Surgical Management of Concavities of the Distal Nose

Facial Plast Surg Clin N Am 12 (2004) 133–156

Surgical management of concavities of the distal nose

Vito C. Quatela, MDa,b, Deirdre S. Leake, MDb,*, Paul Sabini, MDa,b

aLindsay House Center for Cosmetic and Reconstructive Surgery, 973 East Avenue, Rochester, NY 14607, USAbDivision of Otolaryngology, 946 Mt. Hope Avenue, University of Rochester, Rochester, NY 14620, USA

The challenge of rhinoplasty stems from the the growth centers, which translates into abnormal

innumerable variations of the bony and cartilagi-

nous nasal skeleton. No two noses are alike, which

can leave a surgeon struggling to find a predictable

technique. While a template cannot be applied to

every case, the authors have found a series of maneu-

vers that have broad application across a wide spec-

trum of noses. The overriding principle in each case is

that concavities are, with few exceptions, unnatural

and aesthetically unpleasing. The surgeon must real-

ize which anatomical structures are deficient or mal-

formed and how to correct them.

The distal third of the nose can prove particularly

deceptive because of the wide range of anatomic vari-

ations and asymmetries in the lower lateral cartilages.

The appearance and function of the distal third of the

nose depends not only on the innate shape of these

cartilages but also upon their relationship to the upper

lateral cartilages and septum. Mastering this anatomy

and its relationship to topographical architecture

allows for predictable results.

The only naturally occurring concavities of the

nose are a slight supratip break, supra-alar hollows,

and, occasionally, minimal bifidity of the nasal tip.

Abnormal concavities of the nose include those of the

midnasal vault and lower lateral cartilage and those

secondary to skin contracture. Concavities can

arise in the context of upper lateral cartilage disloca-

tion or septal cartilage deflection. A concavity most

often represents a weakness in the patient’s nasal

framework. Etiologies include inherent buckling,

iatrogenic causes, and trauma. In children, minimal

trauma can disrupt cartilage or bone and can affect

1064-7406/04/$ – see front matter D 2004 Elsevier Inc. All right

doi:10.1016/S1064-7406(03)00123-8

* Corresponding author.

E-mail address: [email protected]

(D.S. Leake).

growth and might ultimately develop into a concavity

[1]. Even in the absence of trauma, side-to-side con-

tour asymmetries exist between crura in more than

50% of cases [2]. Identifying the particular defect

preoperatively is not always a simple task, but it will

determine the surgical management of the distal nose,

which leads to the predictable correction of the de-

pressions in the topographical surface anatomy. Cor-

rections of these deformities can involve suture

techniques or onlay grafts, or they might require

extensive anatomic reconstruction and restructuring.

Anatomy

The external nose can be divided into upper,

middle, and lower thirds. The upper third extends

from the nasofrontal angle to the rhinion. The middle

third extends from the rhinion to the caudal border of

the upper lateral cartilages. The lower third is sup-

ported by the cartilaginous septum and the triangular

upper lateral cartilage. The triangular upper lateral

cartilage derives its support from continuity with the

nasal septum, scrolling of the lateral crus (Fig. 1), and

the strong fibrous attachment to the undersurface of

the nasal bones. The upper lateral cartilages can

contribute to dorsal irregularities. The internal valve

is formed from the angle the upper lateral cartilage

forms with the dorsal septum. If this angle is less than

15�, one experiences nasal obstruction. The rhinion is

where nasal bones overlap with septal cartilage near

the superior border of the upper lateral cartilage

(Fig. 2). Trauma frequently causes disruptions at this

point. The anatomic etiology of midnasal asymmetry

can be caused by nasal bone disparity, subluxated

upper lateral cartilage, overexcised upper lateral car-

tilage, or septal deviations. Deviations of the middle

s reserved.

Fig. 1. The relationship between the junction of the upper

lateral and lower lateral cartilages represents a scroll, which

is a hinge mechanism and a major tip support.

V.C. Quatela et al / Facial Plast Surg Clin N Am 12 (2004) 133–156134

third can also be associated with inherent upper

lateral cartilage deformities.

The mobile lower one third of the nose is com-

prised of the skin–subcutaneous tissue envelope,

lower lateral cartilage, the upper lateral scroll, and

the quadrilateral septum. The character of the skin–

subcutaneous envelope can effect the definition of the

tip [3]. The quadrilateral cartilage is midline and

extends posteriorly to meet the perpendicular plate

of the ethmoid and vomer. The septum influences

projection, rotation, and symmetry of the cartilagi-

nous lower one third. The dorsal and caudal borders

intersect to form the septal angle, which is a critical

landmark for determining the position of the nasal tip.

