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Rhinoplasty is undergoing a transformation with the reemergence of dorsal preservation rhinoplasty (DPR) techniques. This article introduces a novel addition to the DPR repertoire, "bony dorsal preservation" (BDP), which has particular application for the correction of crooked noses.This comprehensive overview summarizes current DPR concepts and techniques, the intricate considerations that go into the dorsal osseocartilaginous vault and septal management, and how these are modified to treat the crooked nose. However, current DPR techniques, particularly the low septal strip (LSS), have drawbacks, and the desire to address such issues led to the development of BDP.BDP is ideal for cases where there is no septal base pathology. It maintains the core principle of DPR by lowering dorsal humps without creating open roof deformities. Its unique feature is that it temporarily separates the upper lateral cartilages from the septum while leaving the septal base attachment intact, thus allowing the entire osseocartilaginous vault to be adjusted independently before reconnecting the preserved upper lateral cartilages. This technique offers direct visualization during septal excision and fixation and enables cartilaginous vault movement without sacrificing stability. Compared with LSS, there is more septal cartilage available for harvesting, the risks of a single point of septal fixation are eliminated, and there is the potential to transition to component reduction techniques, if needed. With shared indications and contraindications with other DPR methods, BDP emerges as a valuable addition to the evolving field of rhinoplasty, particularly in addressing the challenges of the crooked nose., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: The skin-soft tissue envelope (STE) is a critical component of rhinoplasty and can have a significant impact on the final result. Skin contour sutures (SCSs) can be used to prevent potential complications related to skin detachment and to improve rhinoplasty results., Objectives: The aim of this study was to assess the efficiency of SCSs for nasal skin approximation., Methods: SCSs involve the use of external sutures to stabilize the STE flap based on the principle that the pressure of the sutures helps to approximate the STE to the underlying nasal skeleton. The first study group demonstrated the utilization of SCSs in 459 consecutive rhinoplasty cases between December 2016 and April 2022 which were retrospectively reviewed. The second study group consisted of 30 patients with thick skin who had insertion of SCSs with ultrasonic evaluation both preoperatively and postoperatively., Results: The average postoperative follow-up period in the first study group was 41 months (range, 12-64 months). Any suture site that was visible after removal of the suture disappeared completely after 6 weeks in most patients. No complications were reported. In the second group the ultrasound data indicated that STE healing was faster as its thickness returns to its preoperative state earlier in the healing process when SCSs were used., Conclusions: SCSs appear to help to decrease severe nasal edema, hematomas, loss of tip definition, fibrosis, and pollybeak deformity, thereby improving the results and predictability of rhinoplasty surgery., (© The Author(s) 2022. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Dorsal augmentation is one of the most challenging procedures in rhinoplasty. Solid grafts and diced fascia graft (DC-F) have been employed for this purpose with varying success. Warping, irregularities, and variability of final height are some of the potential pitfalls., Objectives: The aim of this study was to assess the efficiency of the authors' approach combining multiple grafts for nasal dorsal augmentation. They described a technique employing composite dorsal augmentation that is a combination of a foundation layer utilizing high spreader grafts plus a dorsal gap graft combined with a contour layer of 3 possible types of fascia or DC-F grafts. The combination of the 2 layers for the nasal dorsum can be varied to achieve the required height to correct the patient's deformity and achieve the desired aesthetic goals., Methods: Fifty-one patients who underwent dorsal augmentation with composite technique between 2017 and 2020 were retrospectively reviewed. A step-by-step algorithm was applied to achieve the required dorsal height., Results: The patients were divided into 3 groups according to the type of contour graft: double-layer fascia graft, segmental DC-F, or narrow thin full-length DC-F. Smooth continuity and increased projection of the nasal dorsum were achieved in all patients., Conclusions: Composite dorsal augmentation is an effective technique for dorsal augmentations requiring 4 mm or more of height increase. This technique allows to achieve dorsal augmentation employing a combination of grafts from a single donor site together with camouflaging dorsal irregularities and highlighting dorsal aesthetic lines. This algorithm allows optimization of patients' aesthetic profile., (© The Author(s) 2022. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Preservation rhinoplasty (PR) techniques are continuously evolving and many variations of established techniques have been proposed since Daniel coined this term in 2018., Objectives: The aim of this study was to describe indications for a new "3-level impaction" technique, allowing, in selected cases, a complete profile correction and dorsal reduction without dissection of the dorsal soft tissue envelope (STE)., Methods: Three hundred and fifty primary closed rhinoplasty cases were retrospectively studied from January 2018 and October 2019. Age, sex, race, technical details, surgical time, and complications were registered. Ninety-five dorsa were reduced and shaped without dissecting the dorsal STE by combining: (1) a swinging-door septoplasty with low septal strip resection, (2) endonasal bony cap mosaic osteotomies, and (3) let-down or push-down operation., Results: All patients showed a dramatic change in profile height and shape without either dorsal STE dissection or bony cartilage dorsal tissue resection. Mosaic osteotomies converted the dorsal keystone area from S- to V-shaped dorsum, let-down-operation and low septal strip resection enabled impaction, and profile setting was achieved by quadrangular cartilage flap rotation. The average follow-up time was 14 months (range, 12-16 months)., Conclusions: In selected patients, dorsum can be preserved without STE dissection. By combining multiple endonasal maneuvers it is possible to obtain a dramatic change without dissecting the STE, while simultaneously avoiding any dorsal tissue resection. This method offers a versatile technique in selected patients, which leads to fast recovery and natural results., (© 2021 The Aesthetic Society. Reprints and permission: journals.permissions@oup.com.)

