---

Nasal Framework Deformities, Saddle Nose, and Rhinoplasty - A Complete Guide

---

PART 1: DEFORMITIES OF THE NASAL FRAMEWORK

Upper Third Deformities (Bony Vault)

• Nasal hump (dorsal hump): Excess bone +/- cartilage at the nasal bridge. Can be purely bony, purely cartilaginous, or combined. Very common in Middle Eastern and Southern European patients.
• Crooked/deviated nose: The bony pyramid is off midline. Usually due to trauma or septal deviation. Corrected with osteotomies.
• Open roof deformity: When a large dorsal hump is removed without closing the roof back, a flat, wide-looking dorsum results. Requires spreader grafts + medial and lateral osteotomies to close.

Middle Third Deformities (Cartilaginous Vault - Upper Lateral Cartilages)

• Saddle nose: Collapse/depression of the dorsum due to loss of support (see dedicated section below).
• Inverted-V deformity: The upper lateral cartilages (ULCs) drop inferiorly after rhinoplasty, visible as a dark V-shadow on the dorsum. Usually from failure to reattach ULCs after hump reduction.
• Middle vault narrowing/pinching: Due to ULC collapse inward, narrowing the internal nasal valve (INV). Causes nasal obstruction.

Lower Third Deformities (Tip/Lower Lateral Cartilages)

• Pollybeak deformity: Fullness/bump in the supratip area, giving a parrot-beak appearance. Caused by:
  1. Underreduction of dorsal cartilage/anterior septal angle
  2. Paradoxical pollybeak from excessive dorsal resection causing a soft tissue void that scars
  3. Tip deprojection (loss of tip support) leaving relative supratip excess
• Alar retraction: The alar rim rides too high, showing excessive nostril on frontal view.
• Supra-alar pinching: Over-resection of lateral crura leaves a pinched-in look.
• Tip asymmetry / bossae: Cartilage knuckling visible under thin skin.
• Bulbous tip: Dome too wide and rounded, no definition.
• Ptotic tip (drooping tip): Tip rotates downward - often from septal hematoma, aging, or previous surgery.

---

PART 2: SADDLE NOSE DEFORMITY

What is it?

Causes (Etiology)

Classification (What collapses?)

1. Isolated cartilaginous dorsal collapse - only the cartilaginous vault sinks
2. Combined bony + cartilaginous deficiency - the entire dorsum is low
3. Over-resection of underlying cartilaginous framework - iatrogenic
4. Loss of dorsal septal support - due to necrosis, infection, trauma, autoimmune, cocaine, or septal hematoma

Clinical Features

• Concave nasal profile (the hallmark)
• Columellar retraction (the columella withdraws inward)
• Short nose (vertical height loss)
• Associated septal perforation (especially in syphilis, cocaine, GPA)
• Nasal obstruction
• External and internal deformities

Determining Appropriate Dorsal Height

• In men: dorsum should be straight or slightly convex at the rhinion
• In women: dorsum should be straight or slightly concave
• A low radix can make the dorsum look convex even when it is not - augmenting the radix may be the right answer rather than reducing the dorsum
• Tip projection directly affects how high the dorsum should be - if the tip is under-projected, the dorsum looks too prominent even when normal

---

PART 3: MANAGEMENT OF SADDLE NOSE DEFORMITY

Step 1 - Analysis

Step 2 - Primary Repair Principle

Step 3 - Graft Materials Used

Autogenous (Gold Standard - Preferred)

Alloplastic Materials (If autogenous unavailable/refused)

Key principle: Autogenous > alloplastic. Alloplastic materials have risk of rejection, infection, inflammation, extrusion. Silicone is most common but most problematic at tip region.

Homologous Materials (Now largely abandoned)

Step 4 - Surgical Techniques for Saddle Nose

For Small Defects

• Auricular cartilage grafts are sufficient
• Rolled fascia + diced cartilage can augment dorsum when structural support is not needed

For Major Defects

• Costal cartilage is most effective for establishing structural support of the dorsal septum
• Extended spreader grafts (costal cartilage) attached to a caudal septal replacement graft re-create the L-strut
• Grafts should be canoe-shaped:
  • Cephalic margin: snug in a subperiosteal pocket extending to the desired nasal starting point
  • Caudal margin: terminates in the supratip
  • Lateral margins: beveled to minimize visibility

Skin contracture (common in revision cases)

• When skin contracts over a saddle deformity, it resists expansion
• Dorsal augmentation grafts are needed for both support AND to expand contracted skin
• A piece of temporalis fascia draped over the entire nasal framework can camouflage edge irregularities - placed through intercartilaginous incision or open approach

Staging

• When extensive septal reconstruction + osteotomies are required, stage the procedure: do septal work first, place implants at a second operation
• This reduces the size of implant needed (straighter nose = less augmentation needed)

---

PART 4: RHINOPLASTY - TYPES AND APPROACHES

What is Rhinoplasty?