Deformities are associated with the relationship be-

Fig. 2. (A) The triangular upper lateral cartilages attach to the unde

with the septum medially, and attach to the lower lateral cartilage

ligament attaches to the lateral crura and anterior septal angle. (B)

elements of tip support. The crural septal ligament’s attachment to

crura are also major contributors to tip support.

tween the caudal and anterior dorsal septum, the

lower lateral cartilage, and their relationship with the

upper lateral cartilage and the ala. The septum (espe-

cially the caudal septum) must be straightened and in

midline before focusing on the deformities of the

nasal tip. The lower lateral cartilages can also have a

great effect on the nasal tip position and contour. The

shape of the lower lateral cartilage is complex and

highly variable from individual to individual. The

three components of the lower lateral cartilage are the

medial, middle, and lateral crura (Fig. 2). The medial

crura are attached to the caudal septum by the

membranous septum. The columella that is formed

by both medial crura should project as a gentle curve

below the alar margin (Fig. 2B). The middle crura

bridge the medial and lateral crura. There are two

segments of the middle crura: the lobular segment

and the domal segment. The size of the middle crura

determines the shape of the tip lobule. The combined

medial crura and the two lateral crura should create a

symmetric tripod where the medial crura are the

lower legs and the lateral crura are the upper legs

based on the pyriform aperture [3]. The tip of the

tripod corresponds to the nasal tip and should be the

most projected point on lateral view. The lower lateral

cartilage, its attachment to the upper lateral crura, and

the medial crura’s attachment to the caudal septum

are the major tip supports. The junctions between

the lateral and middle crura correspond to the dome/

tip and are attached to the anterior septal angle by

the interdomal sling. The medial and lateral limbs of

rsurface of the nasal bone at the rhinion superiorly, articulate

inferiorly and the piriform aperture laterally. The interdomal

The size and shape of the lower lateral cartilage are major

the posterior septal angle and its attachment to the medial

V.C. Quatela et al / Facial Plast Surg Clin N Am 12 (2004) 133–156 135

the dome or tip should have symmetrical convexity to

achieve an aesthetic nasal tip. If either limb has a

concave shape, it will appear as a depression in the

individual’s nasal framework. The convex lateral

crura are designed for resisting collapse from nasal

inspiration and supporting the ala. If the lateral crura

are weak or have a concave position, this will also

have a direct effect on the external valve and will

impede airflow. The lateral crura parallel the rim,

diverging 15� from the rim laterally in a cephalad

direction [4]. The caudal border of the lateral crus

parallels the rim of the nostril until it nears the nasal

ala, where the crus curves superiorly to approach the

piriform aperture, which is a bony opening encircled

Fig. 3. (A, B) An inverted V deformity at the rhinion occurs second

displaced medially and inferiorly. (C, D) Postoperative results reve

and lateral osteotomies performed. (E) Intraoperative photograph ill

septum in preparation for placing spreader grafts.

by the edges of the nasal and maxillary bones. The

posterior nasal ala is comprised of fibrofatty tissue

and contains no cartilage. The supratip is superior to

the dome at the juncture of the lateral crus and the

dome of the lower lateral cartilage. It can have a mild

depression called the supratip break. The infratip

marks the juncture of the medial crura and the domes

of the lower lateral cartilages. The septum (especially

the caudal septum) must be straightened and in

midline before focusing on the deformities of the

nasal tip. Nasal tip concavities are mostly caused by

trauma but also can be secondary to rhinoplasty,

Moh’s surgery, or spontaneous buckling, or they

can be congenital.

arily to disarticulation of the upper lateral cartilage, which is

al correction after spreader grafts and onlay grafts are placed

ustrating the separation of the upper lateral cartilage from the

Fig. 3 (continued).


Midnasal vault concavities

The transition from nasal bones to the upper lat-

eral cartilage is usually a smooth one. Concavities of

the midvault include inverted V deformity, unilateral

subluxation of an upper lateral cartilage, dorsal septal

deviation, and saddle nose deformity. An inverted V

deformity is best appreciated on the anterior view

at the rhinion. It represents bilateral concavities of

the superior aspect of the upper lateral cartilage

(Fig. 3A–D) and is caused by bilateral disruption

of the upper lateral cartilage from the nasal bone.