Background: Camouflage of nasal dorsum, aesthetic augmentation, and highlighting the dorsal aesthetic lines are essential elements in modern rhinoplasty. Numerous techniques have been utilized, including deep temporal fascia, rectus abdominis fascia, and diced cartilage in fascia (DC-F). Despite their widespread adoption, technical challenges remain, especially when utilized for aesthetic purposes., Objectives: This paper details the utilization of fascia and DC-F for aesthetic dorsal refinement in primary and secondary cases. One of the main goals was to achieve ideal dorsal aesthetic dorsal lines rather than just volume augmentation., Methods: The authors employed grafts from the deep temporalis fascia and rectus abdominis fascia in 4 configurations: (1) single layer, (2) double layer, (3) full-length DC-F, and (4) partially filled segmental DC-F grafts. Technical refinements included careful determination of dimensions and meticulously suturing to the dorsum at appropriately 10 points to prevent graft displacement., Results: The authors report their experience with 146 clinical cases over 35 months from January 2017 to December 2019. The patients were divided for 4 groups depending on which type of graft was utilized., Conclusions: Autogenous deep temporal fascia, rectus abdominis fascia, and DC-F were utilized to camouflage dorsal irregularities, highlight dorsal aesthetic lines, and aesthetically augment either the entire nasal dorsum or its individual parts. Optimization of cutting, stitching, filling the graft, and careful fixation of these grafts on the nasal dorsum significantly increases the predictability of these techniques and minimizes problems., (© 2021 The Aesthetic Society. Reprints and permission: journals.permissions@oup.com.)

Background: Cone-beam computed tomography has recently rapidly developed worldwide as a versatile and convenient alternative to traditional computed tomography for imaging of the maxillofacial region. However, most surgeons performing rhinoplasty are surprisingly unfamiliar with it, in both the plastic surgery and ear, nose, and throat communities., Methods: The broad clinical experience of a single center over the past 5 years is reviewed. The many applications of cone-beam computed tomography to primary and secondary rhinoplasty are analyzed regarding septum, turbinates, nasal bones, skin thickness, and other issues. The importance of a paradigm shift from a two-dimensional to a three-dimensional approach in image reconstruction is demonstrated, together with the value of surface contour enhancement., Results: Cone-beam computed tomography has a multitude of practical applications highly relevant to rhinoplasty. The surface image will strengthen aesthetic analysis, and the detailed preview of bony and functional anatomy will facilitate surgical planning. Cone-beam computed tomography serves as a roadmap to plan and execute rhinoplasties more predictably and efficiently. The availability of spatial views and accurate detail, together with the possibility of easy, accurate measuring, offers a plenitude of potential applications., Conclusions: Cone-beam computed tomography is a user-friendly, quick technique with abundant advantages in planning any rhinoplasty. It causes the patient no inconvenience and has very few, if any, drawbacks, with these being limited to radiation exposure and limited cost., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Background: An important element of most rhinoplasty surgeries is the treatment of the nasal bones, which involves various combinations of osteotomies and hump removal., Objectives: The aim of this paper was to describe a rhinoplasty technique in which piezoelectric instruments (PEIs) are used to shape nasal bones, with the priority being to preserve the stability of these bones. In most clinical cases, nasal bones can be stabilized if rhinosculpture (RS) is applied broadly, both separately and in combination with different osteotomies, while preserving the nasal bridge., Methods: A step-by-step algorithm was applied to achieve the required aesthetic results when working with PEIs on the bony pyramid, depending on the degree of asymmetry. We used the fully open approach in all clinical cases, which provided the greatest visual field when performing all the steps involved in treating the bony pyramid, thus fully exploiting all the possibilities and advantages of PEIs., Results: We report our experience with 165 clinical cases performed over 18 months from December 2016 to July 2018. The patients were divided into 5 groups, depending on the algorithm selected to treat the bony pyramid., Conclusions: When working with the bony pyramid, our approach limits patient movement, thus ensuring stability of the side walls of the bones in both the short and the long term-a property that greatly improves the aesthetic results., (© 2019 The Aesthetic Society. Reprints and permission: journals.permissions@oup.com.)

Recently there has been a dramatic acceptance of the preservation principle in rhinoplasty surgery. Surgeons worldwide now preform preservation rhinoplasty, which has led to an expanding list of indications and techniques. Most rhinoplasty surgeons have accepted the fundamental principle that preservation is better than resection and that a natural result is superior to a fabricated or reconstructed structure, especially with regards to the nasal dorsum. Currently, the main emphasis is on defining the indications/contraindications, technical refinements, and minimizing complications. This paper provides an overview of the current trends in preservation rhinoplasty. In the 2 years following publication of the Editorial, "The Preservation Rhinoplasty: A New Rhinoplasty Revolution,"  1 there has been a dramatic acceptance of the preservation principle. Numerous surgeons throughout the world are preforming preservation rhinoplasty, which has led to an expanding list of indications and techniques. The majority of rhinoplasty surgeons have accepted the fundamental principle that preservation is better than resection, and that a natural result is superior to a fabricated or reconstructed structure, especially as regards the nasal dorsum. Currently, the main emphasis is on defining the indications/contraindications, technical refinements, and minimizing complications. The present paper is an overview of the current trends in preservation rhinoplasty., (© 2020 The Aesthetic Society.)

Background: Preservation rhinoplasty (PR) is a new chapter in rhinoplasty history. The term was coined by Daniel in 2018 and represents a fundamental change in philosophy., Objectives: The aim of this study is to discuss a single-surgeon case series utilizing PR techniques., Methods: One hundred fifty-three primary rhinoplasty cases were studied retrospectively between December 2016 and August 2017. One hundred cases had at least 1 year of follow-up. Technical details were recorded, including dissection plane, ligament preservation, tip support, lateral crural maneuvers, alar contour grafts, and preservation of the dorsum vs traditional reduction. These 100 cases can be categorized as either complete preservation rhinoplasty (PR-C) or partial preservation rhinoplasty (PR-P)., Results: All patients had open rhinoplasty and the average follow-up time was 13 months. All patients had preservation of the dorsal soft tissue envelope, and in 36 the entire soft tissue envelope and ligaments were preserved. Fifty-four had preservation of the alar cartilages. Thirty-one had dorsal preservation. The combinations include: PR-C (skin, dorsum, and alars): 24; PR-P (skin and dorsum): 2; PR-P (alars and dorsum): 2; and PR-P (skin and alars): 7., Conclusions: In most patients, the dorsal soft tissue envelope and nasal ligaments can be preserved. When possible, the lateral crura should be preserved and tensioning chosen over excision. Dorsal preservation is a versatile technique when proper patient selection is undertaken, and long-term issues with the middle vault and keystone area can be avoided. Some patients will benefit from total preservation where nothing is removed/disrupted and underlying structures are reshaped., Level of Evidence: 4., (© 2019 The Aesthetic Society. Reprints and permission: journals.permissions@oup.com.)

