Comprehensive and systematic preoperative nasofacial analysis is requisite to define surgical goals and achieve satisfactory results. However, aesthetic ideals should be approached cautiously as there is significant variability among different ethnicities.

The senior author (Rod J. Rohrich) approaches the nasofacial examination in a systematic fashion, from three different views—frontal, lateral, and basal (Video 15.1).

Prior to prepping and draping, a 27-gauge needle is used to infiltrate 1% lidocaine containing 1:100,000 epinephrine into the columella, along the infracartilaginous incision, the dorsum, and soft tissues medial and lateral to the nasal bones. The nose is then packed bilaterally with oxymetazoline-soaked pledgets. A moist 3-inch gauze throat pack is placed by the surgeon. This sequence allows ample timing for the vasoconstrictive effect of the local anesthesia to take effect.

A stair-step transcolumellar incision is designed at the narrowest part of the columella and carried into the vestibule 2 to 3 mm laterally. In revision rhinoplasty, the location of the transcolumellar incision is placed in the preferred location regardless of the presence of previous scars.

Next, a wide double hook is placed to evert the alar rim over the fourth finger. This maneuver allows for reliable identification of the caudal margin of the lateral crus upon which an infracartilaginous incision is made in a lateral to medial direction toward the nostril apex. This incision sequence leaves a vestibular tissue bridge under the soft triangle, which is incised last (Video 15.2).

A wide double hook is placed at the nostril apices and retracted caudally. The nasal soft tissues are elevated off the cartilaginous framework with fine dissecting scissors. When the caudal portion of the nasal bones is reached, a Joseph periosteal elevator is used to achieve a limited subperiosteal dissection over the areas of planned bony work.

The oxymetazoline-soaked pledgets are removed from the vestibules bilaterally and a long heavy Vienna nasal speculum is used to microfracture the inferior turbinates through a closed approach from posterior to anterior while pushing the speculum laterally onto the inferior turbinate (Video 15.3).

The five-step component dorsal hump reduction (CDHR) serves to reduce the dorsum in a precise and graduated fashion while maintaining the upper lateral cartilages (ULCs). CDHR begins with (1) separation of the ULCs from the septum (Fig. 15.1), (2) incremental reduction of the septum proper, (3) dorsal bony reduction, (4) verification by palpation, and (5) final modifications (spreader grafts [Fig. 15.2a], autospreader flaps [Fig. 15.2b], suturing techniques, osteotomies) (Videos 15.4 and 15.5).

The ULC tension spanning suture functions to stabilize the ULC to the septum while establishing symmetric dorsal aesthetic lines (Fig. 15.2c).

Autospreader flaps can be performed when there is excess horizontal dimension to the ULCs, typically after reduction of a dorsal hump. The anterior edge of the ULCs is folded inward and a 5–0 PDS suture is secured in a horizontal mattress fashion (Fig. 15.2b).

Additional sutures can be placed cephalically along the ULCs and septum, as needed, for support or improved contour.

Septoplasty may be required in cases of nasal obstruction and/or deviation (septal tilt, anterior posterior deviation, craniocaudal deviation, or septal spurs) or in cases where donor cartilage is required.

Nasal osteotomies are primarily used to narrow a widened bony vault, close an open roof deformity, or straighten deviated nasal bones. The authors prefer a low-to-low percutaneous perforated lateral discontinuous osteotomy (Fig. 15.3a–c). A sharp 2-mm osteotome is introduced percutaneously at the level of the inferior orbital rim and nasofacial junction parallel to the horizontal surface of the maxilla (Video 15.6).

The purpose of cephalic trim is to refine the nasal tip and decrease supratip fullness by reducing the vertical height of the lower lateral cartilages (LLCs). The LLC is separated from the ULC at the scroll area. The cephalic portion of the LLC is trimmed leaving 5 to 7 mm medially and 8 to 10 mm laterally.

Three key tip-suturing techniques to improve position and shape include medial crural, transdomal, and interdomal sutures (Fig. 15.4a, b) (Video 15.7).

Alar rim grafts are frequently employed (>90% of cases) to prevent alar retraction (Fig. 15.5).

The transcolumellar incision is meticulously reapproximated with 6–0 nylon interrupted sutures. A double hook is used to slightly evert the alar rim to place interrupted chromic sutures in the lateral aspect of the infracartilaginous incision. The incision behind the soft triangle is left open and dressed with mupirocin-covered Surgicel (oxidized regenerated cellulose) to avoid suture-driven alar retraction or notching in this region.

Although assessment of alar flare is part of the standard preoperative nasal analysis, the final decision to perform alar flare reduction occurs only after wound closure. The reason for this is because alar flare heavily depends on tip projection, rotation, and by the length/strength of the lateral crura and alar rims.