Cosmetic
Rhinoplasty: Personal Evolution and Milestones
Jack H. Sheen, M.D.
Santa Barbara, Calif.
Over the past 35 years, aesthetic rhinoplasty has evolved
from a generic, reductive operation to a highly individu-
alized, problem-specific operation that often combines
augmentation with reduction. The authors experience
has been marked by the following conceptual and tech-
nical milestones that have contributed to an ongoing ex-
ploration and advancement of nasal surgery: (1) vestibular
stenosis: diagnosis of a surgical consequence; (2) etiology
and treatment of supratip deformity: the dynamic rela-
tionship of soft-tissue contour to skeleton; (3) etiology and
treatment of the tip with inadequate projection: tip graft
design; (4) practical aesthetics of balance: the augmen-
tation-reduction approach to rhinoplasty; (5) support of
the middle vault: functional and aesthetic effects; (6) mal-
position of the lateral crura: recognition and manage-
ment; and (7) the significance of the middle crura: clinical
FIG. 1. Drs. Jack Sheen and Tom Baker at the 1973 Baker-
Gordon Symposium.
From the Department of Surgery, Division of Plastic Surgery, University of California at Los Angeles; and the Department of Surgery, Section
of Plastic Surgery, University of Southern California. Received for publication August 19, 1999; revised September 3, 1999
Presented at the Baker-Gordon Symposium in Miami, Florida, on March 5, 1999.
1820
and aesthetic considerations. (Plast. Reconstr. Surg. 105:
1820, 2000.)
In 1972, I nervously presented my first paper
on secondary rhinoplasty. I had been in prac-
tice for only 7 years, but I was already brazen
and unconventional in my approach to nasal
surgery. Soon after, Tom Baker, who had been
in the audience, courageously offered me
unknown and unprovena place on the Bak-
er-Gordon symposium faculty in 1973, giving
me a forum in which I could demonstrate sur-
gery and express my ideas. Also on that faculty
were my formidable colleagues, Tord Skoog
and Fernando Ortiz Monasterio. With lasting
gratitude to Tom Baker and Howard Gordon, I
considered myself launched (Figs. 1 and 2).
Now I have been asked to account for myself
over these past 30 years by presenting a review
of my personal evolution in rhinoplasty and
FIG. 2. Panel members (left to right) Tord Skoog, Fer-
nando Ortiz Monasterio, and Jack Sheen. (Photograph cour-
tesy of Berta Lewin.)
Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES
defining significant milestones along the way.
First, I had to determine the meaning of a
milestone as it applied to the progress of my
practice. A milestone, of course, is an impor-
tant event or turning point along a continuum
of development. For me, a milestone marks a
particular development based on a process of (1)
observation, (2) realization, and (3) change. This
process is not unusual, but in a few instances it
was applied to issues of such consequence that,
for me, it resulted in a radical departure from
accepted, conventional ways of thinking about
and performing nasal surgery.
I. VESTIBULAR STENOSIS: DIAGNOSIS OF A SURGICAL
CONSEQUENCE
By the mid-1970s, I was examining hundreds
of secondary rhinoplasty patients each year. I
observed that an estimated 80 percent had
some loss of vestibular volume, with mild to
severe impairment of the nasal airway.1 Clearly,
something was wrong with our surgical tech-
nique. I might add that something also was
wrong with our postoperative follow-up. When
1821
I shared my observation with colleagues, most
shrugged, saying they never saw it. The fact is
that it was not expected practice to look. It
surprised me at the time that many plastic
surgeons did not critically examine the inside
of the nose postoperatively; many did not even
have adequate light and a nasal speculum in
their examination room.
When analyzing the problem, I focused on
what was then a routine step in rhinoplasty:
trimming the caudal edge of the upper lateral
cartilage with right-angle scissors2 8 (Fig. 3). I
realized that because the upper lateral carti-
lage is triangular, a straight cut along the
caudal end would result in a mucosal deficit,
inevitably leading to scarring and stenosis9
(Fig. 4).
The changes that resulted were, first, dis-
carding the right-angle scissors and, second,
performing a submucous dissection of the car-
tilage, which preserved mucosa except for the
rare case in which exceedingly redundant mu-
cosa is conservatively trimmed. This left an in-
tact mucosa, functioning internal valves, and a
normal airway. Today, less than 15 percent of
secondary rhinoplasty patients I see have any
loss of vestibular volume; of those, only a few
have severe vestibular stenosis.