Background: In 1971, Janeke and Wright1 published a now classic study on the support of the nasal tip in which they found four areas of anatomic support. These findings led to the "tripod concept" of tip support. Recently, surgeons have begun repairing and/or preserving the nasal ligaments as a method to control tip projection and rotation. Therefore, a reassessment of the nasal ligaments and tip support is warranted., Objectives: The present study was done to investigate the ligamentous and structural support of the nasal tip. Clinically, surgeons are aware of the role of the nasal ligaments and are beginning to utilize tip suture techniques to achieve greater tip refinement and long-term support., Methods: Anatomic studies were conducted on 24 fresh cadavers at the time of autopsy. The two groups consisted of the following: (1) group 1 included dissection of 10 cadavers concentrated on the various ligaments of the nose; and (2) group 2 involved dissections of 14 cadavers analyzing the relationship between the alar domes and the anterior septal angle (ASA)., Results: Regarding the ligaments of the nose, we were able to consistently identify the following ligaments: (1) interdomal; (2) intercrural; (3) Pitanguy's midline; (4) pyriform; and (5) a scroll ligament complex consisting of the longitudinal and vertical scroll ligaments. We did not find two commonly accepted ligaments: (1) a "footplate ligament" from the footplate of the medial crus to the caudal septum; and (2) a "sesamoid ligament" attachment from the accessory cartilage to the pyriform aperture. Dissections done to study the relationship between the domes and ASA revealed that the domes projected an average of 5.7 mm (range, 2.2-9.6 mm) above the ASA and were longitudinally 5.5 mm (range, 2.9-9.5 mm) caudal to the ASA. Thus, there was no direct support from the ASA to the domes., Conclusions: It is our recommendation that surgeons should consider preservation of the nasal ligaments whenever possible and utilize them to manipulate tip projection, position, and rotation. Awareness of the relationship between the dome and the caudal septum will hopefully minimize problems with the tongue-in-groove operation.

Management of the nasal dorsum remains a challenge in rhinoplasty surgery. Currently, the majority of reduction rhinoplasties results in destruction of the keystone area (K-area), which requires reconstruction with either spreader grafts or spreader flaps, both for aesthetic and functional reasons. This article will present the senior author's current operative technique for dorsal preservation in reduction rhinoplasty based on 320 clinical cases performed over a 5-year period. The author's operative technique is as follows: (1) endonasal approach; (2) removal of a septal strip in the subdorsal area whose shape and height were determined preoperatively; (3) complete lateral, transverse, and radix osteotomies; and (4) dorsal reduction utilizing either a push down operation (PDO) or a let down operation (LDO). The PDO consists of downward impaction of the fully mobilized nasal pyramid and is utilized in patients with smaller humps (Less than 4 mm). The LDO consists of a maxillary wedge resection and is performed in patients who need more than 4 mm of lowering. A total of 320 patients had a dorsal preservation operation (DPO). Postoperatively, there were no dorsal irregularities nor inverted-V deformities. Among our 44 personal revision cases, 27 patients (8.74%) had had a previous DPO, 16 of whom required tip revisions with no further dorsal surgery. Of the remaining 11 patients, the main problems were either hump recurrence and/or lateral deviation of the dorsum or widening of the middle third, which required simple surgical revision. Based on the authors' experience, adoption of a PDO/LDO is justified in selected primary patients. The key question before any primary rhinoplasty procedure should be "Can I keep the nasal dorsum intact?" Precise analysis and surgical execution are required to preserve the dorsal osseocartilaginous vault and K-area. Dorsal preservation results in more natural postoperative dorsum lines and a "not operated" aspect without the need for midvault reconstruction. Moreover, this technique is quick and easy to perform by any rhinoplasty surgeon. Rhinoplasty surgeons should consider incorporating dorsal preservation techniques in their surgical armamentarium rather than relying solely on the Joseph reduction method or an open structure rhinoplasty., (© 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Background: Asian cleft rhinoplasty is a unique procedure with specific challenges., Objectives: This paper presents our experience with the use of an open structural technique for Asian cleft rhinoplasty utilizing a complete autologous approach., Methods: An open approach that reconstructs the malpositioned nasal cartilage was utilized. Centrally, the septocolumella graft fixed securely in the midline with extender spreader grafts was utilized to project and lengthen the nose. The dislocated lateral crura on the cleft side was completely detached from the accessory cartilages and mobilized off the vestibular lining. The deficient medial crura was lengthened with the lateral crural steal procedure. The resultant shortened lateral crura was then reconstructed with the lateral crural strut graft (LCSG). This gave the versatility needed to bring the tip cartilages into a more anatomic and symmetrical position. Tip suturing and grafting was performed and dorsal augmentation achieved through diced cartilage wrapped in deep temporal fascia. At closure, when indicated, a modified Tajima reverse-U excision of the vestibular lining was performed to correct the alar hooding on the cleft side. Alar base modifications were done as indicated., Results: From January 2010 to December 2015, 35 Asian patients underwent open cleft rhinoplasty. There were 18 female patients and 17 male patients. Twenty-nine patients were unilateral cleft and 6 were bilateral cleft. The mean follow up was 23 months. All patients were highly satisfied with the functional and aesthetic improvement of the procedure. The complications and revision rates were low., Conclusions: The autologous open structural approach can predictably and consistently give excellent results for Asian cleft rhinoplasty. The result attainable is superior to results attainable before adopting this approach for our patients., Level of Evidence: 4., (© 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com)