Isolated midnasal deformities are more often caused

by trauma causing subluxation of the upper lateral

cartilage with or without additional septal displace-

ments. Resection of a dorsal hump (bone or cartilage)

might weaken or destroy the attachments of the upper

lateral cartilages with the nasal bones. The collapse

into the septum might be immediate or delayed. The

endpoint is an open roof deformity, which might also

appear as a concavity of the dorsum. Other predis-

posing factors for loss of structural integrity or

support of upper lateral cartilages are unequal treat-

ment of nasal bones, excessive resection of the upper

lateral cartilages, and mucosal scarring with internal

valve synechia [5]. Mucosal scarring with internal

valve synechia might follow a full thickness transec-

tion of the upper lateral cartilage from the septum.

Finally, the congenital feature of short nasal bones

predisposes an individual to upper lateral cartilage

collapse. When nasal bones are less than 1 cm

cephalad to caudad, the upper lateral cartilages might

be unable support the overlying soft tissue architec-

ture of the nose [6]. This loss in support can cause

a concavity in the midnasal vault, which not only

causes an aesthetic defect but also impairs the nasal

parabolic airflow by creating a narrowed internal

valve [7]. The valve is narrowed on the concave side,

which results in airflow turbulence, causing the pa-

tient to have nasal obstruction symptoms.

To adequately correct collapse of the upper lateral

cartilages, the surgeon must view the mid third of

the nose in relationship to the nasofrontal angle and

tip. For example, relative concavities of the pyramid

caused by an overprojected tip can be treated by

appropriate tip retrodisplacement with subtle dorsal

augmentation. Surgical repair focuses on adequately

separating the upper lateral cartilages from the sep-

tum (Fig. 3E). The collapse of the upper lateral car-

tilages can be repaired with spreader grafts. An

additional onlay graft might be needed for cosmesis.

The best source structurally for the grafts is autoge-

nous septal cartilage because of its thickness and

strength. Care must be taken to preserve dorsal and

caudal struts 8 to 10 mm wide to maintain structural

integrity [8]. If this amount is not available, the sur-

geon should consider using auricular cartilage or rib

cartilage from ribs 6, 7, 8, and 9. Relative disadvan-

tages to these alternatives are that auricular cartilage

is weaker than septal cartilage and rib cartilage can

become warped if it has any length. An additional

donor site can also be a concern. Spreader grafts

placed between the dorsal edge of the septum and the

medial attachments of the upper lateral cartilage pre-

vent the functional and visible collapse of the middle

vault. It is important to separate both upper lateral

cartilages from the septum to release all tension

forces to ensure that the tip is midline. Alternatively,

flaring sutures have also been used to widen the valve

angle and correct upper lateral collapse. This proce-

dure consists of placing a horizontal mattress suture

that extends from the caudal aspect of the upper

lateral cartilage, which is anchored to the other upper

lateral cartilage, creating a lateral pull using the

dorsum as a fulcrum [7]. This procedure is used for

significant collapse, failure of spreader grafts, and

floppy cartilage that is dislocated from the nasal bone.

A spring or butterfly graft taken from conchal carti-

lage can improve nasal valve collapse, but it will

most likely lead to supratip fullness [5,7]. Finally,

lateral osteotomies are performed to close the open

roof deformity if it exists.

One can also have a unilateral indentation that

reveals a depression on one side inferior to the nasal

bones. In addition to the depression, these patients


appear to have a deviated nose (Fig. 4A–F). Avulsion

of the upper lateral cartilage or unilateral subluxation

[9] away from its attachment caused by rhinoplasty

or trauma will cause this concavity. The underlying

problem is that the upper lateral cartilage on the con-

vex side is too high and the ipsilateral upper lateral

cartilage on the concave side is too short, holding the

Fig. 4. (A) Preoperative photograph revealing a depression at th

concavity. (B) Oblique view reveals a saddle deformity secondary t

from the nasal septal bone. (C) Basal view demonstrates a marked

left spreader graft, tip graft, columellar strut graft, and dorsal on

intermediate osteotomies.

septum to the side of the deviation (Fig. 5) [10].

When this concavity is the result of a traumatic sub-

luxation, closed reduction is a common practice. The

goal of the procedure is to reduce the dislocated

upper lateral cartilage; however, because this injury

leads to misaligned cartilage and not bone, it is un-

usual for a closed reduction to succeed. The cos-

e left upper lateral cartilage with the resultant topographic

o the disarticulation of the upper lateral cartilage and septum

ly deviated caudal septum. (D–F) Postoperative results after

lay graft. Repair also included septoplasty, and lateral and

Fig. 4 (continued).


metic deformity is accompanied by an impingement

of the internal nasal valve. Appropriate management

of the upper lateral cartilage concavity is no different

than in the case of the inverted V deformity except

that it is unilateral. Surgical repair focuses on sepa-

rating the upper lateral cartilage from the septum.