FIG. 3. (Left) The caudal edge of the upper lateral cartilage is approximately 120 degrees from
the dorsal plane. (Right) A routine step in rhinoplasty was trimming the caudal edges of the upper
lateral cartilages with right-angle scissors. The consequent mucosal deficit resulted in scarring
and loss of vestibular volume.
1822
FIG. 4. Severe vestibular stenosis resulting in airway impairment following routine aesthetic
rhinoplasty.
II. ETIOLOGY AND TREATMENT OF SUPRATIP
DEFORMITY: THE DYNAMIC RELATIONSHIP OF SOFT-
TISSUE CONTOUR TO SKELETON
Thirty years ago, supratip deformity was
commonly seen in rhinoplasty patients. The
prevailing opinion was that supratip deformity
was most often caused by inadequate resection
of the dorsum, overlapping lateral walls, or
excess scar formation.10 14 The prevailing treat-
ments were further dorsal reduction, thin-
ning dissections, and steroid injections. The
prevailing outcomes were recurrent supratip
deformities and multiple procedures, many re-
sulting in increased scarring and, at times, ir-
reparable defects (Fig. 5). The only thought
about prevention, as suggested by Safian15 and
Denecke and Meyer,16 was to undercut the an-
terior septum to allow room for granulation
tissue.
But I had a contrary idea about supratip
deformity. I had observed that the soft tissue
often could be compressed down to the septal
edge (Fig. 6). No amount of lowering that
septum would reduce the arch of skin overly-
ing it. The skin had simply reached its limit of
contractility. Sometimes fibrous tissue would
fill in the space, making the area feel firm but
never providing enough structure for a straight
PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000
contour. Realizing that a soft structure needs a
supportive framework to maintain shape, I hy-
pothesized that augmentation, not reduction,
was the answer (Fig. 7).
The story again goes back to Miami. In 1973
and 1974, a secondary rhinoplasty patient with a
supratip deformity and a lot of time and re-
sources was flying across the country and around
the world to consult with plastic surgeons about
her nose (Fig. 8, above and below, left).
It was Fernando Ortiz Monasterio who rec-
ommended that she come to me for her sec-
ondary rhinoplasty. Meanwhile, Ralph Millard
had heard of my unorthodox concept of su-
pratip deformity and, in 1975, invited me to his
symposium in Miami to prove myself in front of
an audience of 500 and a faculty of experts,
including himself, Gustav Aufricht, Reid Ding-
man, Paul Natvig, John Lewis, and Blair Rog-
ers. Because I knew that this patient had con-
sulted with every surgeon on the faculty and
that she was willing to have the procedure per-
formed during the symposium, I could not
possibly refuse. At surgery, I showed that the
anterior septum at the area of the supratip had
already been lowered about 4 mm, as recom-
mended by Dr. Safian.17,18 I then augmented
the dorsum, producing a fine, straight dorsal
Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1823

FIG. 5. Patients who had undergone tissue thinning procedures in attempts to reduce the
arch of skin over the lower third of the nose.

edge, permanently eliminating the supratip
convexity (Fig. 8, above and below, right).
In 1975, I formally presented my clinical
material on supratip deformity, which in-
cluded a report of 100 consecutive secondary
rhinoplasty patients, representing a major
change in the approach to secondary rhino-
plasty. Eighty-two percent of the noses were
corrected by dorsal augmentation.19
Besides the diagnosis and treatment of su-
pratip deformity, the other aspect of this mile-
stone is prevention. Understanding that the
size of the skeletal framework must be propor-
tionate to the size (and character) of the over-
lying soft tissue, the surgeon can prevent su-
pratip deformity by retaining adequate dorsal
support.
1824 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000

FIG. 6. Pressing the supratip down to the anterior septum made it apparent that the supratip
deformity was related to the limits of soft tissue contractility, not the height of the skeleton.
Augmentation was the logical solution.
Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1825

FIG. 7. Case presented at the 1973 Baker Gordon Symposium to demonstrate correction of
a supratip deformity by augmentation of the dorsum and tip grafting.
1826 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000

FIG. 8. Patient operated on at the Millard Symposium 1975, demonstrating augmentation for
supratip deformity. For a condensed version of that surgery, refer to Sheen, J. H. Secondary
Rhinoplasty Surgery (Videotape #9610). Creating the Balanced Nose. Arlington Heights, Ill.: Plastic
Surgery Educational Foundation.
Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES
III. ETIOLOGY AND TREATMENT OF THE TIP WITH
INADEQUATE PROJECTION: TIP GRAFT DESIGN
A question that was frequently asked in my
early days was, Do you do the tip first or the
dorsum first? It just so happened that I usually
set the height of the dorsum first, allowing for
final adjustments. The reason was based on my
insight into supratip deformity. I realized that
the height of the dorsum must be limited by
the size and character of the skin sleeve; it
could be reduced only so much without de-
forming. After determining the limit of reduc-
tion, I was faced with the challenge of achiev-
ing adequate tip projection relative to the
appropriate dorsal height. I was then using
only conventional tip techniques: cephalic
trimming of the alar cartilage, scoring at the
dome to maximize projection. For most noses,
this technique was successful, but not for all. I
observed that there was a characteristic group
of noses in which the alar cartilages were in-
herently inadequate to project the tip beyond
an appropriate dorsal line. Predictably, these
noses would have poor postoperative contours
(including supratip deformity from attempts to
lower the dorsum to the level of the tip). I
named this problem The Tip with Inadequate
Projection and began plotting a solution (Fig.
1827
9). Soon came the realization that aesthetically,
the tip lobule itselfthe area between the col-
umellar-lobular junction and end point of the
tipwas lacking in structure. The next logical
step was to devise a way to support just that
area. Various grafts to fill out the tip such as a
small button, a tent pole, and a fleur de lys
graft had been suggested by Millard, Gorney,
Falces, and others. As far back as 1946, Ma-
liniac suggested small grafts of septal or con-
chal cartilage to fill out the tip of the cleft lip
nose.20 22 None of these designs could provide
the necessary projection to correct the tip with
inadequate projection or the scarred, postsur-
gical nose.
In 1968, I designed a tip graft technique that,
except for the shape and number of grafts, re-
mains unchanged23 (Fig. 10). A pocket is devel-
oped, based at the columellar-lobular junction
and extending anteriorly into the tip lobule. Us-
ing the columellar-lobular-junction as a base, the
graft(s) is placed under just enough tension to
extend the tip to the desired position. The orig-
inal graft had the configuration of a cross-section
of a molar; some saw it as a shield. The width of
the top varied, depending on the thickness of the
soft tissue. With thick tissues, the graft was made
narrow to improve

