Rhinoplasty: Personal Evolution and Milestones

Cosmetic Rhinoplasty: Personal Evolution and Milestones Jack H. Sheen, M.D. Santa Barbara, Calif. Over the past 35 years, aesthetic rhinoplasty has evolved from a generic, reductive operation to a highly individualized, problem-specific operation that often combines augmentation with reduction. The author s experience has been marked by the following conceptual and technical milestones that have contributed to an ongoing exploration and advancement of nasal surgery: (1) vestibular stenosis: diagnosis of a surgical consequence; (2) etiology and treatment of supratip deformity: the dynamic relationship of soft-tissue contour to skeleton; (3) etiology and treatment of the tip with inadequate projection: tip graft design; (4) practical aesthetics of balance: the augmentation-reduction approach to rhinoplasty; (5) support of the middle vault: functional and aesthetic effects; (6) malposition of the lateral crura: recognition and management; and (7) the significance of the middle crura: clinical and aesthetic considerations. (Plast. Reconstr. Surg. 105: 1820, 2000.) In 1972, I nervously presented my first paper on secondary rhinoplasty. I had been in practice for only 7 years, but I was already brazen and unconventional in my approach to nasal surgery. Soon after, Tom Baker, who had been in the audience, courageously offered me unknown and unproven a place on the Baker-Gordon symposium faculty in 1973, giving me a forum in which I could demonstrate surgery and express my ideas. Also on that faculty were my formidable colleagues, Tord Skoog and Fernando Ortiz Monasterio. With lasting gratitude to Tom Baker and Howard Gordon, I considered myself launched (Figs. 1 and 2). Now I have been asked to account for myself over these past 30 years by presenting a review of my personal evolution in rhinoplasty and FIG. 1. Drs. Jack Sheen and Tom Baker at the 1973 Baker- Gordon Symposium. FIG. 2. Panel members (left to right) Tord Skoog, Fernando Ortiz Monasterio, and Jack Sheen. (Photograph courtesy of Berta Lewin.) From the Department of Surgery, Division of Plastic Surgery, University of California at Los Angeles; and the Department of Surgery, Section of Plastic Surgery, University of Southern California. Received for publication August 19, 1999; revised September 3, 1999 Presented at the Baker-Gordon Symposium in Miami, Florida, on March 5, 1999. 1820

Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1821 defining significant milestones along the way. First, I had to determine the meaning of a milestone as it applied to the progress of my practice. A milestone, of course, is an important event or turning point along a continuum of development. For me, a milestone marks a particular development based on a process of (1) observation, (2) realization, and (3) change. This process is not unusual, but in a few instances it was applied to issues of such consequence that, for me, it resulted in a radical departure from accepted, conventional ways of thinking about and performing nasal surgery. I. VESTIBULAR STENOSIS: DIAGNOSIS OF A SURGICAL CONSEQUENCE By the mid-1970s, I was examining hundreds of secondary rhinoplasty patients each year. I observed that an estimated 80 percent had some loss of vestibular volume, with mild to severe impairment of the nasal airway. 1 Clearly, something was wrong with our surgical technique. I might add that something also was wrong with our postoperative follow-up. When I shared my observation with colleagues, most shrugged, saying they never saw it. The fact is that it was not expected practice to look. It surprised me at the time that many plastic surgeons did not critically examine the inside of the nose postoperatively; many did not even have adequate light and a nasal speculum in their examination room. When analyzing the problem, I focused on what was then a routine step in rhinoplasty: trimming the caudal edge of the upper lateral cartilage with right-angle scissors 2 8 (Fig. 3). I realized that because the upper lateral cartilage is triangular, a straight cut along the caudal end would result in a mucosal deficit, inevitably leading to scarring and stenosis 9 (Fig. 4). The changes that resulted were, first, discarding the right-angle scissors and, second, performing a submucous dissection of the cartilage, which preserved mucosa except for the rare case in which exceedingly redundant mucosa is conservatively trimmed. This left an intact mucosa, functioning internal valves, and a normal airway. Today, less than 15 percent of secondary rhinoplasty patients I see have any loss of vestibular volume; of those, only a few have severe vestibular stenosis. FIG. 3.(Left) The caudal edge of the upper lateral cartilage is approximately 120 degrees from the dorsal plane. (Right) A routine step in rhinoplasty was trimming the caudal edges of the upper lateral cartilages with right-angle scissors. The consequent mucosal deficit resulted in scarring and loss of vestibular volume.