A spreader graft should be placed between the septum

and the upper lateral cartilage on the concave side

(Fig. 6A–D) [11]. An onlay graft can be used in

masking the nasal depression, but it will not address

the compromised airway. Onlay grafts are usually

obtained from septal cartilage. Crushing the graft can

act as a filler for a mild depression [8]. Shaving the

convex aspect of the dorsum might allow for partial

correction of the deformity.

A concave upper lateral cartilage might require

outward distraction by a spreader graft, lateral osteo-

tomies, and dorsal augmentation with a graft.

Fig. 5. (A, B) Unequal size or attachment of either upper lateral c

appear on the opposite side of the upper lateral that is ‘‘too high.’’

from the septum, equalizing the position and size of the upper late

achieve this symmetry. It is important to reattach the upper lateral

Concavities of the upper lateral cartilage are not

always a result of disruption of the bony cartilaginous

junction. A dorsal deviation of the septum can result

in an upper lateral cartilage concavity, deviated tip,

and an overall S-shaped appearance of the nose. The

septal deviation drags the upper lateral cartilage

toward itself, leaving a concavity on the opposite side

of the deflection (Fig. 7) [9]. These dorsal deviations

can give rise to the classic C- or S-shaped deformity,

which has a concave and convex side. There can be

one or two concave sides of the lateral nose at the nasal

bony pyramid where it attaches to the upper lateral

cartilage. This deformity is especially visible in thin-

skinned patients. From the anterior topographic view it

is indistinguishable from unilateral midnasal vault

collapse. Intranasal examination of the septum will

differentiate the two. Injury or surgery to one side of

the septum results in unequal tension that causes

artilage to the septum will cause a topographic concavity to

Correction focuses on separating the upper lateral cartilage

ral cartilage. It might be necessary to trim some cartilage to

cartilage to the septum with permanent sutures.

Fig. 6. (A–D) The right upper lateral cartilage concavity is corrected with placement of a unilateral spreader graft. The

spreader graft is sutured to the upper lateral cartilage and septum. Occasionally an additional onlay graft is also needed to correct

a severe concavity.


curling toward the intact side. The torsion stresses are

balanced by scar tissue, hyperplasia of the perichon-

drium, and growth of cartilage on the expanded

convex surface. The concave side is under pressure

and develops chondroplastic activity, destruction, and

absorption. Again, the concavity is a result of the

upper lateral cartilage following the septal deflection.

Patients might also suffer from nasal obstruction

because the actual defect is an internal deformity.

The inferior septum is usually displaced from the max-

illary crest contralateral to the external convexity,

which makes for a difficult long-term repair given that

the cartilage has memory and seems to resume preop-

erative deformity [12]. Surgical correction is achieved

by skeletonizing the mucoperichondrium from the

upper lateral cartilage then separating it from the

Fig. 7. Dorsally deviated septum resulting in concav

septum. The septum is not detached from its anchoring

point on the undersurface of the nasal bones; however,

markedly deviated septal cartilage might need to be

separated from its attachments along the maxillary

crest and the nasal spine. The septum can then be

placed in a midline position. Repositioning the caudal

septum in this way will affect its relationship at the

dorsum with the upper lateral cartilages. Typically the

surgeon will see an exacerbation of the concavity.

The upper lateral cartilages need to be examined for

symmetry and alignment with the dorsal septum. If

one side overrides the dorsum it should be trimmed

(see Fig. 5). When a concavity is present, use of a

spreader graft or suturing will be needed to restore

proper alignment. Scoring the septal cartilage is an

adjunct to repositioning and might be needed for

ities on the contralateral side of the deviation.


the C-shaped septum. Overcorrecting the defect can

be beneficial.

The septum should be approached from above,

separated from the upper lateral cartilages, and scored

on the concave side to relax the cartilage. A spreader

graft is placed on this side to act as a stabilizer retain-

ing the septum in a midline position. The spreader

graft not only serves to maintain septal position but

also to widen the internal valve, improving function.

In addition, an only graft over the upper lateral

cartilage and bony dorsum on the concave side also

Fig. 8. (A–C) Posttraumatic saddle deformity best seen on later

Midnasal flattening or a midvault concavity is the result. (D–G) C

graft of 5 mm of GoreTex, and lateral osteotomies. Intraoperativ

operative results on anterior–posterior, lateral, and basal view rev

might be of benefit. If a severe S-shaped deformity

exists, it is recommended that bilateral spreader grafts

be placed to correct the double concavity.

