A 25-year- old patient presented after three previous rhinoplasties with a wide nasal pyramid and irregularities of the dorsum after grafting with conchal cartilage.

After opening the nose, the anterior septum was found to be overresected. Therefore, a large columellar strut, taken from the septum, was put in a pocket in front of the anterior septal border, and the medial crura were affixed to it. After smoothing the dorsum, paramedian osteotomies were performed with a Lindemann fraise, and then low-to-low lateral and transverse osteotomies were performed transcutaneously. As a result of this mobilization, a satisfactory narrowing of the pyramid was possible. The dorsum was covered with two layers of allogenic fascia (Tutogen). The tip was narrowed by transdomal sutures, and a cap graft from fascia was put on the tip. By using fascia any visibility of the graft was avoided (Fig. 10.1).

A 29-year-old patient was seen after two previous rhinoplasties. In addition to a loss of support from overresection of the septum and incomplete lowering of the dorsum, the nasal pyramid was also overly wide. The reason for the deformity of the nasal pyramid was the extremely thick bone, which required four chisels to cut the strong hump. Initially a parasagittal medial osteotomy with a Lindemann fraise was performed after lowering the dorsum, followed by low-to-low lateral and transverse osteotomies transcutaneously to mobilize the pyramid and narrow it. A cast was put on for 3 weeks to guarantee the narrowing of the bones. The missing support was achieved by a strong sandwich graft from the concha. The tip was narrowed by transdomal sutures and contoured by spanning sutures (Fig. 10.2).

A 51-year-old patient presented after two rhinoplasties, which were followed by nasal trauma. His complaints centered on the deviated nose, an open roof, and a wide tip with asymmetrical nostrils. The facial skeleton was asymmetrical.

The pyramid was straightened and narrowed after parasagittal medial osteotomy and low-to-low lateral osteotomy combined with a transverse osteotomy performed transcutaneously. The dorsum was camouflaged by two layers of alloplastic fascia. Narrowing the tip by transdomal sutures was not effective because of the thick cartilage. Therefore, both domes were divided and then sutured together. A shield graft from the tragus was applied. The residual parts of the tragus were used to graft the supratip area (Fig. 10.3).