Rhinoplasty is the most challenging procedure in all of facial plastic surgery and it has undergone significant changes in the past 25 years. In the past, surgeons used reductive techniques to decrease the size and alter the shape of the underlying cartilage and bone. This frequently produced a smaller, more well defined nose in the immediate postoperative period, but the structure of the nose was weakened and was made more susceptible to collapse and deformity. Surgeons have recently focused more on repositioning and restructuring existing tissues, frequently with suture techniques and cartilage grafting.
The major steps of rhinoplasty will be discussed, including managing the middle vault, stabilizing the nasal base, controlling nasal tip contour, managing the nasal lobule, setting dorsal height, and performing the alar base reduction. Recent articles furthering the development of these rhinoplasty techniques will be discussed. In addition, pertinent anatomic variations will be included in each section, as well as techniques to correct these malformations.
Managing the middle vault
The middle nasal vault is composed of the upper lateral cartilages and the nasal septum. In patients with short nasal bones and long upper lateral cartilages, the middle vault is long and more prone to collapse after dorsal hump reduction. This is especially true in patients treated with reductive rhinoplasty techniques without adequate structural augmentation. The middle vault must therefore be made strong and sufficiently wide to prevent collapse. There are two general techniques that can be applied to the middle vault: the upper lateral cartilage can be left connected to the dorsal septum, or the upper lateral cartilage can be divided from the dorsal septum thereby opening the middle vault.