Saddle nose deformity is a concavity of the nasal

dorsum that is especially noticeable on the lateral

view, which represents a collapse of the nasal dorsum

(Fig. 8A–F). Saddle deformity can be the result of

many factors such as cocaine abuse, trauma, rhino-

plasty, infectious disease (eg, syphilis, leprosy, pyo-

genic septal abscess), septal hematoma, inflammatory

diseases (eg, midline destructive disease, Wegener’s ,

al view from a septal hematoma followed by an abscess.

orrection consists of tip graft, columellar strut, dorsal onlay

e view of the tip graft obtained from autogenous rib. Post-

eal correction of the midvault concavity.


polymorphic reticulosis, relapsing polychondritis),

and neoplasms (eg, inverting papilloma, squamous

cell carcinoma, esthesioneuroblastoma) [13]. The com-

mon feature of these conditions is loss of quadran-

gular cartilaginous support. A saddle deformity can

occur as a result of an overreduction of the dorsum,

leading to an open roof and an inverted V deformity

(Fig. 9A–D). The surgeon must address three interre-

lated tasks: (1) exposure of the defect, (2) augmenta-

tion of the dorsal defect, and (3) correction of the

associated deformities. Associated deformities include

lack of tip support, retracted columella, and a widened,

bony pyramid. The authors recommend that saddle

deformities be repaired with an open approach. Etiol-

ogies of trauma or prior surgery should alert the

surgeon to the likelihood of additional deficits, includ-

ing subluxed upper lateral cartilages and septal deflec-

tions. In these patients a saddle nose can represent loss

of underlying support and deformity of existing struc-

tures. Surgical correction can involve the aforemen-

tioned techniques for concavities of the upper lateral

cartilage and septum. The dorsum will also require

augmentation with a graft. The graft is usually taken

from calvarial bone or the iliac crest to augment the

dorsum. The preferred choice for grafting is autoge-

nous calvarial bone graft, but alloplastic grafts might

be necessary sometimes. Alloplastic materials such as

GoreTex (W.L. Gore and Associates, Flagstaff, AZ)

and Medpor (Medpor Biomaterial, Porex Surgical,

Fig. 8 (conti

Newman, CA) have been used for augmentation (see

Fig. 8G). The surgeon needs to contour the graft

carefully to minimize irregularities and asymmetries.

Tip support is re-established with a columellar strut

and a tip graft. The widened nasal pyramid is ad-

dressed with lateral osteotomies.

Lower lateral cartilage concavities

Lower lateral cartilage concavities can exist sec-

ondary to inherent asymmetries, structural weak-

nesses of crura, or complete absence of the lateral

crura, resulting in a pinched tip. Zelnik and Gingrass

described variations of the lateral crus based on ca-

daveric studies (Fig. 10) [14]. The area of concavity

and the functional impairment dictates the correction.

When a unilateral irregularity exists in the lower

lateral cartilage, the tripod length is affected, causing

not only the topographical concavity but also a

deviation of the nasal tip to the side of the shorter

lateral crus.

The lateral crura should be convex at the nasal

dome with gradual flattening toward the pyriform

aperture. Lower lateral concavities or paradoxical

lateral crura can be idiopathic in origin or exist from

postsurgical weakening. Prevention while performing

a primary rhinoplasty is imperative to protect against

weakened lower lateral cartilages. The authors rec-

ommend repositioning the lateral crura with only

nued).

Fig. 9. (A–F) Multiply revised nose with resultant inverted V deformity from upper lateral cartilage dislocation, saddle deformity

secondary to overreduction, and left lower lateral concavity. Postoperative results on anterior–posterior, lateral, and basal views

following bilateral spreader grafts, tip graft, columellar strut, and left alar replacement graft using concha cymba, lateral

osteotomies, and dorsal onlay graft using GoreTex.


minimal crural resection, attempting to leave 8 to

9 mm of lateral crural width. Flaccid lower lateral

cartilages buckle under the forces of skin tension,

causing the concavity of the nasal sidewall. These

depressions create not only a cosmetic deformity but

they can also cause airway obstruction by projecting

downward into the nasal vestibule, causing external

valve dysfunction, which is especially seen when the

entire lateral crura is concave (Fig. 10E) [15,16]. The

concavities range from mild unilateral depression to

the extreme, which is a bilateral lower lateral con-

cavity called paradoxical lower lateral cartilages.