---

TYPES OF RHINOPLASTY

---

RHINOPLASTY APPROACHES

1. Closed (Endonasal) Approach

• Only intercartilaginous incisions (between upper and lower lateral cartilage)
• Lower lateral cartilage (LLC) is NOT delivered out
• Advantages: No disruption of major tip support, no external scar, intact caudal rim
• Disadvantages: Minimal exposure of LLC, limited tip modification, potential valve scar

• Combines marginal + intercartilaginous (or transcartilaginous) incisions
• LLC is delivered out as a bilaterally pedicled chondrocutaneous flap
• Advantages: Better visualization of entire LLC, good tip/dome access, no external incision
• Disadvantages: Disrupts one major tip support (LLC-ULC attachment), limited tip modification possible, higher revision rates than open approach

2. Open (External) Approach

• Combines a transcolumellar incision (inverted-V or stair-step) + bilateral marginal incisions
• The entire skin-soft tissue envelope (SSTE) is elevated off the nose
• Advantages:
  • Complete exposure of all nasal structures
  • Precise graft and suture placement
  • Best for complex tip work, revision cases, cleft rhinoplasty
  • Lower revision rates than endonasal
  • Ideal for teaching
• Disadvantages:
  • External scar (transcolumellar - usually fades well)
  • Disruption of SSTE (minor tip support mechanism)
  • More postoperative edema and numbness
  • Longer recovery of tip definition (up to 1 year)

Rhinoplasty Incisions Summary

---

PART 5: AUGMENTATION RHINOPLASTY

What is it?

Indications

• Low dorsum (flat nose) - most common in Asian, African patients
• Saddle nose deformity
• Post-traumatic nasal collapse
• Underprojected tip
• Short nose needing lengthening
• After major reduction where too much tissue was removed

Surgical Approach Choice

• Only dorsal work needed? → Endonasal (intercartilaginous or extended septoplasty incision)
• Tip work also needed? → External/open approach - offers best control for combined dorsal + tip augmentation + lengthening

Augmentation Materials (already detailed above - same principles apply)

Alloplastic Implants for Augmentation

• L-shaped silicone strut - traditional Asian rhinoplasty; augments dorsum + lengthens nose. But tension on the tip → risk of skin breakdown and extrusion, especially at the tip
• Modern approach in Asia: Alloplastic for dorsal upper 2/3 + autologous tissue for tip (tip grafts, cap grafts, columellar struts, caudal extension grafts)
• Straight silicone implant for dorsum only
• Gore-Tex (ePTFE): preferred over silicone for dorsum if autologous not available; softer, less palpable, minimal fibrous ingrowth = removable
• Medpor: more tissue integration, harder to remove
• Key technical point: Bevel/taper all implant edges; fix with sutures to avoid slippage; irrigate copiously with antibiotic solution; avoid undue tension

Autologous Tissue for Augmentation

• Stacked cartilage grafts (septal, ear, rib) - layers sutured together
• Diced cartilage wrapped in fascia (DCF) - excellent dorsal contour, no edge visibility
• Articulated costal cartilage - for major augmentation needs
• Iliac crest / calvarial / rib bone - for bony vault augmentation

Special Considerations: Non-Caucasian (Asian/African/Middle Eastern)

• Asian nose: Wide dorsum, flat, low radix, bulbous tip, thick skin. Despite appearing wide, lateral osteotomies are rarely needed - midline augmentation creates illusion of narrowing
• Tip augmentation: Thick skin in Asian patients camouflages minor irregularities but demands high structural support from the cartilaginous framework
• Warping of rib graft: Avoid by carving the central core of the rib or cutting obliquely into symmetric cortical portions
• Middle Eastern patients requesting hump reduction: Strong dorsum has cultural significance - careful preoperative counseling needed; scooping the dorsum may be culturally unacceptable

Complications of Augmentation Rhinoplasty

• Implant extrusion (especially silicone at tip)
• Infection
• Migration/slippage
• Skin breakdown over the tip
• Visible edges of implant (thin-skinned patients)
• Long-term: warping of rib grafts, resorption of cartilage

---

PART 6: FUNCTIONAL RHINOPLASTY

What is it?

Preoperative Assessment

• Complete nasal history: obstruction, allergies, trauma, prior surgery
• Identify which structures cause obstruction:
  • Deviated septum
  • Inferior turbinate hypertrophy
  • Internal nasal valve (INV) collapse
  • External nasal valve (ENV) collapse
  • Paradoxical inferior turbinate
• Cottle maneuver: lateral cheek/lateral nasal wall displacement to open the valve - improvement = positive test (but unreliable alone; gentle lateral displacement of ULC is a better predictor)

---

Structure 1: The Nasal Valve

• The narrowest part of the nasal airway
• Formed by the angle between the dorsal septum and the caudal edge of the upper lateral cartilage (ULC)
• Normal angle: 10-15 degrees
• Surrounded by: septum medially, ULC superolaterally, inferior turbinate/nasal floor inferiorly
• This is the "keystone" - stenosis here dramatically increases airflow resistance

• The nasal vestibule/nostril opening
• Supported by: lower lateral cartilages, soft tissue of alar lobule, columella
• Collapse here causes visible nostril collapse on inspiration

---

Structure 2: Septoplasty for Functional Rhinoplasty

• Releases ULCs from dorsal septum (improves valve)
• Corrects septal deviations deforming the INV
• In a severely deviated nose - bilateral ULC release + spreader graft + osteotomies as needed