There are three reasons why the asymmetric crooked nose is one of the greatest challenges in rhinoplasty surgery. First, the complexity of the problem is not appreciated by the patient nor understood by the surgeon. Patients often see the obvious deviation of the nose, but not the distinct differences between the right and left sides. Surgeons fail to understand and to emphasize to the patient that each component of the nose is asymmetric. Second, these deformities can be improved, but rarely made flawless. For this reason, patients are told that the result will be all "-er words," better, straighter, cuter, but no "t-words," there is no perfect nor straight. Most surgeons fail to realize that these cases represent asymmetric noses on asymmetric faces with the variable of ipsilateral and contralateral deviations. Third, these cases demand a wide range of sophisticated surgical techniques, some of which have a minimal margin of error. This article offers an in-depth look at analysis, preoperative planning, and surgical techniques available for dealing with the asymmetric crooked nose., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: In rhinoplasty surgery, management of the bony vault and lateral walls is most often performed with mechanical instruments: saws, chisels, osteotomes, and rasps. Over the years, these instruments have been refined to minimize damage to the surrounding soft tissues and to maximize precision., Objectives: This article will present the evolution of the authors' current operative technique based on 185 clinical cases performed over an 19-month period using piezoelectric instrumentation (PEI)., Methods: A two-part study of cadaver dissections and clinical cases was performed using PEI. Evolution of the authors' clinical technique and the operative sequence were recorded., Results: Thirty cadaver dissections and 185 clinical cases were performed using PEI, including 82 primary and 103 secondary cases. An extended subperiosteal dissection was developed to visualize all aspects of the open rhinoplasty including the osteotomies. Ultrasonic rhinosculpture (URS) was utilized in 95 patients to shape the bony vault without osteotomies. To date, 11 revisions (6%) have been performed. There were no cases of bone asymmetry, irregularity, or excessive narrowing requiring a revision., Conclusions: Based on the authors' experience, adoption of PEI is justified and offers more precise analysis and surgical execution with superior results in altering the osseocartilaginous vault. With extensive exposure, surgeons can make an accurate diagnosis of bony deformity and safely contour the bones to achieve narrowing and symmetry of the bony dorsum. Stable osteotomies can be performed under direct vision with precise mobilization and control. As a result of PEI, the upper third of the rhinoplasty operation is no longer shrouded in mystery. LEVEL OF EVIDENCE 4: Therapeutic., (© 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Surface aesthetics of an attractive nose result from certain lines, shadows, and highlights with specific proportions and breakpoints. Analysis emphasizes geometric polygons as aesthetic subunits. Evaluation of the complete nasal surface aesthetics is achieved using geometric polygons to define the existing deformity and aesthetic goals. The relationship between the dome triangles, interdomal triangle, facet polygons, and infralobular polygon are integrated to form the "diamond shape" light reflection on the nasal tip. The principles of geometric polygons allow the surgeon to analyze the deformities of the nose, define an operative plan to achieve specific goals, and select the appropriate operative technique., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The plunging tip refers to a deformity in which the nasal tip plunges on smiling., Objectives: To understand the plunging tip, we have updated our series of 25 cosmetic rhinoplasty patients who complained of a plunging tip with a focus on the anatomic changes of the nose on smiling., Methods: Twenty-five female cosmetic primary rhinoplasty patients who complained of a nasal tip that plunged on smiling were photographed in static and smiling sequences preoperatively and one year postoperatively. Different nasal angles and landmarks were measured to study changes of the nose., Results: Pre- and postoperatively, there was no statistically significant difference in the changes in the nasal angles and landmarks on smiling. At one year postoperatively, 2 patients had nasal tips that continued to plunge on smiling; these patients had requested no increase in tip rotation preoperatively. Only 2 patients had columellar base muscles cut for reasons other than treating the plunging tip., Conclusions: This is the first prospective, evidence-based study on the plunging tip. Measurements of the nose before and after surgery demonstrate that the nasal tip moves less than 1 mm and 1 degree on smiling. Treatment of the plunging tip illusion was effective by increasing the tip angle in repose. No columellar base muscles were cut to treat the plunging tip, and the nose moved just as much after surgery as before. Cutting or manipulating muscles is not necessary for treatment. To treat the illusion, the surgeon must increase tip rotation., (© 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Background: The dorsal hump and dorsal aesthetic lines have been considered bony and cartilaginous structures. Knowledge of the anatomy of the osseocartilaginous vault is essential for obtaining aesthetically pleasing results of rhinoplasty., Objectives: The authors described the morphology, embryology, and clinical relevance of the nasal vault and the changes that occur in this area during rhinoplasty., Methods: Dissections were performed on 15 fresh adult cadavers to examine the anatomy of the osseocartilaginous vault. Intraoperative endoscopic examination of the vault also was performed in 9 rhinoplasty patients before and after dorsal hump reduction., Results: In the cadaver study, the average length of the dorsal keystone area, measured along the dorsal septum, was 8.9 mm, and the average width was 4.9 mm. No significant difference in length was observed between cadaver subgroups with straight or humped nasal profiles. The extent of lateral overlap of the nasal bones with the cephalic portion of the upper lateral cartilages varied. In rhinoplasty patients, the average length of the cartilaginous vault exposed during dorsal reduction was 7.6 mm., Conclusions: The aesthetic lines and profile of the nose before dorsal reduction are dictated by the cartilaginous vault. After reduction, the dorsal lines are determined by the bony vault edges. In routine rhinoplasty, reduction of dorsal height generally corresponds to removal of the dorsal cartilaginous septum., (© 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Background: The analysis of nasal anatomy, and especially the nasal bones including the osseocartilaginous vault, is significant for functional and aesthetic reasons., Objectives: The objective was to understand the anatomy of the nasal bones by establishing new descriptions, terms, and definitions because the existing parameters were insufficient. Adequate terminology was employed to harmonize the anthropometric and clinical measurements., Methods: A two-part harvest technique consisting of resecting the specimen and then creating a replica of the skull was performed on 44 cadavers to obtain specific measurements., Results: The nasal bones have an irregular, variable shape, and three distinct angles can be found along the dorsal profile line beginning with the nasion angle (NA), the dorsal profile angulation (DPA) and the kyphion angulation (KA). In 12% of cases, the caudal portion of the nasal bones was straight and without angulation resulting in a "V-shape" configuration. In 88% of cases, the caudal portion of the bone was angulated, which resulted in an "S-shape" nasal bone configuration. The intervening cephalic bone, nasion to sellion (N-S), represents the radix while the caudal bone, sellion to r (S-R), represents the bony dorsum., Conclusions: By standardizing and measuring existing nasal landmarks and understanding the different anatomic configurations of the nasal bones, rhinoplasty surgeons can better plan their operations within the radix and bony and osseocartilaginous vaults., (© 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Background: Although frequently performed in rhinoplasty, nasal osteotomies have been unpredictable in consistently controlling postoperative alterations in bony morphology in many patients. Consequently, a detailed algorithm for an individualized approach to osteotomy is needed to achieve superior aesthetic and functional outcomes., Objectives: The authors aimed to propose a component-oriented and individualized approach for nasal osteotomy in rhinoplasty., Methods: Clinical outcomes were reviewed for 150 consecutive patients who underwent rhinoplasty. Type and frequency of specific osteotomy procedures and preoperative and postoperative photographs were examined., Results: A total of 97 cases with at least 12 months of follow-up data were evaluated. In 92 of 97 patients (95%), a lateralized medial oblique osteotomy was performed; 70 (72%) required bilateral intermediate osteotomy, and 21 (22%) required unilateral osteotomy. Forty-one patients (42%) underwent bilateral base osteotomy and 24 (25%) underwent unilateral base osteotomy. No base osteotomy was performed in 32 patients (33%) who had aesthetically pleasing lateral wall width and no convexity of the posterior portion of the lateral bony wall., Conclusions: The osteocartilaginous vault is asymmetric in the majority of patients undergoing rhinoplasty. Anatomic variations in the height, length, and/or width of the bony vault can significantly influence its shape and symmetry. Various principles and techniques for nasal osteotomy increase predictability of outcomes while improving nasal aesthetics and function. LEVEL OF EVIDENCE 4: Therapeutic., (© 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Tip rhinoplasty is a key component of aesthetic rhinoplasty. An understanding of the correlation between tip surface aesthetics and the underlying anatomic structures enables proper identification and correction of tip abnormalities. Surface aesthetics of the attractive nose are created by certain lines, shadows, and highlights with specific proportions and breakpoints. In this Featured Operative Technique, the authors describe a stepwise process for tip rhinoplasty that conceptualizes aesthetic subunits as geometric polygons to define the existing deformity, the operative plan, and the aesthetic goals. Tip rhinoplasty is described in detail, from initial markings through incisions and dissection. The autorim graft concept is explained, and lateral crural steal and footplate setback techniques are described for the attainment of symmetric domes with correct lateral crural resting angles. Methods in columellar reconstruction are described, including creating the columella (C') breakpoint and the infralobular caudal contour graft. The principal author (B.Ç.) has applied these techniques to 257 consecutive "polygon rhinoplasties" over the past 3 years., (© 2014 The American Society for Aesthetic Plastic Surgery, Inc.)