Mild concavities exist topographically when the me-

dial portion or the lateral potion of the lateral crura

are concave (Fig. 11A, B, E, F). Repair depends on

the significance of the concavity and is best ap-

proached by open rhinoplasty. Concavities of a lesser

degree in this area can be repaired with suture

techniques, alar batten grafts, onlay grafts, or domal

division with resewing (Fig. 11C, D). Neu, Tebbetts,

Fig. 9 (continued).

Fig. 10. (A) Normal convex lower lateral cartilage. (B–F) All

other concavities act to weaken the lateral crus and fore-

shorten a limb of the tripod, causing tip deviation to the side

of the concavity. Surgical management can consist of placing

onlay grafts for mild concavities, rotating the cartilage 180�on itself for paradoxical lateral crura, to the extreme of

completely replacing the lower lateral with concha cymba for

severe deformities.


and Toriumi describe using small interlocking

mattress sutures to correct cartilage irregularities

[2,17,18]. Sutures are believed to hold cartilages in

the desired position to allow the soft tissue to act as a

cast [18]. Separate domal sutures can be applied to

each dome to make changes on each lower lateral.

The advantage of the suture technique is that it is

reversible [18]. Contraindications to the suture tech-

nique include weak pliable cartilages, narrow tip

cartilages, marked tip asymmetry, an excessively

rotated tip, or an overprojected nasal tip [18]. Batten

grafts are designed from septal or auricular cartilage

and are placed at the level of the supra-alar crease in a

nonanatomic position, supporting the concavity. The

only graft is sutured in place to act as a stabilizer and

hold the lateral crura in the convex position. An onlay

graft can camouflage a medial or lateral concavity of

the lateral crura. A triangular excision at the dome or

dome division might be needed for excessively long

lateral crura that are buckled.

Concavities of a greater degree can be treated by

inverting the lateral crura on itself or recreating them

with conchal cartilage. Because the normal lateral

crura curvature is reversed in a paradoxical lateral

crura, resecting the paradoxical portion, inverting it,

and suturing it back into place can leave a convex

lateral crura (Fig. 12). Bilateral paradoxical lateral

crura can be repaired by excising and removing each

lower lateral cartilage, flipping it, and suturing the

right onto the left and the left onto the right, thereby

turning a concavity into a convexity, as seen in

Fig. 19. When the existing lateral crura are insuffi-

cient they can be rebuilt using a conchal graft. The

convex shape of the conchal cartilage is an ideal

substitute for the lower lateral cartilage (Fig. 14A, B).


Fig. 12. Domal division of the concave lateral crura, rotating it 180� and suturing it into place with permanent sutures. A tip graft

is recommended for camouflaging and further support.


A tip graft might also be needed and can correct

structural deficiency by anchoring the medial crura

and lateral crura to a rigid platform, which simulta-

neously establishes tip shape and projection while

camouflaging irregularities. The tip graft is sutured

onto the lower lateral cartilage complex at the desired

projection and angle. The graft should project at least

2 to 3 mm above the nasal dorsum [3]. Care must be

taken while using tip grafts in thin-skinned patients.

They might be contraindicated in the thinnest of skin

because of the possibility of surface irregularities.

Lateral crural concavities can also be caused by

structura1 defects in the medial crura. These defects of

the medial crura cause a buckling of the lateral crura,

creating a depression at the tip. These concavities

appear as a divot on one side of the nose that causes a

distortion of the nasal tip, creating the illusion of a

deviated nose. The topographic appearance is similar

to a concave lower lateral cartilage. This depression at

the dome or domal dimple can be secondary to defi-

ciency in size of one medial crura, inherent buckling

of the medial crura, or inadequate projection of one

lower lateral cartilage at the dome (Figs. 15A–C)

[17,19]. Repair is accomplished by separating the

medial crura to allow equalization of the dome and

repositioning the cartilage to achieve symmetry. A

columellar strut is placed to secure the complex,

which straightens the buckled area and causes an

increase in projection. The strut graft should be placed

between the medial crura just above the nasal spine,

1 to 2 mm below the dome [3]. In addition to a

columellar strut, fixation of the caudal septum to the

posterior aspect of the medial crura/strut complex

Fig. 11. (A, B) Anterior–posterior and close-up views of bilateral lo

than the left. (C, D) Intraoperatively, the buckling of the right latera

buckling of the medial crura is often seen in conjunction with latera

onlay grafts. During open rhinoplasty these grafts were created prec

In addition, the strut was used to correct the medial crura buckli

concavities is seen in the anterior–posterior and close-up views.

helps to further straighten the deformity. The surgeon

must remember that the caudal septum also influences

the shape of the medial crura. Thus, it is imperative

that any septal correction be made simultaneously. A

tip graft is used for structural support and camouflag-

ing to create a symmetric dome (Fig. 16).