FIG. 9. (Left) Patient exhibiting a tip with inadequate projection. (Center) Conservative dorsal reduction
produced a supratip deformity. Note that the tip projection remained unchanged after primary surgery. (Right)
Seven-year postoperative result following dorsal graft and tip graft.
1828 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000

FIG. 10. (Above) Original tip graft technique. Opening incision at the columellar-
lobular junction. (Center) A pocket is developed as the incision progresses along the alar
rim. (Below) Graft is inserted into the pocket. The development of the pocket remains
unchanged. Today, multiple grafts are routine.

the mechanical advantage. With thin skin the
top was wider. I was now using this technique
not only for deficient primary tips but also in
secondary cases, in which the alar cartilages
had been overly resected. The use of tip grafts
greatly enhanced the results in a wide variety of
cases. At first, the patients and I were all
smiles.
Soon there were problems. Some of the
grafts became visible, as the edges blanched
the overlying skin. Others slipped upward or
sideward, creating asymmetries and unsightly
contours. To correct these mishaps, additional
grafts were placed to obtain good contour and
symmetry. To prevent them, I then changed
my tip augmentation technique to use multiple
grafts as a routine.
By the mid-1970s, I had added ear cartilage
to the tip graft materials (under the influence
of Burt Brent) and was beginning to use
crushed cartilage with excellent results. The
first remarkable case using crushed cartilage
involved a scarred, postsurgical nose with mul-
tiple grooves in the tip lobule. Clearly, the
Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1829
usual tip graft would not have corrected this single grafts, and flat lobules can be improved
problem. What I wanted was not so much to with the use of crushed cartilage grafts. With
project the tip lobule but to expand it. So I thousands of tip grafts, time has proven that
crushed nine pieces of cartilage and carefully they are effective and they last over the long-
stuffed them into the tip (Fig. 11). With the term (Fig. 12).
success of this case, crushed cartilage emerged The tip grafts I use today are made of septal,
as an extremely useful and versatile graft ma- ear, or rib cartilage.24 They are used either
terial. Noses with thin skin, asymmetries, visible unmodified, bruised, crushed, or morselized,

FIG. 11. This patient with a scarred tip received nine crushed cartilage grafts. She is shown
preoperatively and at 4 years postoperatively.
1830 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000

FIG. 12. A 10-year follow-up on a secondary cleft lip nose.

often in combination. A combination of solid
grafts for support and projection, and soft
grafts for fill and contour, is a versatile and
effective solution to a variety of tip deficits. A
buttress graft of ethmoid bone is sometimes
used to stabilize the position of loose grafts
within the pocket. Recently, I have been using
tangential sections of the ninth ribsolid,
crushed, or morselized. Early results are good,
but the verdict is still out.
Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1831

FIG. 13. Patients characterized as having a low radix disproportion. These patients have a low
root and a large nasal base, producing a bottom heavy nose. Minimizing the base by augmenting
the root illustrates the concept of balance in rhinoplasty.