Background: Rhinoplasty surgeons routinely excise or incise the lateral crura despite nostril rim retraction, bossa, and collapse. Given recent emphasis on preserving the lateral crura, a review of the lateral crura's anatomy is warranted., Objectives: The authors quantify specific anatomical aspects of the lateral crura in cadavers and clinical patients., Methods: This was a 2-part investigation, consisting of a prospective clinical measurement study of 40 consecutive rhinoplasty patients (all women) and 20 fresh cadaver dissections (13 males, 1 female). In the clinical phase, the alar cartilages were photographed intraoperatively and alar position (ie, orientation), axis, and width were measured. Cadaver dissections concentrated on parts of the lateral crura (alar cartilages and alar ring) that were inaccessible clinically., Results: Average clinical patient age was 28 years (range, 14-51 years). Average cadaver age was 74 (range, 57-88 years). Clinically, the distance of the lateral crura from the mid-nostril point averaged 5.9 mm, and the cephalic orientation averaged 43.6 degrees. The most frequent configuration of the axis was smooth-straight in the horizontal axis and a cephalic border higher than the caudal border in the vertical axis. Maximal lateral crura width averaged 10.1 mm. In the cadavers, average lateral crural dimensions were 23.4 mm long, 6.4 mm wide at the domal notch, 11.1 mm wide at the so-designated turning point (TP), and 0.5 mm thickness. The accessory cartilage chain was present in all dissections., Conclusions: The lateral crura-alar ring was present in all dissections as a circular ring continuing around toward the anterior nasal spine but not abutting the pyriform. The lateral crura (1) begins at the domal notch and ends at the accessory cartilages, (2) exhibits a distinct TP from the caudal border, (3) has distinct horizontal and vertical vectors, and (4) should have a caudal border higher than the cephalic border. Alar malposition may be associated with position, orientation, or configuration.

Background: Costal cartilage grafts are used more frequently in secondary rhinoplasty. However, these procedures result in patients that require further revision operations that are not trivial. The purpose of this study was to assess the outcomes of reconstructive rhinoplasty performed on patients with a history of prior secondary or tertiary rhinoplasty using autogenous costal cartilage grafts., Methods: A retrospective review was conducted of tertiary rhinoplasty procedures. Outcomes of interest included the indications for the revision operation; revision rate following the tertiary costal cartilage revision; whether or not the use of costal cartilage grafts for the reconstructive rhinoplasty was a planned event; and perioperative incidents such as infection, structural collapse, and scarring requiring further surgery., Results: Forty-six patients met inclusionary criteria. The revision rate following tertiary rhinoplasty performed by the primary author was found to be 24 percent (11 of 46). The reasons for these revision operations were nasal airway obstruction (n = 6), aesthetic dissatisfaction (n = 4), and infection (n = 1). Outcomes of the revisions were satisfactory, with no adverse complications requiring further surgery., Conclusions: Reconstructive rhinoplasty may be required in patients who have undergone previous costal cartilage grafting for secondary rhinoplasty. These revision operations can be performed successfully to help patients achieve both improved function and aesthetic results but have a higher than usual revision rate themselves. The revisions of these operations can be managed with standard revision operations that result in satisfactory outcomes., Clinical Question/level of Evidence: Therapeutic, IV.

Background: The plunging tip is defined as a nasal deformity where the nasal tip descends or "plunges" during smiling., Objective: The authors prospectively measure a series of 25 patients with a focus on the anatomic changes of the nose before and after the patient smiles., Methods: Twenty-five women who presented for cosmetic primary rhinoplasty and complained of a plunging tip were included in the study. Three angles were measured on lateral view (tip angle, nasolabial angle, and columella inclination angle), along with changes in tip, subnasale, and alar crease. The Simon tip rotation angle (STRA) measured tip position in relation to the static tragus. The alar rim angle measured the angle of the alar rim at the nostril. Changes in static and smiling positions were compared., Results: Tip, nasolabial, and the columella inclination angles decreased between static and smiling positions by 10.9, 11.8, and 11.9 degrees, respectively. Tip position dropped by 0.9 mm, while the subnasale and alar crease junction elevated by 1.3 and 3.7 mm, respectively. The STRA, an angle independent of alar base movement, decreased by less than 1 degree. The alar rim angle increased by 9.9 degrees., Conclusions: Our data demonstrate that the nasal tip changes its position less than 1 mm with a full smile. The concept of a "plunging tip" is an optical illusion. In reality, the alar crease and subnasale elevate and the alar rim straightens, while the tip position changes minimally. Objectively, the tip moves less than 1 mm and less than 1 degree using the STRA.