1822 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 FIG. 4. Severe vestibular stenosis resulting in airway impairment following routine aesthetic rhinoplasty. II. ETIOLOGY AND TREATMENT OF SUPRATIP DEFORMITY: THE DYNAMIC RELATIONSHIP OF SOFT- TISSUE CONTOUR TO SKELETON Thirty years ago, supratip deformity was commonly seen in rhinoplasty patients. The prevailing opinion was that supratip deformity was most often caused by inadequate resection of the dorsum, overlapping lateral walls, or excess scar formation. 10 14 The prevailing treatments were further dorsal reduction, thinning dissections, and steroid injections. The prevailing outcomes were recurrent supratip deformities and multiple procedures, many resulting in increased scarring and, at times, irreparable defects (Fig. 5). The only thought about prevention, as suggested by Safian 15 and Denecke and Meyer, 16 was to undercut the anterior septum to allow room for granulation tissue. But I had a contrary idea about supratip deformity. I had observed that the soft tissue often could be compressed down to the septal edge (Fig. 6). No amount of lowering that septum would reduce the arch of skin overlying it. The skin had simply reached its limit of contractility. Sometimes fibrous tissue would fill in the space, making the area feel firm but never providing enough structure for a straight contour. Realizing that a soft structure needs a supportive framework to maintain shape, I hypothesized that augmentation, not reduction, was the answer (Fig. 7). The story again goes back to Miami. In 1973 and 1974, a secondary rhinoplasty patient with a supratip deformity and a lot of time and resources was flying across the country and around the world to consult with plastic surgeons about her nose (Fig. 8, above and below, left). It was Fernando Ortiz Monasterio who recommended that she come to me for her secondary rhinoplasty. Meanwhile, Ralph Millard had heard of my unorthodox concept of supratip deformity and, in 1975, invited me to his symposium in Miami to prove myself in front of an audience of 500 and a faculty of experts, including himself, Gustav Aufricht, Reid Dingman, Paul Natvig, John Lewis, and Blair Rogers. Because I knew that this patient had consulted with every surgeon on the faculty and that she was willing to have the procedure performed during the symposium, I could not possibly refuse. At surgery, I showed that the anterior septum at the area of the supratip had already been lowered about 4 mm, as recommended by Dr. Safian. 17,18 I then augmented the dorsum, producing a fine, straight dorsal

Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1823 FIG. 5. Patients who had undergone tissue thinning procedures in attempts to reduce the arch of skin over the lower third of the nose. edge, permanently eliminating the supratip convexity (Fig. 8, above and below, right). In 1975, I formally presented my clinical material on supratip deformity, which included a report of 100 consecutive secondary rhinoplasty patients, representing a major change in the approach to secondary rhinoplasty. Eighty-two percent of the noses were corrected by dorsal augmentation. 19 Besides the diagnosis and treatment of supratip deformity, the other aspect of this milestone is prevention. Understanding that the size of the skeletal framework must be proportionate to the size (and character) of the overlying soft tissue, the surgeon can prevent supratip deformity by retaining adequate dorsal support.

1824 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 FIG. 6. Pressing the supratip down to the anterior septum made it apparent that the supratip deformity was related to the limits of soft tissue contractility, not the height of the skeleton. Augmentation was the logical solution.

Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1825 FIG. 7. Case presented at the 1973 Baker Gordon Symposium to demonstrate correction of a supratip deformity by augmentation of the dorsum and tip grafting.

1826 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 FIG. 8. Patient operated on at the Millard Symposium 1975, demonstrating augmentation for supratip deformity. For a condensed version of that surgery, refer to Sheen, J. H. Secondary Rhinoplasty Surgery (Videotape #9610). Creating the Balanced Nose. Arlington Heights, Ill.: Plastic Surgery Educational Foundation.

Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1827 III. ETIOLOGY AND TREATMENT OF THE TIP WITH INADEQUATE PROJECTION: TIP GRAFT DESIGN A question that was frequently asked in my early days was, Do you do the tip first or the dorsum first? It just so happened that I usually set the height of the dorsum first, allowing for final adjustments. The reason was based on my insight into supratip deformity. I realized that the height of the dorsum must be limited by the size and character of the skin sleeve; it could be reduced only so much without deforming. After determining the limit of reduction, I was faced with the challenge of achieving adequate tip projection relative to the appropriate dorsal height. I was then using only conventional tip techniques: cephalic trimming of the alar cartilage, scoring at the dome to maximize projection. For most noses, this technique was successful, but not for all. I observed that there was a characteristic group of noses in which the alar cartilages were inherently inadequate to project the tip beyond an appropriate dorsal line. Predictably, these noses would have poor postoperative contours (including supratip deformity from attempts to lower the dorsum to the level of the tip). I named this problem The Tip with Inadequate Projection and began plotting a solution (Fig. 9). Soon came the realization that aesthetically, the tip lobule itself the area between the columellar-lobular junction and end point of the tip was lacking in structure. The next logical step was to devise a way to support just that area. Various grafts to fill out the tip such as a small button, a tent pole, and a fleur de lys graft had been suggested by Millard, Gorney, Falces, and others. As far back as 1946, Maliniac suggested small grafts of septal or conchal cartilage to fill out the tip of the cleft lip nose. 20 22 None of these designs could provide the necessary projection to correct the tip with inadequate projection or the scarred, postsurgical nose. In 1968, I designed a tip graft technique that, except for the shape and number of grafts, remains unchanged 23 (Fig. 10). A pocket is developed, based at the columellar-lobular junction and extending anteriorly into the tip lobule. Using the columellar-lobular-junction as a base, the graft(s) is placed under just enough tension to extend the tip to the desired position. The original graft had the configuration of a cross-section of a molar; some saw it as a shield. The width of the top varied, depending on the thickness of the soft tissue. With thick tissues, the graft was made narrow to improve FIG. 9.(Left) Patient exhibiting a tip with inadequate projection. (Center) Conservative dorsal reduction produced a supratip deformity. Note that the tip projection remained unchanged after primary surgery. (Right) Seven-year postoperative result following dorsal graft and tip graft.

