INCREASE ROTATION

Lateral crural steal

Transdomal suture that recruits lateral crura medially

Base-up resection of caudal septum (variable effect)

Cephalic resection (variable effect) Lateral crural overlay

Columellar strut (variable effect) Plumping grafts (variable effect)

Illusions of rotation: increased double break, plumping grafts (blunting nasolabial angle)

DECREASE ROTATION (COUNTERROTATE)

Full transfixion incision Double-layer tip graft Shorten medial crura Caudal extension graft Reconstruct L-strut, as in rib graft reconstruction (integrated dorsal graft/columellar structure of saddle nose)

INCREASE PROJECTION

Lateral crural steal increased projection, increased rotation

Tip graft

Plumping grafts

Premaxillary graft

Septocolumellar sutures (buried) Columellar strut (variable effect) Caudal extension graft

DECREASE PROJECTION

High partial, or full transfixion incision

Lateral crural overlay (decreased projection, increased rotation)

Nasal spine reduction

Vertical dome division with excision of excess medial crura, with suture reattachment

INCREASE LENGTH

Caudal extension graft Radix graft

Double-layer tip graft Reconstruct L-strut

DECREASE LENGTH

See increase rotation

Also, deepen nasofrontal angle

Set-back and suture medial crura to midline caudal septum

TIP REFINEMENT

Cephalic resection (volume reduction)

Dome-binding sutures

Vertical dome division, with suture reconstitution Tip graft

REFERENCES

  1. Tardy ME. Rhinoplasty: the art and the science. Philadelphia : WB Saunders, 1997.
  2. Johnson CM Jr, Toriumi DM. Open structure rhinoplasty. Philadelphia : WB Saunders, 1990.
  3. Tardy ME, Toriumi DM. Philosophy and principles of rhinoplasty. In: Cummings CW, Fredrickson JM,
  4. Harker LA, et al., eds. Otolaryngology: head & neck surgery. 2nd ed. St. Louis : Mosby Year Book, 1993: 278-294