Background: Plastic surgeons have long recognized the importance of performing chin augmentation concurrent with a rhinoplasty to achieve facial balance. However, few surgeons consider the benefits of combining a rhinoplasty with brow modification to achieve a better aesthetic result. By increasing the size of the middle third of the face, the nose will automatically appear smaller., Objective: The authors describe anatomical dissections that provided perspective on the facial anatomy of the areas being studied and report the results of concurrent browlift and rhinoplasty procedures in a retrospective series of patients., Methods: The present study consisted of 2 parts: anatomical dissections and a retrospective chart review. The nose and central forehead area were dissected in 7 fresh cadavers at the time of autopsy to understand the anatomical relationship between the various muscles in the radix/glabellar region and to assess the muscle resection occurring in the clinical procedures. We also reviewed the charts of 24 patients who underwent combined rhinoplasty and brow modification with the senior author (R.K.D.) during a 2-year period (July 2010 to June 2012). Younger patients underwent a central browlift (CBL) with screw fixation, while older patients (ages 34-60 years) underwent full 5-incision endoscopic forehead lifting., Results: The age range for patients in this series was 14 to 60 years. Two patients were men and 22 were women. There were 12 primary and 12 secondary procedures in the series; 13 patients underwent CBL and 11 had EFL. The mean follow-up was 18 months. One patient had a persistent fluid accumulation in the glabellar region, which required drainage. One patient requested additional refinement of her nasal tip., Conclusion: Modification of the central brow can dramatically change the aesthetic polygons of the nose/glabellar region. A CBL with radix/glabellar muscle excision is important in younger patients who need a well-defined nasion and older secondary patients who feel that the upper third of their nose is still heavy. A full EBL can enhance the facial appearance of older patients in whom a rhinoplasty alone would have a modest impact.

Background: Congenital deficiencies of the alar cartilages are rare and often visible at birth but can occasionally present later., Objectives: The authors review the anatomical development and discuss the incidence and treatment of congenital defects within the alar cartilages seen in rhinoplasty cases., Methods: The charts of 869 consecutive patients who underwent open rhinoplasty were retrospectively reviewed, and 8 cases of congenital defects of the alar cartilage within the middle crura were identified. Intraoperative photographs were taken of the alar deformities, and each patient underwent surgical correction. To simplify analysis, a classification of the defects was developed. A division was a cleft in the continuity of the alar cartilage with the 2 ends separate. A gap was a true absence of cartilage ranging from 1 to 4 mm, which can be accurately assessed in unilateral cases. A segmental loss was a defect greater than 4 mm., Results: The 8 cases of deformity could be classified as 4 divisions, 3 gaps, and 1 segmental loss. None of the patients had a history of prior nasal trauma or nasal surgery. Six patients were women and 2 patients were men. In all cases, adequate projection and stability were achieved with a columellar strut. Asymmetry was minimized through concealer or tip grafts. There were no complications., Conclusions: Surgeons performing rhinoplasty surgery will encounter and should be prepared to deal with unexpected congenital defects of the alar cartilage. These defects within the middle crura will require stabilization with a columellar strut and, often, coverage with a concealer tip graft. We speculate that the cause of these defects is a disruption of the hedgehog signals that may arrest the condensation or block the differentiation of the underlying neural crest cells.

Background: Closed reduction and splinting are generally recommended in the acute management of nasal fractures. Although open reduction is recommended for more severe nasal fractures, immediate functional and cosmetic open rhinoplasty following nasal fractures has not been described for Asian noses., Objectives: The authors document their experiences with combining open reduction of acute nasal fractures with simultaneous cosmetic correction of preexisting aesthetic concerns in an Asian population., Methods: Twenty-five Asian patients underwent primary functional and cosmetic open rhinoplasty immediately following acute nasal fracture. Grafts consisted of autologous material, including septum, concha, rib, and deep temporal fascia. Prior to opening the nose, anatomical reduction of the bony vault fractures was performed. Spreader grafts were used to stabilize the fractured or dislocated dorsal septum as well as to straighten the nose. Aesthetic refinement of the nose included lengthening, refining the tip, and increasing tip projection and was performed according to the patients' aesthetic desires. Patient satisfaction was subjectively reported on a 1 to 10 scale., Results: Mean follow-up was 17 months (range, 10-24 months). Twenty-three patients rated the results of their procedures as 7 or higher. Functionally, all patients were breathing as well or better postoperatively compared with their preinjury functional state. One patient (4%) underwent a secondary filler procedure for a slight dorsal irregularity., Conclusions: Immediate cosmetic and functional open rhinoplasty is safe, predictable, and effective in Asian patients., Level of Evidence: 4.

Surface aesthetics of the attractive nose are created by certain lines, shadows, and highlights, with specific proportions and breakpoints. Our evaluation of the nasal surface aesthetics is achieved using the concept of geometric polygons as aesthetic subunits, both to define the existing deformity and the aesthetic goals. Surgical techniques have been developed and modified to achieve the desired surface appearance, and those are detailed in this article. The principles of geometric polygons allow the surgeon to analyze the deformities of the nose, to define an operative plan to achieve specific goals, and to select the appropriate operative technique. These aesthetic concepts and surgical techniques were used in 257 consecutive rhinoplasties performed in the past 3 years by the principal author (B.Ç.).