---

Structure 3: Spreader Grafts (Middle Vault / INV Repair)

What they do:

• Maintain or improve nasal valve patency
• Align dorsal aesthetic lines and establish middle vault width
• Straighten a deviated dorsal septum
• Reconstruct an open roof deformity
• Reestablish contour between middle vault and bony vault

Shape: Rectangular in cross section

Placement:

• Sit at the apex of the INV, between the ULC and dorsal septum
• Can extend cephalically under the nasal bones, or caudally to splint a caudal septal extension graft

Technique (open or endonasal):

1. ULCs are detached from the dorsal septum
2. Spreader grafts placed into desired position between ULC and dorsal septum
3. Secured with resorbable mattress sutures
4. A "clocking suture" can subtly correct a tilted septum; major deviations need septal reconstruction

For deviated dorsal septum:

• Thicker graft on the concave side, thinner on the convex side - the asymmetry straightens the dorsum

Submucosal placement (alternative):

• Spreader grafts placed into submucosal pockets at the apex of the INV WITHOUT detaching ULCs
• Viable when no significant dorsal septal deviation or ULC displacement
• Acts as a cantilever to expand the INV

---

Structure 4: Batten Grafts (External Nasal Valve)

• Alar batten grafts bolster the lateral nasal wall and external valve
• Used when LLC over-resection or aging has removed lateral wall support
• Cartilage grafts (septal preferred) sewn to the undersurface of the lateral crura

---

Causes of INV Collapse Specifically

1. Malpositioned or migrated spreader grafts (post-rhinoplasty)
2. Scarring at INV from endonasal incisions
3. Inferomedial displacement of the ULC (after rhinoplasty without ULC reattachment)
4. Dorsal septal deviations
5. High septal bowing
6. Inferior turbinate hypertrophy
7. Paradoxical inferior conchal curve

---

Causes of ENV Collapse

1. Previous rhinoplasty with over-resection or morselization of LLCs
2. Natural aging - the scroll between ULC and LLC unfurls, losing support
3. Cartilage/soft tissue losing inherent stiffness

---

Tip Modification for Functional AND Cosmetic Purposes

Goal

For Bulbous Tip

• Cephalic trim: Remove a strip from the cephalic edge of the LLC; always leave 8-10 mm of alar cartilage width for support
• Suture tip contouring: Transdomal + interdomal sutures improve definition without excision
• Lateral crural strut grafts: Sewn to undersurface of lateral crura - flatten contour AND strengthen the lateral crura to prevent external valve collapse
• Vertical lobule (dome) division: Excise a portion of intermediate crura and reapproximate

To Increase Tip Projection

• Transdomal/interdomal sutures
• Lateral crural steal
• Shield graft, cap graft
• Columellar strut or caudal septal extension graft
• Septocolumellar suture

Tip Models (understanding rotation and projection)

• Tripod Model: Conjoined medial crura + lateral crura on each side = three legs of a tripod; changing the length of any leg alters tip rotation and projection
• M-Arch Model: Incorporates the intermediate crural curvature for more accurate tip mechanics

---

Osteotomies in Rhinoplasty

• Close an open roof defect (after dorsal hump reduction)
• Straighten a crooked nose
• Narrow a broad upper third

---

Crooked Nose Management

---

PART 7: POSTOPERATIVE CARE

• External nasal splint for 10-14 days to maintain nasal bone and cartilage position
• Head elevation + ice packs for 2-3 weeks
• Swelling, pain, bruising expected for 2-3 weeks
• Periorbital ecchymosis if osteotomies performed
• Full 1 year needed for complete resolution of nasal tip swelling (especially after open rhinoplasty)
• Approximately 10% of primary rhinoplasty patients will require operative revision
• Revision should NOT occur for at least 1 year to allow all swelling and tissue remodeling to stabilize

---

QUICK MEMORY AID

NASAL FRAMEWORK DEFORMITIES
├── Upper 1/3 (Bony): Hump, Crooked, Open roof
├── Middle 1/3 (Cartilaginous): SADDLE, Inverted-V, INV collapse
└── Lower 1/3 (Tip): Pollybeak, Alar retraction, Bulbous, Ptotic

SADDLE NOSE CAUSES: TIACCD
T - Trauma/septal hematoma
I - Iatrogenic (over-resection)
A - Autoimmune (GPA, relapsing polychondritis)
C - Cocaine/Congenital
C - Cocaine → septal perforation
D - Disease (syphilis, TB, leprosy)

RHINOPLASTY TYPES:
Cosmetic = Primary / Reduction / Augmentation
Functional = septum + valves + turbinates
Ethnic = usually Augmentation

APPROACHES:
CLOSED = No scar, limited exposure
   └── Non-delivery (intercartilaginous only)
   └── Delivery (LLC brought out)
OPEN = Transcolumellar scar, full exposure, best for revision/tip work

SPREADER GRAFT = Fix for INV collapse, placed BETWEEN ULC and septum
BATTEN GRAFT = Fix for ENV collapse, placed UNDER lateral crura

---