Significant reduction in the mid nasal

profile for an immediate nasal result has proven to be an over reduction in the profile alignment

five to ten years down the line.

One important criterion in reducing the cartilaginous profile is maintaining the integrity of the

mucoperichondrium. My first maneuver before reducing any cartilaginous dorsum is to

undermine the mucoperichondrium from the undersurface of the upper lateral cartilages as they

join the septum. In years past, a complete reduction of the cartilaginous profile was performed

with a #11 blade and a trans upper lateral cartilage septum and even mucoperichondrium, if

necessary. The evolution and conservative reduction of this profile in combination with

separating the mucoperichondrium and often separating the upper lateral cartilages prior to

dorsal septal reduction has offered a more stable predictive result. Separate reduction of the

upper lateral cartilages from the septum is a much more controlled reduction. In addition,

separating the upper lateral cartilages from the septum and forming a pocket for spreader grafting

has been helpful to maintain the width integrity of the mid nasal vault as well as the internal

nasal valve. Despite no traumatic reduction of the upper lateral cartilages and cartilaginous

profile and no dislocation iatrogenically of the cartilaginous dorsum from the bony dorsum, late

inward contracture of one or both sides of the cartilaginous mid nasal vault has occurred three to

ten years later. This creates a relative bony bump on one or both sides of the rhinion and an

otherwise depressed look, pinched look or hour glass deformity as a late consequence of standard

profile reduction.

Prior to placement of any kind of stabilizing spreader grafts, the bony cartilaginous dorsum

needs to be reduced appropriately. Again, conservative reduction is indicated, but I prefer, if

possible, to use a sharp Cinelli osteotome. A Cinelli osteotome is used due to the fact that it has

guards on either side. Sharp edges that are otherwise not beveled with an osteotome can create

incisions laterally in the dorsal nasal skin if over aggressive reduction of the hump is performed.

Rasping is used whenever possible and certainly to smooth any rough edges of the nasal bones

after they have been reduced sharply with an osteotome.

It is worthwhile to note that lesser reduction of the overall bony and cartilaginous profile has

been performed with increased identification for the need and use of radix grafts. Noting a

deeper slightly acute nasal frontal angle has been very helpful in planning use of an

augmentation graft in this area. This allows maintenance of a stronger bony and cartilaginous

profile and less reduction of the structural tissues, yet achieving a nice straight smooth aesthetic

result. Increasing use of spreader grafts in patients with relatively short nasal bones, tall dorsal

humps, and narrow nasal pyramids preoperatively has indicated increased use of an open

approach to accomplish this. Suturing the upper end of the spreader grafts to the dorsal septum

just caudal to the perpendicular plate and overlying nasal bones is challenging through the closed

or endonasal approach. Predicting this late potential for inferior and lateral contracture of the

upper lateral cartilages, leaving a dorsal ridge of bony and cartilaginous septum visible has

increased the use of spreader graft and morselized onlay grafts at the end of the operation.

Certainly, correcting the deformity with an onlay graft is helpful and can be used in the future.

However, the use of a small onlay graft in relatively concave upper lateral cartilage as a primary

preventive procedure is extremely helpful and is placed at the very end of the operation prior to

splint placement. It is often required to perform medial osteotomies in order to properly position

the spreader grafts. In the endonasal approach, with minimum hump reduction, one can

sometimes maintain enough integrity to keep the spreader graft in place without suturing.

However, with any hump reduction, it is required to suture the graft so that it does not cantilever

upward and form a visible contour abnormality. Use of spreader grafts is primarily for

preventive cosmetic deformities and is only occasionally used for true improvement of internal

nasal valve widening and airway improvement. (A couple of patient examples showing the use

of radix grafts, spreader grafts, profile plasty and hump reduction.)

Overall indications for spreader grafts are as follows:

1. Unilateral asymmetry with infracture or inward curvature of one upper lateral

cartilage. This could be a posttraumatic condition, iatrogenic from previous surgery, or

developmental.

2. Bilateral inward curvature of upper lateral cartilages with “hour glass” appearance. This is

most commonly iatrogenic.

3. An extremely narrow pyramid with a tall dorsal hump and thin skin and short nasal bones.

4. Prophylactically preventing delayed contracture deformity of the upper lateral cartilage bony

nasal bone junction.

5. Stabilizing the mid-nasal vault.

6. Correction of mid-nasal vault deviation, both from a true corrective deviation standpoint,

stabilizing the dorsal nasal septum as well as a camouflage technique.

7. The use of bilateral spreader grafts as a cantilever to lengthen the overly rotated lobule.

Osteotomies

My preferred technique for osteotomies involves always completing medial osteotomy with or

without hump removal using a 6.0 millimeter curved osteotome transmucosally from inside the

nasal vault. The procedure is done via an open technique. Occasionally a medial osteotomy will

be completed with a 3.0 or 4.0 millimeter osteotome under direct vision and not transmucosally.

However, once the medial osteotomies are complete, a #15 blade is used to make an incision just

superior to the anterior end of the inferior turbinate along the piriform aperture. Subperiosteal

dissection, forming a path for the guarded Nievert osteotome is made on the under surface of the

nasal process of the maxilla and nasal bone. This is a submucal periosteal elevation on the

internal aspect, not the lateral aspect, of the nasal bone. Once completed, a guarded Nievert

osteotome is used with the guard internal and the outward sharp pointed edge beveled off at a 45

degree angle. This allows one to perform the low curved lateral osteotomy and any mucosal

tears would be internal, allowing internal oozing to occur rather than bruising and extra edema

laterally or out under the eyes and in the midface.

Profile plasty may also involve dorsal augmentation for relative and true saddle nose

deformities. These may be either congenital, posttraumatic, or iatrogenic. The use of implants for dorsal augmentation has enhanced the overall aesthetic results of rhinoplasty. In most all cases, one can avoid the use of autogenous rib cartilage. I personally do not favor using any kind of bone