IV. PRACTICAL AESTHETICS OF BALANCE: THE
AUGMENTATION-REDUCTION APPROACH TO
RHINOPLASTY
As a milestone this is my favorite. Over time,
I embraced the observation that high and low
and large and small manifest each other. Raising
the root of the nose diminishes the apparent
projection of the base; projecting the base di-
minishes the apparent height of the dorsum.
Narrowing the upper vault of the nose accen-
1832
tuates the width of the base, and vice versa. For
me, this observation represents a major con-
ceptual shift and marks the point of departure
from the standard Joseph rhinoplasty, as a se-
quence of reductive surgical steps (Fig. 13).
To the clinician, the exciting part of this
concept is the potential for practical applica-
tion. If changing the nasal configuration is
analyzed and planned as a matter of balance
rather than reduction, then the surgeon can
manipulate anatomic components to achieve
aesthetic effects that otherwise would be unob-
tainable given the inherent limitations of an
individuals tissues. Equally important is the
ability to create the illusion of reduction while
preserving skeletal support.25
Seen from this point of view, an apparent
hump may be only a relative hump and there-
fore can be eliminated by elevating the adja-
cent tissue. The questions may arise, When is
a hump not a hump? or How do you know
when a hump is a hump? My answer is: A
hump is a hump only when the rest of the nose
can spare it.
Case Illustration
A 39-year-old woman, 5 feet 10 inches tall
(Fig. 14), had findings that may be summa-
rized as follows:
FIG. 14. Patient shown preoperatively and 14 months after surgery with a balanced retrousse
nose.
PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000
low radix disproportion
bony arch to nasal base disproportion
ultraprojecting base
nostril-lobule disproportion
long nose with drooping nasal tip
flaring nostrils.
Discussion
This was a large nose on the large face of a
tall patient. The patient, who wanted a smaller,
more retrousse nose, was advised about tissue
limitations and about the danger of sacrificing
contour for size. In my experience, given the
particular base-heavy structure of her nose, a
conventional reductive rhinoplasty would
likely result in an unattractive, surgical-
appearing nose. It was explained that the nose
could be made to appear more refined by im-
proving the angles and proportions.
Twenty-five years ago I would have used the
root as a point of reference in reducing this
sizable hump. But 25 years ago, I had not yet
seen literally thousands of supratip deformities
that resulted from this misjudgment. This pa-
tient has a low radix disproportion26; that is,
the root is low relative to the base. If the dor-
sum were lowered to a plane in line with the
radix, the dorsal skin would not be supported
and a supratip deformity would likely result.
Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES
The alternative of raising the radix has three
positive effects: (1) minimizing the dorsal con-
vexity, (2) preserving skeletal structure, and
(3) diminishing the apparent size of the base.
In this case, the nasal base itself poses chal-
lenges. The alar base is relatively wide, the
nasal tip is ultraprojecting, and the nostrils
are disproportionately long relative to the tip
lobule. The nostril-lobule disproportion had
to be addressed.27 My plan was to increase
lobular size by tip grafts and decrease the
nostril size by alar resection. Projection of
the nasal base would be countered by root
augmentation.
The frontal contour is also a problem of
balance. The bony arch is narrow, which con-
traindicates osteotomy and suggests augmenta-
tion to diminish the relative width of the base.
Spreader grafts provide continuity of the mid-
dle vault and ensure function of the internal
valves. Conservative reduction of the flaring
nostrils, including lobular and vestibular sides,
and preserving a medial flap for a smooth sill28
would narrow the alar base without compro-
mise to contour or function. Nostrils can be
reduced only so much without distortion.
Therefore, augmentation of the upper vaults is
of great benefit because it minimizes the
amount of alar resection required to ade-
quately narrow the base.
The surgical plan is summarized as follows:
1833
transfixion incision of columella, anterior
third only
wide skeletonization
rasp the radix to prepare for graft
trim dorsum
develop spreader graft pockets
septal submucous resection to harvest graft
material
place bruised cartilage grafts at the root
place spreader grafts
trim caudal edges of upper lateral cartilages
augment lateral bony arch, bilateral
alar resection, lobular, and vestibular exci-
sion
place tip graft.
Figure 15 shows intraoperative photographs.
Comments
This patient, shown 14 months after surgery,
exemplifies the concept of augmentation-
reduction to achieve a balanced nose (Figure
14, right, and 16, right. The nose is not small,
but it is correct in contour and function. A
large nose, especially one with a projecting
base, can be a trap. The soft tissue will not
contract down to an overly reduced skeleton
without sacrificing contour. With an under-
standing of this very real limitation, every
surgeon performing rhinoplasty should be
inspired by the possibilities presented by se-
lective augmentation.
 FIG. 15. (Above, left) Resection of the anterior segment of the middle vault. Note the visible
septal T, which effectively supports the lateral walls and spreads the apices of the internal valves.
(Above, right) Specimens obtained from septum to correct airway obstruction and for use as grafts.
(Center, left) The root graft consists of segments of bruised or morselized septal cartilage, layered, and
sutured together. (Center, right and below, left) Crushed cartilage grafts to be placed over each
lateral wall of the bony arch. (Below, right) Spreader grafts shown before placement.
 FIG. 16. Same patient as seen in Figure 14, preoperatively and shown 14 months postoper-
atively. A balanced, retrousse nose. (Above) Increased width of bony arch and a narrower base
have improved balance. (Center) Elevation of root diminishes the apparent size of the base.
(Below) Basal view shows a narrower base in addition to a smooth sill, the result of preservation
of a medial flap with the alar resection.
1836
FIG. 17. Primary rhinoplasty patient with collapsing in-
ternal valves on inspiration. He was the first patient diagnosed
as having short nasal bones and the first to receive spreader
grafts.
FIG. 18. (Left) Diagnosis of short nasal bones often can be made by visual examination.
Palpation verifies the boundary of the caudal bony arch. (Right) X-ray film shows nasal bones
to be about 1 cm long.
PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000
V. SUPPORT OF THE MIDDLE VAULT: FUNCTIONAL
AND AESTHETIC EFFECTS
With the exception of Tord Skoog, who re-
placed the dorsal roof following reduction of
the anterior septum,29 no one in the early days
of rhinoplasty attached much importance to
the integrity of the middle vault. Lowering the
dorsum was just another routine step in a re-
ductive operation. In the 1950s and 1960s, sur-
geons actually tried to produce scooped
noses. Lipsett took pride in creating a dorsum
that was razor thin. Postsurgical noses of that
era were characteristically caved in on the sides
and functionally compromised.
Like everyone else, I was taught to routinely
perform an osteotomy and to resect the dor-
sum, thinking only of reduction. Narrower,
smaller, lower, shorter: those were our goals.
But even as I was dutifully narrowing my pa-
tients noses, I began to observe three recur-
ring postoperative problems: (1) narrowing of
the internal valves with impaired airways; (2)
visible fall-in of the middle vault, seen on
oblique view; and (3) inverted V deformity, a
visible demarcation between the middle and
bony vaults, apparent on front view. As increas-
ing numbers of secondary rhinoplasty patients
streamed through my examining room, this
Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1837
observation became crystallized. I realized that
our surgery was causing a discontinuity be-
tween the middle and bony vaults. I guessed,
wrongly, that the upper lateral cartilages might
separate from their bony attachment during
rasping, thus causing them to fall in. But this
idea was dispelled in the anatomy laboratory,
where I discovered that a horse trainer would
have difficulty pulling the cartilages away from
the nasal bones. It wasnt until I met one par-
ticular primary rhinoplasty patient, that the
etiology and treatment of middle vault impair-
ment began to emerge.