Currently, most rhinoplasty surgeons focus their analysis and operative techniques on the upper nasal base, with its alar cartilages. They tend to minimize the lower nasal base, composed of the columellar base, nostril sills, and alar lobules. The requisite operative techniques are often considered ancillary techniques. In this article, the authors describe anatomical composition of the columellar base, nostril sill, and alar lobule; discuss the presence of a distinct lower nasal base; and reevaluate the nasal musculature and the nasal superficial muscular aponeurotic system in an anatomical cadaver model. They also discuss the results of both a detailed literature review (for articles related to the levator labii superioris alaeque nasalis, orbicularis oris, depressor septi nasalis, myrtiformis, and dilator naris) and the results of their own dissection of 45 fresh cadavers.

Rhinoplasty in patients of Asian descent presents a different set of challenges for rhinoplasty surgeons. Most Asian noses are characterized by a thick skin envelope, low radix and dorsum, bulbous tip, weak lower lateral cartilages, and a short columella. In this article, the authors describe an autogenous approach to Asian rhinoplasty that achieves aesthetic results comparable to the use of silicone implants without the associated risks observed with alloplastic implants. The technique consists of the following: (1) harvesting of grafts, (2) an open approach with skin defatting, (3) septal harvest, (4) placement of a septocolumellar graft, (5) nasal tip refinement, (6) radix and dorsal augmentation, (7) osteotomies, (8) alar base modifications, and (9) closure and casting.

Any discussion of grafting the dorsum in secondary rhinoplasty must take into account the different indications (aesthetic, augmentation, and structure) as well as recent changes in materials and techniques (fascia, diced cartilage). We have placed solid dorsal grafts with diced cartilage grafts either as an isolated diced cartilage graft in fascia graft or as the aesthetic dorsal contour layer of a composite reconstruction. The rational for this profound change in selection and indication of dorsal grafts for revising the overresected dorsum will become clear as the various alternative materials and techniques are analyzed. Currently, we only employ autogenous tissues., (Copyright © 2012 by Thieme Medical Publishers, Inc.)

Background: The goal of this article is to help U.S. plastic surgeons better understand why Indian American rhinoplasty is different from other ethnic rhinoplasties in their practice. The study is composed of three parts: a review of the cultural perspectives of Indian Americans toward aesthetic surgery, an investigation into the aesthetic ideals of the Indian American nose, and an overview of operative strategies to achieve these ideals., Methods: A total of 35 Indian Americans who were dissatisfied with their nasal appearance were analyzed, 15 prospectively and 20 retrospectively. Group 1 consists of 15 Indian American women who were unhappy with the appearance of their nose. Standard photographs and anthropometric measurements were taken. Anterior and lateral photographic views were morphed to the patient's subjective ideal. Actual and ideal images were compared and analyzed. Group 2 consists of a retrospective review of 20 consecutive Indian American rhinoplasty cases with a follow-up of 1 to 6 years., Results: The majority of the group 1 participants complained of a dorsal "hump," a downwardly rotated tip, and/or a large nose. The average subjective ideal nasolabial angle was determined to be 101.6 degrees. Based on the authors' analysis, three categories of nasal deformities were identified and operative strategies are discussed. Evaluation of the 20 clinical cases indicated that a more conservative surgical approach is warranted in these patients., Conclusions: Indian American rhinoplasty patients present a challenging range of nasal deformities requiring careful surgical planning. A clear understanding of the patient's desires is essential to achieving patient satisfaction., Clinical Question/level of Evidence: Therapeutic, IV.

Based on a 25-year experience, the author considers open tip suture techniques to be the best method of achieving consistent and reproducible tip changes that can please patients with a wide variety of tip deformities. The described technique consists of selecting the ideal combination of the following six sutures: (1) columellar strut and suture, (2) domal creation, (3) interdomal, (4) domal equalization, (5) tip position, and (6) lateral crural convexity. If additional definition is required, then tip refinement grafts can be added to accommodate thicker skin or lateral crura abnormalities., (© Thieme Medical Publishers.)

Middle Eastern Rhinoplasty (MER) offers a challenging subset of nasal deformities. It has far greater variety in anatomical characteristics than previously thought and requires careful surgical planning. Critical techniques include the following; 1) reduce the specific component of the dorsal deformity, 2) use a balanced approach of augmentation and reduction whenever possible, 3) as reduction increases the need for spreader grafts increases, and 4) achieve tip shape with structural support and not excision., (Thieme Medical Publishers.)

Over the last 2 decades, many of the difficulties in shaping primary tips and rebuilding destroyed secondary tips have been solved through the use of tip sutures and grafts. Dorsal grafts, which are a highly visible determinant of the nasal profile and contour, have become the greatest challenge in rhinoplasty surgery. This article reviews the author's different approaches to dorsal grafts using fascia and diced cartilage, either separately or in combination., (Copyright 2010. Published by Elsevier Inc.)

Background: There have been relatively few articles in the English language on secondary Middle Eastern rhinoplasty. This article analyzes the cause and treatment of secondary Middle Eastern rhinoplasty., Methods: A prospective study of 40 consecutive female secondary Middle Eastern rhinoplasty patients was completed., Results: The majority of secondary rhinoplasty patients were older than 25 years. Half of the patients had undergone a single prior rhinoplasty and the other half had undergone multiple operations, ranging in number from two to five. A wide variety of surgical techniques was necessary because of the broad range of presenting deformities, patients' requests, and the author's preferred procedures., Conclusions: The principal reasons for secondary rhinoplasty in Middle Eastern patients were a failure to correct the original deformity and the presence of visible surgical stigmata. The persistent complaints were a poorly defined tip and a long, droopy nose. Surprisingly, most secondary rhinoplasty patients had thin skin (55 percent), which necessitated fascia or dermis grafts to conceal surgical stigmata. At the time of secondary surgery, there was an absence of structure in these noses as evidenced by the prior 0 percent insertion of spreader grafts and the 10 percent use of columellar struts in prior open cases. Also, there was little evidence of other structural grafts, including alar rim, alar battens, or lateral crural strut grafts. Insertion of structural support appears essential to control primary deformities and to repair secondary deformities.