A subtle bifid tip can be aesthetically pleasing;

however, in thin-skinned patients or patients who

have a wide angle of divergence it can appear exces-

sive, creating a midline domal dimple Fig. 17A [19].

When there is absence of sufficient intervening soft

tissue between the medial crura, it also creates a bifid

appearance of the infratip lobule and interdomal area

(Fig. 17B–E), which produces a vertical concavity

midline starting at the infratip and extending down to

the columella. Patients often dislike the dent or con-

cavity that results from the bifidity. A simple solution

is to use a temporalis fascia graft over the nasal tip

area and use judicious tip grafting and interdomal

sutures to camouflage the area.

The ideal nasal base resembles an equilateral tri-

angle, with an outward bowing of the posterior alar

rims and a rounding of the nasal tip. Overzealous

resection or inherently weak or absent lateral crura

results in a pinched tip appearance, which represents

a complete loss of structural support of the lower

lateral cartilages (Fig. 18A, B). Because the anterior

midportion of the nostril rim is supported directly by

the lateral crus, it will collapse leading to a bilateral

symmetric concavity (ie, pinched tip). Posteriorly, the

rim has no cartilage support but is held in position by

thick alar skin, which gives the nose a cloverleaf

configuration on the basal view and causes supra-alar

wer lateral crura concavities with the right more pronounced

l crura is where the topographic concavity exists. Associated

l crura weaknesses. (E, F) Concavities repaired with bilateral

isely and sutured to optimally efface the concave lateral crus.

ng. A tip graft aided in camouflaging. Improvement of the

Fig. 13. (A–C) Anterior, basal, and lateral view of patient who had an overly aggressive reduction of the cartilaginous

framework, causing skin contractions to distort normal anatomy. A deep concavity is seen near her left dome. (D) Intra-

operatively, displaced dorsal calvarial bone graft is seen. There is no discernable normal tip cartilage structure. A tip graft placed

through a closed approach was severely rotated by forces of the skin envelope. (E–G) Postoperative results reveal correction of

concavities after placement of bilateral spreader grafts, left alar batten grafts at the alar rim, a dorsal calvarial bone graft, a strut,

and a tip graft.


hollowing on the anterior view. Generally, this defect

is best served by an open approach for repair.

Surgical management of the pinched tip requires

structural repair, including placing a strut, tip graft,

and alar batten grafts. The shape of the graft depends

on the severity of the collapse. If the entire cephalic

portion of the lateral crura has been resected, repair

would warrant complete replacement of the cartilage

with concha cymba (see Fig. 14A, B). Concha cymba

is fashioned as a cartilage graft that is the same length

of the lateral crus. This graft is referred to as a batten

graft, or a lateral crural spanning graft that pushes the

collapsed lateral crus outward and is sutured to the

stabilized septal angle. This graft will not only help

the aesthetic result but will also repair the functional

loss of the external valve.

Concavities secondary to skin contracture

Successful outcomes in tip rhinoplasty depend

upon a delicate interplay between the contracting

skin soft tissue envelope and underlying skeletal

framework. If the nasal skeleton has been weakened,

the contraction forces of the soft tissue envelope can

Fig. 13 (continued).


distort the skeleton even further [16]. In patients who

have had aggressive reduction rhinoplastic surgery,

the skin envelope can overwhelm the stability of the

cartilaginous framework (Fig. 13A–G). When the

skin is thin and the skeleton has been weakened,

the end result is buckling and a surface concavity.

When using grafts, care should be taken to blend the

edges of the graft, especially in thin-skinned patients.

Bulbous tips might require judicious tip defatting to

accentuate nasal tip architecture [3]. Excessive thin-

ning of the skin at the tip can also lead to surface

irregularities independent of the patient’s skin char-

acteristics. Prevention is the key to success. If exces-

sive thinning does occur, plumping up the area with

an onlay graft, temporalis fascia graft, dermal graft,

or homograft dermis (AlloDerm, Life Cell, Wood-

land, Texas) can be of benefit. Repair of skin con-

tractures requires adequate undermining of the soft

tissue from what little structural support is available.

Placing a graft between the skin and underlying

structure is not enough to prevent a recurrence.