Short Nasal Bones

FIG. 19. Diagrammatic representation of the effect of re-
section of the roof of the middle vault and its correction by
spreader grafts.
A male patient, with no history of prior sur-
gery, requested that I improve his airway with-
out changing the nasal contour (Fig. 17).
When I examined him with a nasal speculum,
the septum was obviously straight and the air-
ways were wide open. I cant see anything
wrong with the inside of your nose, I said. He
gave me a quizzical look and inhaled deeply.
Well I still cant breathe, he insisted. I looked
again. Yes, now I can breathe, he said, his
breath fogging the speculum. But when you
take that instrument out, I cant. Then, when
examining him without the speculum, I saw
that on inspiration, the internal valves col-

FIG. 20. Inverted V deformity is frequently seen in patients with short nasal bones. This
patient, with an appropriate dorsal height, is shown before and after spreader graft placement.
Had she needed dorsal augmentation, spreader grafts would not have been necessary, because
the width of the dorsal graft would provide the necessary support.
1838
lapsed against the septum. Thinking about
normal anatomy, I placed a cotton applicator
at the apex of the internal valve and asked the
patient to breathe. With the applicator in
place, he breathed well.
Now I was faced with two questions: Why
were the internal valves collapsing and what
could be done about it? A careful look showed
a nose that was long and narrow, with practi-
cally no bony arch. On palpation, the nasal
bones were found to be less than a centimeter
long. It was clear then that the middle vault was
lacking the support usually provided by a sub-
stantial bony arch. Thus began my campaign of
measuring every bony arch I saw. I concluded
that most nasal bones extend about half the
distance between the radix and the angle of
the septum. Twenty-five percent of that dis-
tance I considered to be short (Fig. 18). I then
realized the clinical significance of the length
of nasal bones for rhinoplasty patients and re-
ported my findings in 1976 at the meeting of
the American Society of Plastic and Recon-
structive Surgeons in Boston.30
Significantly, in the nose with short nasal
bones the middle vault is not held laterally by
the support of the bony arch. Medially, the
primary support to the internal valves is the
broad anterior edge of the septum, or the top
of the septal T. When the anterior septum is
resected to lower the dorsum, the walls will fall
medially and airway impairment and an in-
verted V deformity may result. In cases with
short nasal bones, osteotomy is contraindi-
cated and something must be done to expand
the internal valves.
PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000
Spreader Grafts
Returning to my milestone patient with short
nasal bones, I must say that at the time I was
just fishing for ideas. With the cotton applica-
tor came the answer: A sticklike graft placed
along the anterior edge of the septum would
spread the apex of the internal valve (just like
the applicator), moving the medial portions of
the lateral walls outward. This would widen and
support the patients long middle vault and
improve his airway. The graft was named for its
function: spreader graft.3133 The technique I
used for this patient remains unchanged ex-
cept for the sequence. The initial incision ex-
tends through the perichondrium. The narrow
pocket is developed with a Cottle perichon-
drial elevator, flat side against the septum,
maintaining a mucosal attachment at the ante-
rior septum. In the past, I made the pockets
and then reduced the dorsum. Today I reduce
the dorsum and then make the pockets to en-
sure an anterior mucosal attachment, which
prevents slippage of the graft.
With the success of spreader grafts for this
patient, the technique was soon extended for
use in the postsurgical nose (without a dorsal
graft), asymmetries of the dorsum, and se-
lected primary cases. Spreader grafts replace
the broad, anterior portion of the septal T that
is removed with any significant dorsal hump
(Fig. 19). Therefore, these grafts prevent the
functional and visible sequelae of middle vault
fall-in as well as restore middle vault support in
the postoperative patient or in patients with
short nasal bones (Fig. 20).
Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES
VI. MALPOSITION OF THE LATERAL CRURA:
RECOGNITION AND MANAGEMENT
Malposition is not the best term for this an-
atomic feature, but I have used it since the
early 1970s, so it is too late to take it back. I now
realize that what I observed as a malposition of
the lateral crura is not an abnormal position of
the cartilage, but a somewhat common varia-
tion of normal anatomy. I had learned that the
1839
normal, expected position of the alar cartilage
almost parallels the alar rim. Grays Anatomy of
the Human Body describes the cartilage as di-
verging from the alar rim at about 15 degrees.34
So when I observed alar cartilages at a 60-
degree cephalic slant, it seemed to me that
they were malpositioned.35,36
The first patient who brought my attention
to the position of the alar cartilages demon-