Background: Middle Eastern rhinoplasty is becoming more frequent in the United States. Mature patients request a more refined, feminine nose, whereas younger patients (aged 15 to 25 years) want a smaller, "cuter" nose., Methods: The author completed a prospective study of 50 consecutive female primary Middle Eastern rhinoplasty patients. The presenting anatomy, including the alar anatomy, and selected surgical techniques and their variations for particular cases were recorded., Results: The majority of patients requested and received a significant change in their nasal appearance. Of the 40 patients followed for 18 months, three (7.5 percent) had revisions, two minor and one moderate. There were no functional complaints., Conclusions: The author emphasizes the need for structure throughout the nose, with use of both spreader grafts and columellar struts, to support the large and often heavy skin sleeve. Tip suture techniques, with or without tip grafts, are highly effective and there is no need for destructive tip techniques.

In cosmetic rhinoplasty, the patient's satisfaction is most often determined by the quality of the tip surgery, but perfecting a technique for consistently attractive tips can be challenging. As a result, rhinoplasty surgery is now entering a new era of "designer tip" operations, wherein surgeons can employ a combination of open suture tip techniques and tip refinement grafts to achieve consistent results. The grafts are made from excised lateral crural cartilage and, depending upon the specific aesthetic goals, the shape can include the following:domal, shield, diamond, folded, or combination. It is possible to alter dome-defining points, tip point, projection,definition, volume, and size and shape. A study of 100 consecutive female rhinoplasties indicated that tip sutures alone were used in 36% of cases, while a tip refinement graft was added to a sutured tip in 59% of cases.

Background: The author has used diced cartilage grafts in nasal surgery for more than 30 years. However, the number of cases and the variety of techniques have increased dramatically over the past 6 years., Methods: The author uses three methods of diced cartilage in rhinoplasty surgery: diced cartilage, diced cartilage wrapped in fascia (with fascia then sewn closed), and diced cartilage covered with fascia (with the recipient area covered with fascia after graft placement). The constructs are highly varied to fit the specific defect. Pieces of diced cartilage without any fascia can be placed in pockets in the peripyriform area, radix, or alongside structural rib grafts., Results: Over a 2-year period, the author treated 546 rhinoplasty cases in which 79 patients (14 percent) had a total of 91 diced cartilage grafts. There were 34 primary and 45 secondary operations involving the radix (n = 11), half-length grafts (n = 14), full-length dorsum (n = 43), peripyriform (n = 16), infralobule (n = 4), and lateral wall (n = 3). All charts were reviewed for the 256 rhinoplasties performed in 2006 of which 30 patients had 35 diced cartilage grafts. With a median follow-up of 19 months (range, 13 to 25 months), two patients had had revisions unrelated to their diced cartilage grafts. The three most common technical problems were overcorrection, visibility, and junctional step-offs., Conclusions: Diced cartilage grafts are a valuable addition to rhinoplasty surgery. They are highly flexible and useful throughout the nose. Their use simplifies one of the greatest challenges in all of rhinoplasty--dorsal augmentation. Complications have been relatively minor and their correction relatively simple.

Background: Saddle nose is one of the most challenging deformities in all of rhinoplasty surgery. Recent advances in aesthetic reconstructive surgical techniques warrant discussion of this subject., Methods: A review of saddle nose cases revealed that an important subgroup exists, which has been designated the septal saddle nose deformity. The pathophysiology was weakening or loss of septal support, and not the classic dorsal overresection. A prospective study of 25 consecutive cases was then completed, with emphasis on analysis, classification, and treatment., Results: Prior attempts at classification have emphasized cause. The author's study indicated that the majority of cases had multiple causes, with acute trauma followed by a complete septorhinoplasty the most common, as opposed to simple fracture reduction. In addition, 10 of 25 cases were true secondary saddle nose deformities. Classification was divided into types I through V based on presenting deformities and method of treatment. A new method of composite reconstruction was devised that allows one to construct a deep structural foundation layer that is then superimposed with an aesthetic layer., Conclusions: Septal saddle nose is an important entity that must be recognized and treated, especially when it is progressive. Composite reconstruction offers a unique solution to saddle nose deformity, as it is a flexible method of restoring structural support and aesthetic contour.

Treatment of saddle noses challenges the surgeon to provide esthetic form and functional improvement despite the presence of a limited amount of tissue to work with. The previous emphasis on alloplastic materials was a testament not only to the poor results obtained with autogenous tissues but also the unwarranted promise of the "miracles of modern chemistry." Only in the last 5 years have multiple surgeons begun to achieve outstanding results using autogenous tissues. It is hoped that this article will encourage younger surgeons to build on this foundation and provide hope to a group of patients who deserve our best efforts. Saddle nose and cleft lip nose deformity warrant a commitment to surgical excellence.

Background: Grafting the radix and dorsum of the nose has been controversial and the plastic surgery community has recently revisited diced cartilage grafts. Previous articles by the authors reported clinical failures of diced cartilage-Surgicel-wrapped grafts and the successful implementation of diced cartilage-fascia-wrapped grafts for rhinoplasty procedures. This article investigates four means of radix and dorsum augmentation, including banked and fresh septum., Methods: Twenty-seven human specimens were taken from rhinoplasty patients: six failed diced cartilage-Surgicel-wrapped grafts, eight diced cartilage-fascia-wrapped grafts, and 13 specimens of fresh cartilage or previously placed cartilage grafts. All were stained with hematoxylin and eosin, Masson's trichrome, safranin-O, glial fibrillary acidic protein, and Evans' van Gieson stains and analyzed for chondrocyte viability, matrix proteins, and regenerative potential of the cartilage., Results: The diced cartilage-Surgicel-wrapped grafts showed disorganized fibrosis, loss of nuclei in chondrocyte lacunae, and negative glial fibrillary acidic protein staining. All specimens contained remnants of Surgicel and evidence of foreign body reaction. The diced cartilage-fascia-wrapped grafts showed normal histologic characteristics, healthy cartilage pieces with viable chondrocytes in their lacunae, positive glial fibrillary acidic protein staining, and organized capsule of fibrosis surrounding the cartilage pieces. The fascia was viable and showed an organized architecture distinctly different from the disorganized scar tissue of the diced cartilage-Surgicel-wrapped grafts., Conclusions: Given the histologic findings, diced cartilage-Surgicel-wrapped grafts absorbed due to foreign body reaction. Diced cartilage-fascia wrapped grafts survived and demonstrated normal cartilage viability. According to the clinical performance and analysis of these grafts, diced cartilage-fascia is the most reliable way to augment the nasal dorsum and radix with autologous diced cartilage.