1828 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 FIG. 10. (Above) Original tip graft technique. Opening incision at the columellarlobular junction. (Center) A pocket is developed as the incision progresses along the alar rim. (Below) Graft is inserted into the pocket. The development of the pocket remains unchanged. Today, multiple grafts are routine. the mechanical advantage. With thin skin the top was wider. I was now using this technique not only for deficient primary tips but also in secondary cases, in which the alar cartilages had been overly resected. The use of tip grafts greatly enhanced the results in a wide variety of cases. At first, the patients and I were all smiles. Soon there were problems. Some of the grafts became visible, as the edges blanched the overlying skin. Others slipped upward or sideward, creating asymmetries and unsightly contours. To correct these mishaps, additional grafts were placed to obtain good contour and symmetry. To prevent them, I then changed my tip augmentation technique to use multiple grafts as a routine. By the mid-1970s, I had added ear cartilage to the tip graft materials (under the influence of Burt Brent) and was beginning to use crushed cartilage with excellent results. The first remarkable case using crushed cartilage involved a scarred, postsurgical nose with multiple grooves in the tip lobule. Clearly, the

Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1829 usual tip graft would not have corrected this problem. What I wanted was not so much to project the tip lobule but to expand it. So I crushed nine pieces of cartilage and carefully stuffed them into the tip (Fig. 11). With the success of this case, crushed cartilage emerged as an extremely useful and versatile graft material. Noses with thin skin, asymmetries, visible single grafts, and flat lobules can be improved with the use of crushed cartilage grafts. With thousands of tip grafts, time has proven that they are effective and they last over the longterm (Fig. 12). The tip grafts I use today are made of septal, ear, or rib cartilage. 24 They are used either unmodified, bruised, crushed, or morselized, FIG. 11. This patient with a scarred tip received nine crushed cartilage grafts. She is shown preoperatively and at 4 years postoperatively.

1830 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 FIG. 12. A 10-year follow-up on a secondary cleft lip nose. often in combination. A combination of solid grafts for support and projection, and soft grafts for fill and contour, is a versatile and effective solution to a variety of tip deficits. A buttress graft of ethmoid bone is sometimes used to stabilize the position of loose grafts within the pocket. Recently, I have been using tangential sections of the ninth rib solid, crushed, or morselized. Early results are good, but the verdict is still out.

Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1831 FIG. 13. Patients characterized as having a low radix disproportion. These patients have a low root and a large nasal base, producing a bottom heavy nose. Minimizing the base by augmenting the root illustrates the concept of balance in rhinoplasty. IV. PRACTICAL AESTHETICS OF BALANCE: THE AUGMENTATION-REDUCTION APPROACH TO RHINOPLASTY As a milestone this is my favorite. Over time, I embraced the observation that high and low and large and small manifest each other. Raising the root of the nose diminishes the apparent projection of the base; projecting the base diminishes the apparent height of the dorsum. Narrowing the upper vault of the nose accen-