FIG. 21. (Above, left) The first patient on whom malposition was diagnosed. (Above, right) On
front view, the cephalic orientation of the lateral crura is clearly visible, with the characteristic
parentheses, which mark the margins of the alar cartilages. (Below, left) Pressure on the alar rim
reveals a sharp outline of the position of the lateral crus. (Below, right) On basal view, the poorly
supported alae and the square perimeter of the base are characteristic. However, the cartilages
can be either broad or narrow at the tip.
1840
strated a dramatic picture of malposition (Fig.
21). On front view, the nasal tip was ball-like
and bordered by parentheses. On basal view,
there was notching in the alar rims, where the
cartilages angled cephalad. I realized that the
standard approach to trimming the cartilages
would not be effective and might cause distor-
tion. I then decided to dissect out the alar
cartilages and rotate them downward to pro-
vide substance and support to the rims (Fig.
FIG. 22. (Above) The lateral crus is dissected from the
vestibular skin. (Center) The completely dissected lateral crus.
(Below) Repositioned crus in newly formed pocket, parallel to
the alar rim.
PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000
22). Postoperatively, the alar rims were well
supported, thereby eliminating the tip paren-
theses (Fig. 23).
After this case, I began to find malposition of
the alar cartilages in a variety of forms and
degrees. However, the characteristic findings
were consistent: lack of alar rim support and
some degree of visible parentheses, which
manifest the caudal edges of the cephalically
positioned lateral crura. Malpositions were
everywhere. This recognition became impor-
tant as the clinical relevance and application
became increasingly apparent. If a significant
malposition is unrecognized preoperatively,
the standard cephalic trim of the alar cartilage
may result in postoperative distortions. For ex-
ample, the usually safe intracartilaginous inci-
sion is made parallel to the alar rim, but if the
cartilages are cephalically rotated, this tech-
nique may result in transection of the carti-
lages, often creating visible stumps or knuckles
postoperatively. Secondary rhinoplasty patients
with undiagnosed or untreated malpositions
share identifiable defects; most notable are tip
deformities and notching of the alar rims (Fig.
24).
Now that malposition had made itself
known, what was to be done? Obviously, diag-
nosis was paramount. At first, my treatment was
straightforward: repositioning of the lateral
crura. With experience, I abandoned that tech-
nique because of the occurrence of some dis-
tortion at the apex of the nostril. Then I ex-
perimented with the more radical technique of
total resection of the lateral crura, then replac-
ing them as free grafts along the alar rims. A
third option is to leave them alone.
Whether to leave the cartilages alone de-
pends more on the patients desires than on
any other factor. I always ask, What do you
think of your nose on front view? If the patient
does not specifically mention the round tip, I
then ask, What about these grooves here, do
they bother you at all? If the patient says no,
then I will plan a conservative approacha tip
graft to project and define the tip and alar rim
grafts for support. The improvement is good,
but subtle. For many patients, this conservative
result is quite satisfactory and for the surgeon
who may not be comfortable with resecting the
cartilages and reconstructing the base, this is
certainly the safest technique (Fig. 25).
Resection of the cartilages and replacing
them in the alar rims is technically challenging.
Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1841

FIG. 23. Patient shown 14 months after surgery with good support to the alar rims and
improved tip projection.

