If needed I start the surgery by taking ear cartilage (I always keep the option open to take a graft from the ear if needed)
If you need conchal cartilage, take that first through an anterior approach (preferably). You can take a larger graft and there will be less bleeding compared to a posterior approach. The incision is just on the inside of the anthelix. Leave the last cm of skin before the tragus connected to the cartilage to prevent wrinkling of the skin. If the patient really doesn’t want a scar on the anterior side of the ear, use the posterior approach. Incision 3cm long halfway the height of the ear. Stay 1cm above the tragus. Undermine towards the mastoid spreading with the scissors and cauterizing. Go the opposite way till the anthelical fold which is concave on the back of the ear. No need to place needles through the cartilage. Full thickness incision leaving the skin intact. Go into the plain anterior to the cartilage and resect at the base leaving the last cm intact. Coagulation.
If you wish to take a septal graft or to correct the septum start with a hemitransfiction incision on the left side, 1,5cm long. Stay under the anterior septal angle. Go subperichondrial with your scissors in one point and then cut the fibers above it. Open with a Cottle elevator and when you feel you can insert the speculum, do it. Hold the speculum up with your left hand. If you are to remove a big hump, loosen the mucosa from the u.l.c. On the left undermine till the perpendicular plate, on the right (through the left nostril,) for about 1cm. This is to allow an upward rotation of the medial crus (tongue in groove). Separate the ventral part of the septum from the dorsal part with a 15 blade. Continue cutting the graft with the Cottle elevator. Normally you leave an L strut with a width of about 1cm, but if you need long grafts you can take the whole ventral part of the septum, unless you wish to lengthen the septum and need stability. Mobilise the superior part of the graft with curved scissors, the ventral part with a curved chisel. Don’t pull the graft until it is fully mobilised. In case of a septal deviation resect the ventral part of the septum and sometimes a wedge from the superior part (but leave the most dorsal part of the superior part connected to the perpendicular plate) so you can swing the septum in it’s proper position. Fixate the Dorso-inferior angle of the septum to the nasal spine with a suture if you feel it’s necessary. If the bone is deviated too, you remove it with a chisel or burr. Another option is to medialise the perpendicular plate after having made a vertical bone cut in the ventral part and a bone cut as dorsal as possible (Storz N3090 Becker double action bone cutting instrument). If you need a very long graft and the septum is completely attached to the perpendicular plate, you can also take the antero-ventral part of the septum. You don’t need a complete L-strut in this situation. Make a pocket for the tongue in groove (if needed) by pulling the columella down with a double hook in your left hand pushing the columella forward with your middle finger. Make the pocket with scissors in your right hand. Close the incision (vicryl 5-0) while holding the speculum vertically to stretch the incision. Place mattress sutures where you took the graft in case of excessive undermining or bleeding.
Start by freeing the lower lateral cartilages: Present the rim of the lateral crus with a double hook retractor and identify it with the back of your knife. Make an incision along the rim and pull it forward with a single hook retractor. Undermine for 2mm with scissors, the tip pointing away from the cartilage. Continue the incision low enough along the medial crus (about 2mm from the nostril). Go with scissors from right to left nostril (transfixion incision) and make the skin incision over the columella with a 15 blade, holding the scissors under the skin. The tip of the inverted V should be halfway the height of the nostrils. Cautherise the vessels before you cut them. 3) Freeing of dorsum: Pull the skin up with a double hook retractor and pull the lower cartilages down with inverted double hook retractors. Dissect over the perichondrium (white). Change the double hook for a blunt retractor and search for the anterior septal angle. Continue the dissection through the white plane till the nasofrontal angle. Make a pocket with scissors over the periosteum of the nasal bone. Scratch the periosteum off the bone with a raspatorium and indicate with a skinmarker how much you wish to resect the dorsum. Free the upper lateral cartilages from the skin with a blade over a distance of 1cm. If the skin is very fatty you can remove the fat with your scissors until the subdermal layer (white). DON’T GO ANY DEEPER. Cephalic trim leaving about 7 – 8mm of the upper laterals. Reduction of the dorsum: Lower the bony dorsum with a heavy rasp (elbow should be up to avoid damage to the ulc) but not completely as it might change when you do the osteotomies(irrigation.) Approach the anterior septal angle and remove 1mm of cartilage with a blade. Go to the subperichondrial plane under the upper lateral cartilages with a Cottle and detach the mucosa. Grab the septum with a long anatomical pincet pushing the lateral cartilages aside and remove the cartilaginous hump with a blade starting from the bone. Be conservative and don’t lower rhinion too much as it will drop when you do the osteotomies.
Overlay of the medial crus if necessary should be done in the lobular segment, about 4 – 5mm under the dome.
If the premaxilla needs to be augmented, create a pocket and fill it either with blocks of cartilage or with Mersilene mesh. Always place a strut in the pocket between the medial crurae. You can use a strong piece of septal cartilage or folded conchal cartilage. The thickest side of the strut should be directed towards the maxilla. Secure it with 2 full bite Donati’s that pass through the strut. Make sure the medial crus is in the same vertical level left and right. Now take the skin under the dome with a pincet and with a scissors you separate the skin from the llc. Go left and right and then spread with your scissors. For double dome technique from 2,5mm medial to 2,5mm lateral of the dome. If you wish to do a steel, go 5 – 7mm lateral of the dome. Place the dome creating sutures (one at each side). Important that the 2 domes are almost in the same level. Now comes the subdomal Donati suture and interdomal suture. Trim the upper laterals (cephalic strip). If you wish to do a lateral overlay this is the moment. A spanning suture halfway the lateral crus (in vertical sense) can give a supratip pinch if you wish.
You change the direction of the chisel once you are lateral enough and halfway the nose you turn towards the dorsum to end the lateral osteotomy +/- 10mm over the medial canthus (less than 5mm from the rim of the bone). The lateral osteotomy needs to be really curved, almost like a half circle. If you cannot fracture the bone by mobilization from the inside with a butter knife (or something like it) you have to do a medial osteotomy that ends where the lateral osteotomy ended. An intermediate osteotomy you do when the nasal bone is convex or concave. If you have planned to do the 3 osteotomies, start with the medial osteotomy using a straight chisel, then the intermediate one with a straight chisel and then the lateral osteotomy with a curved guarded chisel. Check if the nose is straight. If not , mobilize the septum more. Transverse (percutaneous) osteotomies are not necessary.
Do more rasping of the dorsum and lowering of the septum along a long pincet if necessary.
Suture the upper laterals to the septum. If you wish to place spreader grafts, this is the moment (so after the osteotomies). After removal of a big hump you should place spreader grafts that are each 1,5mm thick. You can also use them to straighten the dorsum or with onlay grafts). Fixate them with 2 Donati’s. Stop bleeders of the dorsum. If you wish to augment the dorsum, use beveled cartilage for small augmentations and a roll of Mersilene mesh for large augmentations. It comes in pieces of 15 x 30cm. Cut them in 4 and make a roll out of it and secure it with 1 You can use the cephalic trim to close the soft triangles over the apex of the nostrils. (thick cartilages, thin skin) Sutures of the columella and incisions inside the nose. If you have cartilage grafts left over, put them back in the septum. If you did excessive undermining or it bleeds, put mattress sutures.
First make the medial incisions for the sil reduction. They should be symmetrical. Then follow the alar crease as far as you think is necessary. Place the lateral incisions in the sil (3 – 6mm lateral to the medial ones at the end of the curvature). Remove skin in between. Make the upper incision for the afr towards the inferior end of the lateral incision in the sil. Skin excision, suturing.