1832 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 tuates the width of the base, and vice versa. For me, this observation represents a major conceptual shift and marks the point of departure from the standard Joseph rhinoplasty, as a sequence of reductive surgical steps (Fig. 13). To the clinician, the exciting part of this concept is the potential for practical application. If changing the nasal configuration is analyzed and planned as a matter of balance rather than reduction, then the surgeon can manipulate anatomic components to achieve aesthetic effects that otherwise would be unobtainable given the inherent limitations of an individual s tissues. Equally important is the ability to create the illusion of reduction while preserving skeletal support. 25 Seen from this point of view, an apparent hump may be only a relative hump and therefore can be eliminated by elevating the adjacent tissue. The questions may arise, When is a hump not a hump? or How do you know when a hump is a hump? My answer is: A hump is a hump only when the rest of the nose can spare it. Case Illustration A 39-year-old woman, 5 feet 10 inches tall (Fig. 14), had findings that may be summarized as follows: low radix disproportion bony arch to nasal base disproportion ultraprojecting base nostril-lobule disproportion long nose with drooping nasal tip flaring nostrils. Discussion This was a large nose on the large face of a tall patient. The patient, who wanted a smaller, more retrousse nose, was advised about tissue limitations and about the danger of sacrificing contour for size. In my experience, given the particular base-heavy structure of her nose, a conventional reductive rhinoplasty would likely result in an unattractive, surgicalappearing nose. It was explained that the nose could be made to appear more refined by improving the angles and proportions. Twenty-five years ago I would have used the root as a point of reference in reducing this sizable hump. But 25 years ago, I had not yet seen literally thousands of supratip deformities that resulted from this misjudgment. This patient has a low radix disproportion 26 ; that is, the root is low relative to the base. If the dorsum were lowered to a plane in line with the radix, the dorsal skin would not be supported and a supratip deformity would likely result. FIG. 14. Patient shown preoperatively and 14 months after surgery with a balanced retrousse nose.

Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1833 The alternative of raising the radix has three positive effects: (1) minimizing the dorsal convexity, (2) preserving skeletal structure, and (3) diminishing the apparent size of the base. In this case, the nasal base itself poses challenges. The alar base is relatively wide, the nasal tip is ultraprojecting, and the nostrils are disproportionately long relative to the tip lobule. The nostril-lobule disproportion had to be addressed. 27 My plan was to increase lobular size by tip grafts and decrease the nostril size by alar resection. Projection of the nasal base would be countered by root augmentation. The frontal contour is also a problem of balance. The bony arch is narrow, which contraindicates osteotomy and suggests augmentation to diminish the relative width of the base. Spreader grafts provide continuity of the middle vault and ensure function of the internal valves. Conservative reduction of the flaring nostrils, including lobular and vestibular sides, and preserving a medial flap for a smooth sill 28 would narrow the alar base without compromise to contour or function. Nostrils can be reduced only so much without distortion. Therefore, augmentation of the upper vaults is of great benefit because it minimizes the amount of alar resection required to adequately narrow the base. The surgical plan is summarized as follows: transfixion incision of columella, anterior third only wide skeletonization rasp the radix to prepare for graft trim dorsum develop spreader graft pockets septal submucous resection to harvest graft material place bruised cartilage grafts at the root place spreader grafts trim caudal edges of upper lateral cartilages augment lateral bony arch, bilateral alar resection, lobular, and vestibular excision place tip graft. Figure 15 shows intraoperative photographs. Comments This patient, shown 14 months after surgery, exemplifies the concept of augmentationreduction to achieve a balanced nose (Figure 14, right, and 16, right. The nose is not small, but it is correct in contour and function. A large nose, especially one with a projecting base, can be a trap. The soft tissue will not contract down to an overly reduced skeleton without sacrificing contour. With an understanding of this very real limitation, every surgeon performing rhinoplasty should be inspired by the possibilities presented by selective augmentation.

FIG. 15. (Above, left) Resection of the anterior segment of the middle vault. Note the visible septal T, which effectively supports the lateral walls and spreads the apices of the internal valves. (Above, right) Specimens obtained from septum to correct airway obstruction and for use as grafts. (Center, left) The root graft consists of segments of bruised or morselized septal cartilage, layered, and sutured together. (Center, right and below, left) Crushed cartilage grafts to be placed over each lateral wall of the bony arch. (Below, right) Spreader grafts shown before placement.

FIG. 16. Same patient as seen in Figure 14, preoperatively and shown 14 months postoperatively. A balanced, retrousse nose. (Above) Increased width of bony arch and a narrower base have improved balance. (Center) Elevation of root diminishes the apparent size of the base. (Below) Basal view shows a narrower base in addition to a smooth sill, the result of preservation of a medial flap with the alar resection.

1836 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 FIG. 17. Primary rhinoplasty patient with collapsing internal valves on inspiration. He was the first patient diagnosed as having short nasal bones and the first to receive spreader grafts. V. SUPPORT OF THE MIDDLE VAULT: FUNCTIONAL AND AESTHETIC EFFECTS With the exception of Tord Skoog, who replaced the dorsal roof following reduction of the anterior septum, 29 no one in the early days of rhinoplasty attached much importance to the integrity of the middle vault. Lowering the dorsum was just another routine step in a reductive operation. In the 1950s and 1960s, surgeons actually tried to produce scooped noses. Lipsett took pride in creating a dorsum that was razor thin. Postsurgical noses of that era were characteristically caved in on the sides and functionally compromised. Like everyone else, I was taught to routinely perform an osteotomy and to resect the dorsum, thinking only of reduction. Narrower, smaller, lower, shorter: those were our goals. But even as I was dutifully narrowing my patients noses, I began to observe three recurring postoperative problems: (1) narrowing of the internal valves with impaired airways; (2) visible fall-in of the middle vault, seen on oblique view; and (3) inverted V deformity, a visible demarcation between the middle and bony vaults, apparent on front view. As increasing numbers of secondary rhinoplasty patients streamed through my examining room, this FIG. 18. (Left) Diagnosis of short nasal bones often can be made by visual examination. Palpation verifies the boundary of the caudal bony arch. (Right) X-ray film shows nasal bones to be about 1 cm long.

Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1837 observation became crystallized. I realized that our surgery was causing a discontinuity between the middle and bony vaults. I guessed, wrongly, that the upper lateral cartilages might separate from their bony attachment during rasping, thus causing them to fall in. But this idea was dispelled in the anatomy laboratory, where I discovered that a horse trainer would have difficulty pulling the cartilages away from the nasal bones. It wasn t until I met one particular primary rhinoplasty patient, that the etiology and treatment of middle vault impairment began to emerge. Short Nasal Bones FIG. 19. Diagrammatic representation of the effect of resection of the roof of the middle vault and its correction by spreader grafts. A male patient, with no history of prior surgery, requested that I improve his airway without changing the nasal contour (Fig. 17). When I examined him with a nasal speculum, the septum was obviously straight and the airways were wide open. I can t see anything wrong with the inside of your nose, I said. He gave me a quizzical look and inhaled deeply. Well I still can t breathe, he insisted. I looked again. Yes, now I can breathe, he said, his breath fogging the speculum. But when you take that instrument out, I can t. Then, when examining him without the speculum, I saw that on inspiration, the internal valves col- FIG. 20. Inverted V deformity is frequently seen in patients with short nasal bones. This patient, with an appropriate dorsal height, is shown before and after spreader graft placement. Had she needed dorsal augmentation, spreader grafts would not have been necessary, because the width of the dorsal graft would provide the necessary support.

1838 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 lapsed against the septum. Thinking about normal anatomy, I placed a cotton applicator at the apex of the internal valve and asked the patient to breathe. With the applicator in place, he breathed well. Now I was faced with two questions: Why were the internal valves collapsing and what could be done about it? A careful look showed a nose that was long and narrow, with practically no bony arch. On palpation, the nasal bones were found to be less than a centimeter long. It was clear then that the middle vault was lacking the support usually provided by a substantial bony arch. Thus began my campaign of measuring every bony arch I saw. I concluded that most nasal bones extend about half the distance between the radix and the angle of the septum. Twenty-five percent of that distance I considered to be short (Fig. 18). I then realized the clinical significance of the length of nasal bones for rhinoplasty patients and reported my findings in 1976 at the meeting of the American Society of Plastic and Reconstructive Surgeons in Boston. 30 Significantly, in the nose with short nasal bones the middle vault is not held laterally by the support of the bony arch. Medially, the primary support to the internal valves is the broad anterior edge of the septum, or the top of the septal T. When the anterior septum is resected to lower the dorsum, the walls will fall medially and airway impairment and an inverted V deformity may result. In cases with short nasal bones, osteotomy is contraindicated and something must be done to expand the internal valves. Spreader Grafts Returning to my milestone patient with short nasal bones, I must say that at the time I was just fishing for ideas. With the cotton applicator came the answer: A sticklike graft placed along the anterior edge of the septum would spread the apex of the internal valve (just like the applicator), moving the medial portions of the lateral walls outward. This would widen and support the patient s long middle vault and improve his airway. The graft was named for its function: spreader graft. 31 33 The technique I used for this patient remains unchanged except for the sequence. The initial incision extends through the perichondrium. The narrow pocket is developed with a Cottle perichondrial elevator, flat side against the septum, maintaining a mucosal attachment at the anterior septum. In the past, I made the pockets and then reduced the dorsum. Today I reduce the dorsum and then make the pockets to ensure an anterior mucosal attachment, which prevents slippage of the graft. With the success of spreader grafts for this patient, the technique was soon extended for use in the postsurgical nose (without a dorsal graft), asymmetries of the dorsum, and selected primary cases. Spreader grafts replace the broad, anterior portion of the septal T that is removed with any significant dorsal hump (Fig. 19). Therefore, these grafts prevent the functional and visible sequelae of middle vault fall-in as well as restore middle vault support in the postoperative patient or in patients with short nasal bones (Fig. 20).

Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1839 VI. MALPOSITION OF THE LATERAL CRURA: RECOGNITION AND MANAGEMENT Malposition is not the best term for this anatomic feature, but I have used it since the early 1970s, so it is too late to take it back. I now realize that what I observed as a malposition of the lateral crura is not an abnormal position of the cartilage, but a somewhat common variation of normal anatomy. I had learned that the normal, expected position of the alar cartilage almost parallels the alar rim. Gray s Anatomy of the Human Body describes the cartilage as diverging from the alar rim at about 15 degrees. 34 So when I observed alar cartilages at a 60- degree cephalic slant, it seemed to me that they were malpositioned. 35,36 The first patient who brought my attention to the position of the alar cartilages demon- FIG. 21. (Above, left) The first patient on whom malposition was diagnosed. (Above, right) On front view, the cephalic orientation of the lateral crura is clearly visible, with the characteristic parentheses, which mark the margins of the alar cartilages. (Below, left) Pressure on the alar rim reveals a sharp outline of the position of the lateral crus. (Below, right) On basal view, the poorly supported alae and the square perimeter of the base are characteristic. However, the cartilages can be either broad or narrow at the tip.

1840 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 strated a dramatic picture of malposition (Fig. 21). On front view, the nasal tip was ball-like and bordered by parentheses. On basal view, there was notching in the alar rims, where the cartilages angled cephalad. I realized that the standard approach to trimming the cartilages would not be effective and might cause distortion. I then decided to dissect out the alar cartilages and rotate them downward to provide substance and support to the rims (Fig. FIG. 22. (Above) The lateral crus is dissected from the vestibular skin. (Center) The completely dissected lateral crus. (Below) Repositioned crus in newly formed pocket, parallel to the alar rim. 22). Postoperatively, the alar rims were well supported, thereby eliminating the tip parentheses (Fig. 23). After this case, I began to find malposition of the alar cartilages in a variety of forms and degrees. However, the characteristic findings were consistent: lack of alar rim support and some degree of visible parentheses, which manifest the caudal edges of the cephalically positioned lateral crura. Malpositions were everywhere. This recognition became important as the clinical relevance and application became increasingly apparent. If a significant malposition is unrecognized preoperatively, the standard cephalic trim of the alar cartilage may result in postoperative distortions. For example, the usually safe intracartilaginous incision is made parallel to the alar rim, but if the cartilages are cephalically rotated, this technique may result in transection of the cartilages, often creating visible stumps or knuckles postoperatively. Secondary rhinoplasty patients with undiagnosed or untreated malpositions share identifiable defects; most notable are tip deformities and notching of the alar rims (Fig. 24). Now that malposition had made itself known, what was to be done? Obviously, diagnosis was paramount. At first, my treatment was straightforward: repositioning of the lateral crura. With experience, I abandoned that technique because of the occurrence of some distortion at the apex of the nostril. Then I experimented with the more radical technique of total resection of the lateral crura, then replacing them as free grafts along the alar rims. A third option is to leave them alone. Whether to leave the cartilages alone depends more on the patient s desires than on any other factor. I always ask, What do you think of your nose on front view? If the patient does not specifically mention the round tip, I then ask, What about these grooves here, do they bother you at all? If the patient says no, then I will plan a conservative approach a tip graft to project and define the tip and alar rim grafts for support. The improvement is good, but subtle. For many patients, this conservative result is quite satisfactory and for the surgeon who may not be comfortable with resecting the cartilages and reconstructing the base, this is certainly the safest technique (Fig. 25). Resection of the cartilages and replacing them in the alar rims is technically challenging.

Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1841 FIG. 23. Patient shown 14 months after surgery with good support to the alar rims and improved tip projection. The dissection from the vestibular side is difficult. However, with experience, the dissection becomes easier, faster, and less traumatic. The grafts are effectively fixed in position by 5-0 plain sutures. I do not recommend this technique to the occasional nasal surgeon. Placing fragile strips of alar cartilage in meticulously made pockets requires a familiar and respectful touch. But for me, this has been the most successful technique to support the alar rims in cases of malposition (Figs. 26 through 28). Regardless of the method of treatment, the most important aspect of malposition is recognition. The position of the lateral crura relative to the alar rim should be assessed in every rhinoplasty patient to prevent untoward results, to modify technique as necessary, and to ensure the best aesthetic result for patients whose alar cartilages require special management.

1842 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 FIG. 24. Patients with undiagnosed malposition treated by standard tip refining techniques, which resulted in tip distortions. Note that all have notched alar rims and visible stumps of the remaining lateral crura.

Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1843 FIG. 25. Preoperative and postoperative views of patient with malposition of the crura treated by leaving the alar cartilages untouched. A tip graft was placed and the alar rims were supported by grafted strips of cartilage. The patient also received a root graft, spreader grafts, and a slight reduction of the dorsum.

1844 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 FIG. 26. Patient with complete resection of alar cartilages lateral to the medial genua replacement with narrow strips of cartilage to support the alar rims. Tip grafts and a dorsal graft were also done.

Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1845 FIG. 27. Oblique and basal views of the patient shown in Figure 26.