The dissection from the vestibular side is diffi-
cult. However, with experience, the dissection
becomes easier, faster, and less traumatic. The
grafts are effectively fixed in position by 5-0
plain sutures. I do not recommend this tech-
nique to the occasional nasal surgeon. Plac-
ing fragile strips of alar cartilage in meticu-
lously made pockets requires a familiar and
respectful touch. But for me, this has been
the most successful technique to support the
alar rims in cases of malposition (Figs. 26
through 28).
Regardless of the method of treatment, the
most important aspect of malposition is recogni-
tion. The position of the lateral crura relative to
the alar rim should be assessed in every rhino-
plasty patient to prevent untoward results, to
modify technique as necessary, and to ensure the
best aesthetic result for patients whose alar carti-
lages require special management.
1842 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000

FIG. 24. Patients with undiagnosed malposition treated by standard tip refining techniques, which resulted in tip distortions.
Note that all have notched alar rims and visible stumps of the remaining lateral crura.
Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1843

FIG. 25. Preoperative and postoperative views of patient with malposition of the crura treated
by leaving the alar cartilages untouched. A tip graft was placed and the alar rims were supported
by grafted strips of cartilage. The patient also received a root graft, spreader grafts, and a slight
reduction of the dorsum.
1844 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000

FIG. 26. Patient with complete resection of alar cartilages lateral to the medial genua re-
placement with narrow strips of cartilage to support the alar rims. Tip grafts and a dorsal graft
were also done.
Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1845

FIG. 27. Oblique and basal views of the patient shown in Figure 26.
1846 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000

FIG. 28. Surgical steps to correct malposition in the patient in Figures 26 and 27. (Above, left)
Specimen from rhinoplasty. Note the degree of bony deformity. (Above, right) Right lateral crus
dissected out to the medical gene. (Center) Lateral crura completely removed. (Below, left)
Trimmed lateral crus positioned for suturing in alar rim. (Below, right) Dorsal graft of septal
cartilage prior to placement.
Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1847

FIG. 29. Patient operated on in 1968. Her alar cartilage configuration was ideal for the
standard tip refining technique.

VII. THE SIGNIFICANCE OF THE MIDDLE CRURA:

CLINICAL AND AESTHETIC CONSIDERATIONS
This milestone is an example of how one can
look at something every day, for years, and
never really see it. I was taught that an alar
cartilage consists of two segments, the medial
and lateral crus, which join at the dome or
lateral genu. Medical illustrations confirmed
this impression, showing a long, continuous
structure bent in the middle. It never occurred
to me to question the accepted anatomy. When
researching it later, I found that Grays Anato-
my34 mentions, almost parenthetically, a transi-
tional area but gives no description, nor is it
represented in any illustration. No wonder it
went unnoticed. I had never heard or read any
reference to it, nor seen it illustrated in pre-
sentations, let alone any mention of a possible
clinical significance.
Informed by the accepted anatomy, I had
been intently studying alar cartilages but was
still perplexed by unanswered questions. The
many variations in the surface anatomy of the FIG. 30. Cadaver dissection showing three distinct seg-
tip remained a puzzle. In particular, I was in- ments of the alar cartilage. The middle crus (red portion) is
terested in the angulation at the columellar- bounded by the medial and lateral genua.
1848 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000

FIG. 31. Three-segment anatomy of the alar cartilage. (Left) Angle of rotation at the medial
genu defines the columellar-lobular junction; (right) angle of divergence determines the inter-
crural distance.

FIG. 32. (Left) A typical snub nose reflects short middle crura, resulting in inadequate
projection of the nasal tip. (Right) Patient is shown 8 years after tip grafting.

lobular junction and the various facets seen in
different nasal tips. From the beginning, I
could get some results I was proud of, such as
the one I often used in my early presentations.
This patient, operated on in 1968, happened
to have the ideal cartilages for the standard
technique (Fig. 29). Then, as I gained experi-
ence, I could not understand why the same
technique failed to produce consistent results.
I could not create the desired facets and angu-
lations at will. I felt that until these features
were understood, I could not adequately diag-
nose and control tip contours.
One day, quite unexpectedly, I saw what I
had been looking at. In an anatomy laboratory,
I had dissected out and exposed an entire alar
cartilage. At once, it was obvious. Between the
medial and lateral crus, there was a distinct
segment that extended from a medial genu to
a lateral genu: a middle crus37,38 (Fig. 30). With
that observation, the surface anatomy of the
nasal base finally made sense. The base con-
sisted of three definite units: the columella, the
tip lobule, and the alar rims. The columellar-
lobular junction indicated the medial genu, or
the angulation between the medial and middle
crura. This angle I defined as the angle of rota-
tion (Fig. 31, left). The height of the lobule
reflected the length of the middle crura, and
on front view the tip was defined by the dis-
tance between the lateral genua. This distance
was determined by the angle of divergence, or the
relationship of the middle crura to each other
(Fig. 31, right). Thus for me, the middle crus
Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES 1849

