Nonoperative Technique

In patients for whom operative intervention is questionable because of previous surgery, unobtainable expectations, or concerns of a body dysmorphic disorder (BDD) variant, nasal contouring with injectable fillers has been extremely successful.

Operative Technique

The closed approach is used when a moderate dorsal reduction without spreader grafts and minimal tip work is planned. An open rhinoplasty is mainly performed when multiple maneuvers are needed, including spreader grafts and complex tip work.

An open rhinoplasty is performed with a stair-step columellar incision at the narrowest part of the columella. The soft tissue is separated from the alar in the subperichondrial plane until the tip is degloved. The dorsum is mobilized with a periosteal elevator. A cephalic trim is often performed first, leaving an appropriate width of lateral alar cartilage to provide strong support.

The options for dorsal reduction are as follows:

• 1.
  

  Modest dorsal reduction (<1 mm) only requires rasping of the bone and sharp shaving of the cartilaginous dorsum.

  
  
• 2.
  

  Reductions of more than 2 mm first require separating the upper lateral cartilage from the septum to prevent mucosal injury before the cartilaginous dorsum is resected with angled septal scissors and rasping of the bony dorsum.

The options for dorsal nasal augmentation are as follows:

• 1.
  

  Temporalis fascia graft for 1 mm of augmentation or to disguise the dorsum in the case of extremely thin skin

  
  
• 2.
  

  Septal cartilage onlay for 1 to 2 mm that includes the need for definition temporal fascia and

  
  
• 3.
  

  Crushed cartilage (auricular) sausage technique for 2 to 4 mm

  
  
• 4.
  

  Rib cartilage when structural support is needed or more than 4 mm is desired

  
  
• 5.
  

  Fascia is well suited for radix grafts because multiple layers may be used to obtain the desired thickness

The resultant open roof defect from dorsal reduction is closed using an external 2-mm osteotome low to high or low to low medial oblique osteotomy. A medial oblique osteotomy is first performed using a 3-mm osteotome. This results in a more predictable osteotomy closure in the male nose.

The middle vault is then reconstructed:

• 1.
  

  The redundant upper lateral cartilages are often folded medially and sutured to the septum with 5-0 PDS sutures to reconstruct the nasal dorsum.

  
  
• 2.
  

  Spreader grafts are liberally used to reconstruct the internal nasal valve, straighten the nose, and/or achieve strong dorsal aesthetic lines.

Finally, the lower third is addressed. The intention is to establish well-supported and symmetric lower lateral cartilages, tip rotation of 90 to 95 degrees, and columellar-lobular angle of 10 to 45 degrees. Projection is achieved in a stepwise fashion, first with suture stabilization of the medial lower lateral cartilage, with or without a floating columellar strut if maintenance of the tip projection is desired. A transdomal mattress suture is used if up to 2 mm of additional projection is needed. A columellar strut reaching the nasal spine or dorsal extension graft is used if significant projection is needed. Finally, onlay grafts are occasionally necessary for increased tip projection or definition, but are avoided, if possible, to prevent the well-known risk of graft visualization.

Skin thickness plays a key role in which maneuvers are performed to create a masculine nose. Less aggressive tip sutures are needed in thin-skinned patients, whereas thick-skinned patients may not even show the most aggressive suture work. Suture techniques with tip-defining transdomal sutures and interdomal sutures are performed last and assessed with periodic skin redraping to determine progress. A tip dorsal measurement of 7 to 11 mm is desired and measured with calipers prior to closing. Less than 7 mm can be necessary when no supratip break is necessary, and more than 7 mm is necessary in a scarred or thick soft tissue envelope.

Closure is started by precise alignment of the stair-step incision with 6-0 nylon sutures and carried laterally to the skin-mucosal junction. The mucosa is then closed with 5-0 chromic simple interrupted sutures. Redundant mucosa is trimmed as needed.

The nose is protected with Steri-Strips and an Aquaplast dressing. An internal Doyle splint is used if the septum is altered; it is always secured transseptally with 3-0 silk sutures.