1846 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 FIG. 28. Surgical steps to correct malposition in the patient in Figures 26 and 27. (Above, left) Specimen from rhinoplasty. Note the degree of bony deformity. (Above, right) Right lateral crus dissected out to the medical gene. (Center) Lateral crura completely removed. (Below, left) Trimmed lateral crus positioned for suturing in alar rim. (Below, right) Dorsal graft of septal cartilage prior to placement.

Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1847 FIG. 29. Patient operated on in 1968. Her alar cartilage configuration was ideal for the standard tip refining technique. VII. THE SIGNIFICANCE OF THE MIDDLE CRURA: CLINICAL AND AESTHETIC CONSIDERATIONS This milestone is an example of how one can look at something every day, for years, and never really see it. I was taught that an alar cartilage consists of two segments, the medial and lateral crus, which join at the dome or lateral genu. Medical illustrations confirmed this impression, showing a long, continuous structure bent in the middle. It never occurred to me to question the accepted anatomy. When researching it later, I found that Gray s Anatomy 34 mentions, almost parenthetically, a transitional area but gives no description, nor is it represented in any illustration. No wonder it went unnoticed. I had never heard or read any reference to it, nor seen it illustrated in presentations, let alone any mention of a possible clinical significance. Informed by the accepted anatomy, I had been intently studying alar cartilages but was still perplexed by unanswered questions. The many variations in the surface anatomy of the tip remained a puzzle. In particular, I was interested in the angulation at the columellar- FIG. 30. Cadaver dissection showing three distinct segments of the alar cartilage. The middle crus (red portion) is bounded by the medial and lateral genua.

1848 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 FIG. 31. Three-segment anatomy of the alar cartilage. (Left) Angle of rotation at the medial genu defines the columellar-lobular junction; (right) angle of divergence determines the intercrural distance. FIG. 32. (Left) A typical snub nose reflects short middle crura, resulting in inadequate projection of the nasal tip. (Right) Patient is shown 8 years after tip grafting. lobular junction and the various facets seen in different nasal tips. From the beginning, I could get some results I was proud of, such as the one I often used in my early presentations. This patient, operated on in 1968, happened to have the ideal cartilages for the standard technique (Fig. 29). Then, as I gained experience, I could not understand why the same technique failed to produce consistent results. I could not create the desired facets and angulations at will. I felt that until these features were understood, I could not adequately diagnose and control tip contours. One day, quite unexpectedly, I saw what I had been looking at. In an anatomy laboratory, I had dissected out and exposed an entire alar cartilage. At once, it was obvious. Between the medial and lateral crus, there was a distinct segment that extended from a medial genu to a lateral genu: a middle crus 37,38 (Fig. 30). With that observation, the surface anatomy of the nasal base finally made sense. The base consisted of three definite units: the columella, the tip lobule, and the alar rims. The columellarlobular junction indicated the medial genu, or the angulation between the medial and middle crura. This angle I defined as the angle of rotation (Fig. 31, left). The height of the lobule reflected the length of the middle crura, and on front view the tip was defined by the distance between the lateral genua. This distance was determined by the angle of divergence,orthe relationship of the middle crura to each other (Fig. 31, right). Thus for me, the middle crus

Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1849 FIG. 33. (Above, left) Square tip reflecting long middle crura with a wide angle of rotation. (Right) Three-segment alar cartilage as it relates to surface contour. (Below, left) Postoperative result obtained by partial resection of the middle crura and tip grafting.

1850 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 FIG. 34. (Left) Critical analysis of the individual patient s alar cartilage the size, shape, and position of each component enables effective surgical management of the nasal tip. (Right) Patient shown following resection of the crura lateral to the medial genu and reconstruction with septal cartilage grafts to the dorsum and nasal tip. Ear cartilage was used to support the alar rims. was the missing link in nasal tip anatomy. With it, diagnosis and management of a variety of nasal base configurations was possible. One frequently encountered configuration is the broad tip. Keeping the relationship between the middle crura in mind, one can see that a broad tip is the manifestation of a wide angle of divergence. Conversely, a narrow angle of divergence creates a pointed tip, lacking the attractive defining point of the lateral genu seen on oblique view. The length of the middle crura also determines characteristic tip contours. What I termed a tip with inadequate projection usually reflects short middle crura. To the extreme, a snub nose is the result of very short, or nonexistent, middle crura (Fig. 32). Historically, these noses have often been treated by composite grafts to lengthen the columella. With critical observation, however, it is apparent that the columella is not the primary problem. The lack of projection is usually caused by a deficient tip lobule; that is, short middle crura. The logical treatment for a deficient lobule is to place tip grafts to project and define the nasal tip, thus duplicating the role of the middle crura. Less common but also typical in appearance is the tip with long middle crura. Long middle crura are manifest by a tall lobule or a long infratip segment (Fig. 33). In these cases, the nasal tip appears to be square on profile. Recognition of long middle crura is necessary for a satisfactory result, because techniques that address only the lateral crura will not affect the desired change. Only excision of part of the middle crura will decrease the height of the lobule. Understanding the alar cartilage as a threepart structure, with each part having a specific role in the contour of the nasal base, and understanding that the size, shape, and position of each component influences the aesthetics of the tip, enables the surgeon to analyze the anatomic basis for each patient s nasal contour and to plan an operation that is appropriate and effective (Fig. 34). Finally, I would like to comment on the Endonasal method of rhinoplasty, which, when I learned it, was the only method. All of the

Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1851 observations, realizations, and resulting changes have been made under the conditions of an endonasal approach and could not have been made otherwise. Some of the techniques, such as placing free grafts in discrete pockets, are not applicable to the open method, but the principles still apply. This is not the time or place for a comparison with the now popular open method, but one reflection is salient. Much of what I have learned and continue to learn from nasal surgery is dependent on seeing and touching the nose in its normal, covered state. As I operate, a dynamic takes place between me and the nasal tissues, between what I am imposing on the nasal contour and what it will accept. I would find it difficult to duplicate the subtlety of this experience working on exposed skeleton. At present, I would make one exception the case of malposition. Because of the technical difficulty of repositioning or replacing the lateral crura, it may be that the open approach enables more controllable management of malpositioned cartilages. It is an interesting experience to reflect on the evolution of one s thinking on a particular subject over a long period of time. My subject is small, but for me, the possibilities have always been great. I like noses. I like to think about changing them and I like to think about changing the ways in which we change them to achieve ever improving and predictable results. To that end, these are my seven personal milestones to date. I m working toward an even number. Jack H. Sheen, M.D. 216 W. Pueblo Street, Suite A Santa Barbara, Calif. 93105 ACKNOWLEDGMENT I would like to express appreciation to my wife, Anitra, for her assistance in the writing of this article. REFERENCES 1. Sheen, J. H. Aesthetic Rhinoplasty, 1st Ed. St. Louis: Mosby, 1978. P. 26. 2. Converse, J. M. 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Millard (Ed.), Symposium on Corrective Rhinoplasty. St. Louis: Mosby, 1976. P. 161. 12. Rees, T. D., and Wood-Smith, D. Cosmetic Facial Surgery. Philadelphia: Saunders, 1973. Pp. 456 460. 13. Rees, T. D., Krupp, S., and Wood-Smith, D. Secondary rhinoplasty. Plast. Reconstr. Surg. 46: 332, 1970. 14. Meyer, R. Secondary Rhinoplasty. In W. Berman (Ed.), Rhinoplastic Surgery. St. Louis: Mosby, 1989. Pp. 223 226. 15. Safian, J. Fact and fallacy in rhinoplasty. Plast. Reconstr. Surg. 12: 24, 1953. 16. Deneke, H. J., and Meyer, R. Corrective and Reconstructive Rhinoplasty. New York: Springer-Verlag, 1967. P. 451. 17. Sheen, J. H. Secondary Rhinoplasty Surgery. In D. R. Millard (Ed.), Symposium on Corrective Rhinoplasty. St. Louis: Mosby, 1976. Ch. 16. 18. Sheen, J. H. Secondary Rhinoplasty Surgery (Videotape #9610). Creating the Balanced Nose. Arlington Heights, Ill.: Plastic Surgery Educational Foundation. 19. Sheen, J. H. A new look at supratip deformity. Ann. Plast. 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1852 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000 31. Sheen, J. H., and Sheen, A. P. Aesthetic Rhinoplasty, 2nd Ed. St. Louis: Mosby, 1987. Pp. 530 536. 32. Sheen, J. H. Spreader graft: A method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast. Reconstr. Surg. 73: 230, 1984. 33. Sheen, J. H. Spreader graft revisited. Perspect. Plast. Surg. 3: 155 163. 34. Gray, H. Anatomy of the Human Body, 28th Ed. Philadelphia: Lea & Febiger, 1967. P. 1119. 35. Sheen, J. H. Aesthetic Rhinoplasty, 1st Ed. St. Louis: Mosby, 1978. Pp. 432 461. 36. Sheen, J. H., and Sheen, A. P. Aesthetic Rhinoplasty, 2nd Ed. St. Louis: Mosby, 1987. Pp. 988 1011. 37. Sheen, J. H., and Sheen A. P. Aesthetic Rhinoplasty, 2nd Ed. St. Louis: Mosby, 1987. Pp. 25 45. 38. Sheen, J. H. Middle crus: The missing link in alar cartilage anatomy. Perspect. Plast. Surg. 5: 31, 1991.