Additional cartilage grafts will be needed to rebuild

the nasal skeleton according to the methods described

previously in this article.

Fig. 14. (A, B) In the severely deformed lower lateral crus, it might be impossible to salvage any useful cartilage remnant. In

these cases excision of the lower lateral crus is accomplished and replacement with concha cymba is performed. The concha

cymba has the natural three-dimensional qualities needed to create the normal convexity of the lower lateral cartilage.

Fig. 15. (A–C) Correction of concavity resulting from medial crural buckling or a congenital difference in size by placement of

a columellar strut graft. The columellar strut graft is sutured to the medial crura not only to stabilize the unit but also to equalize

the length of the medial crura by straightening out the buckling or advancing the shorter medial crura.


Fig. 16. (A,B) Anterior and basal views show that the right lateral crus is concave and the medial crura is deviated to the opposite

side. (C–E) Intraoperatively, the medial crural buckling to the left was verified, as was the right-sided lower lateral crural

buckling, creating a shortening of the right tripod limb and a depression of the right dome. This problem was repaired with onlay

grafts to stabilize the right lower lateral cartilage and restore its length. A strut and tip graft was used to improve medial crural

support and camouflage the tip. (F, G) Postoperative result.




Fig. 17. (A) Tip bifidity reveals that the combination of thin skin and a wide angle of divergence of the lateral crura can play a

factor in this concavity. (B–E) Concavity at the center of the dome is seen on oblique view and anterior–posterior close-up view.

This patient had exceedingly thin skin, resulting in the dimple at her tip. For this patient a temporalis fascia graft was all that was

needed for correction, as seen on anterior–posterior view.




Fig. 18. (A, B) This close-up anterior–posterior view reveals a severely pinched tip from overresection of the cartilaginous

framework. The concavity is seen lateral to the dome. Correction requires complete restructuring of the framework with auto-

genous cartilage. Postoperative results with alar batten grafts from concha cymba, strut, and tip graft.


Fig. 19. (A–C) Most concavities are hybrids of different etiologies. A variety of concavities are noted in this primary nose on

anterior–posterior, lateral, and oblique views, including dorsal septal deflection, left upper lateral depression, bilateral para-

doxical lateral crura with complete concavities, and the beginning of a dorsal depression. (D–F) Intraoperatively, bilateral

paradoxical concavities are noted. The paradoxical lateral crura represent a complete concavity of the lateral crus instead of the

usual convexity. Treatment consisted of detachment of the lateral crus from the piriform aperture, domal division, and separation

of the cartilage form vestibular mucosa, which was left intact. The right and left lower lateral cartilages were inverted, keeping

the caudal edge’s relationship to the alar rim the same. Reconstruction is achieved by way of domal suturing and suture plication

of the cartilage to the vestibular mucosa. The right lateral crus became the left and vice versa, turning a concavity into a

convexity. (G– I ) Postoperative results after the following was performed: placement of left spreader graft, inversion of lower

lateral cartilages, 4 mm GoreTex dorsal onlay graft, alar base narrowing, strut and tip graft, and lateral osteotomies.





Summary

Normal topographic anatomy of the distal nose is a

reflection of the delicate integration between the lower

lateral cartilage, the upper lateral cartilage, the sep-

tum, and skin. Understanding these relationships will

help the rhinoplasty surgeon diagnose and treat con-

cavities of the distal nose. Most patients present with a

hybrid of these defects. For example, the patient in

Fig. 19 presented for a primary rhinoplasty. A variety

of concavities can be noted and include dorsal septal

deflection, upper lateral cartilage avulsion on the left,

bilateral lower lateral complete concavities, and the

beginning of a dorsal depression (Fig. 19A–I). The

nasal skeleton and the skin and soft tissue are nor-

mally in equilibrium, but trauma and reduction rhino-

plasty disrupts this equilibrium. Skeletal distortion can

lead to septal deflection, middle vault collapse, or alar

buckling [20]. It is important to realize that correction

of deflection or depression by excision needs to be

balanced with augmentation, which provides balance

for the previously disequilibrated skeletal and soft tis-

sue forces. Augmentation can be done with spreader

grafts, tip grafts, columellar strut, and dorsal grafts. A

patient’s soft tissue envelope will also play a major

role in the success of a septorhinoplasty. The surgical

principles of septorhinoplasty such as judicious res-

culpting of the cartilaginous framework, respect of

major tip support, tip grafting technique, and postop-

erative tissue contraction still apply and must be

placed in conjunction with repairing a pathological

topographic concavity.

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Surgical Management of Concavities of the Distal Nose