• Aesthetic: Large nose, nasal hump, wide nose, droopy nasal tip (Figure 1)
• Functional: Difficult breathing and deviated septum
• Congenital: Cleft lip and palate, congenital nasal abnormalities
• Traumatic nasal fracture
• Inflammatory conditions: connective tissue disorders, immune disorders
• Iatrogenic: recreational drug use, cocaine

Figure 1. Rhinoplasty candidates.

• Cartilages
• Lower lateral cartilages (Figure 2)
• Upper lateral cartilages
• Septal cartilage
• Nasal bones
• Nasal superficial muscular aponeurotic system (SMAS)
• Soft tissue envelope beneath skin and above bone and cartilage
• Continuous with SMAS layer of forehead
• Skin envelope

Figure 2. Caption.

• Rotation versus counter-rotation (Figure 3)
• Projection versus deprojection
• Dorsal versus caudal

Figure 3. Caption.

• Surgical
• Open: skin incision in columellar base of nose
• Closed: no exterior incision, interior incision hidden from external view
• Nonsurgical: fillers used to augment nose

• General
• Sedation
• Local with adrenaline used to reduce hemorrhage and dissect tissue planes

• Packing of nasal cavity with vasoconstrictor
• Septoplasty if required
• Full transfixation incision
• Partial transfixation incision
• Killian incision (Figure 4)
• Mid-columellar incision
• Bilateral marginal incisions
• Tip surgery including tip augmentation, elevation, support, projection, commonly cephalic trim of lower lateral cartilages
• Nasal dorsum: commonly reduction of hump
• Alteration of projection
• Deprojection (Figure 2)
• Increased projection with grafts
• Osteotomies to narrow nasal bones
• Transcutaneous versus endonasal osteotomies
• Lateral and medial osteotomies
• Shape of osteotomy, e.g., high to low
• Closure of skin and mucosa
• Alar reduction if required
• Packing of nose internally if required
• Splinting of nose with thermoplastic splint

Figure 4. Killian incision.

• Autologous
• Septal cartilage
• Auricular cartilage
• Costal cartilage
• Nonautologous
• Silicone
• Medpore
• Gortex

• Intraoperative complications
• Hemorrhage
• Collapse of boney pyramid
• Osteotomies
• Rocker deformity: This deformity results when the medial osteotomy creates a fracture higher in the thicker part of the nasal bones, resulting in loose nasal bones.
• Open roof deformity: After reduction of a nasal hump, the bones are insufficiently narrowed, resulting in a wide nasal dorsum.
• Step deformity: Uneven reduction in nasal bones resulting in visible boney ridge
• Trauma/tears: skin, mucoperichondrium, septum
• Early postoperative complications
• Hemorrhage
• Epistaxis
• Septal hematoma
• Swelling
• Infection
• Skin necrosis
• Cerebrospinal fluid rhinorrhea
• Numbness and pain
• Transient episodes of anxiety or depression
• Late postoperative complications
• Polly beak nasal deformity
• Septal perforation (3%-25%)
• Tip: Nasal bossae, droop, hanging columella
• Aesthetic misjudgments
• Scarring
• Revision rhinoplasty 5-15%
• Persistent psychological complications

1. Azizzadeh et al. Master techniques in rhinoplasty. Elsevier. 2011
2. Gall R, Blakley B, Warrington R, Bell DD. Intraoperative anaphylactic shock from bacitracin nasal packing after septorhinoplasty. Anesthesiology. Nov 1999;91(5):1545-1547.
3. Hallock GG, Trier WC. Cerebrospinal fluid rhinorrhea following rhinoplasty. Plast Reconstr Surg. Jan 1983;71(1):109-113.
4. Sarwer DB, Pertschuk MJ, Wadden TA, Whitaker LA. Psychological investigations in cosmetic surgery: a look back and a look ahead. Plast Reconstr Surg. Apr 1998;101(4):1136-1142.
5. Anderson JR, Ries WR. Rhinoplasty: Emphasizing the External Approach. New York: Thieme Inc;1986.
6. Lawson W, Kessler S, Biller HF. Unusual and fatal complications of rhinoplasty. Arch Otolaryngol. Mar 1983;109(3):164-169.
7. McCollough EG. Nasal Plastic Surgery. Philadelphia: WB Saunders;1994.
8. Rees TD, Krupp S, Wood-Smith D. Secondary rhinoplasty. Plast Reconstr Surg. Oct 1970;46(4):332-340.
9. Tebbetts JB. Primary Rhinoplasty: A New Approach to the Logic and Techniques. St Louis, Missouri: Mosby Inc; 1998.
10. Teichgraeber JF, Riley WB, Parks DH. Nasal surgery complications. Plast Reconstr Surg. Apr 1990;85(4):527-531.
11. Safe II, Sadek EY, Surgical importance of Nasal SMAS in Open Rhinoplasty. Egypt J Plast Reconst Surg. 2010; 34(1) Jan 135-138.
12. Becker DG, Ransom E, Guy C, Bloom J. Surgical Treatment of Nasal Obstruction in Rhinoplasty. Aesthetic Surgery Journal. May/June 2010 vol. 30 no. 3 347-378.