FIG. 33. (Above, left) Square tip reflecting long middle crura with a wide angle of rotation.
(Right) Three-segment alar cartilage as it relates to surface contour. (Below, left) Postoperative
result obtained by partial resection of the middle crura and tip grafting.
1850 PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000

FIG. 34. (Left) Critical analysis of the individual patients alar cartilagethe size, shape, and position
of each component enables effective surgical management of the nasal tip. (Right) Patient shown
following resection of the crura lateral to the medial genu and reconstruction with septal cartilage grafts
to the dorsum and nasal tip. Ear cartilage was used to support the alar rims.

was the missing link in nasal tip anatomy. With
it, diagnosis and management of a variety of
nasal base configurations was possible.
One frequently encountered configuration
is the broad tip. Keeping the relationship be-
tween the middle crura in mind, one can see
that a broad tip is the manifestation of a wide
angle of divergence. Conversely, a narrow an-
gle of divergence creates a pointed tip, lacking
the attractive defining point of the lateral genu
seen on oblique view.
The length of the middle crura also deter-
mines characteristic tip contours. What I
termed a tip with inadequate projection usu-
ally reflects short middle crura. To the ex-
treme, a snub nose is the result of very short,
or nonexistent, middle crura (Fig. 32). Histor-
ically, these noses have often been treated by
composite grafts to lengthen the columella.
With critical observation, however, it is appar-
ent that the columella is not the primary prob-
lem. The lack of projection is usually caused by
a deficient tip lobule; that is, short middle
crura. The logical treatment for a deficient
lobule is to place tip grafts to project and de-
fine the nasal tip, thus duplicating the role of
the middle crura.
Less common but also typical in appearance
is the tip with long middle crura. Long middle
crura are manifest by a tall lobule or a long
infratip segment (Fig. 33). In these cases, the
nasal tip appears to be square on profile. Rec-
ognition of long middle crura is necessary for a
satisfactory result, because techniques that ad-
dress only the lateral crura will not affect the
desired change. Only excision of part of the
middle crura will decrease the height of the
lobule.
Understanding the alar cartilage as a three-
part structure, with each part having a specific
role in the contour of the nasal base, and
understanding that the size, shape, and posi-
tion of each component influences the aesthet-
ics of the tip, enables the surgeon to analyze
the anatomic basis for each patients nasal con-
tour and to plan an operation that is appropri-
ate and effective (Fig. 34).
Finally, I would like to comment on the En-
donasal method of rhinoplasty, which, when I
learned it, was the only method. All of the
Vol. 105, No. 5 / RHINOPLASTY: PERSONAL EVOLUTION AND MILESTONES
observations, realizations, and resulting
changes have been made under the conditions
of an endonasal approach and could not have
been made otherwise. Some of the techniques,
such as placing free grafts in discrete pockets,
are not applicable to the open method, but
the principles still apply. This is not the time or
place for a comparison with the now popular
open method, but one reflection is salient.
Much of what I have learned and continue to
learn from nasal surgery is dependent on see-
ing and touching the nose in its normal, cov-
ered state. As I operate, a dynamic takes place
between me and the nasal tissues, between
what I am imposing on the nasal contour and
what it will accept. I would find it difficult to
duplicate the subtlety of this experience work-
ing on exposed skeleton. At present, I would
make one exceptionthe case of malposi-
tion. Because of the technical difficulty of
repositioning or replacing the lateral crura,
it may be that the open approach enables
more controllable management of malposi-
tioned cartilages.
It is an interesting experience to reflect on
the evolution of ones thinking on a particular
subject over a long period of time. My subject is
small, but for me, the possibilities have always
been great. I like noses. I like to think about
changing them and I like to think about chang-
ing the ways in which we change them to
achieve ever improving and predictable results.
To that end, these are my seven personal mile-
stones to date. Im working toward an even
number.
Jack H. Sheen, M.D.
216 W. Pueblo Street, Suite A
Santa Barbara, Calif. 93105
ACKNOWLEDGMENT
I would like to express appreciation to my wife, Anitra, for
her assistance in the writing of this article.
REFERENCES
1. Sheen, J. H. Aesthetic Rhinoplasty, 1st Ed. St. Louis:
Mosby, 1978. P. 26.
2. Converse, J. M. Surgical Treatment of Facial Injuries, 3rd
Ed. Baltimore: Williams & Wilkins, 1974. P. 782.
3. Rees, T. D., and Wood-Smith, D. Cosmetic Facial Surgery.
Philadelphia: Saunders, 1973. P. 439.
4. Brown, J. B., and McDowell, F. Plastic Surgery of the Nose.
St. Louis: Mosby, 1951. Pp. 118 119.
5. Lewis, J. R. Atlas of Aesthetic Plastic Surgery. Boston: Little,
Brown, 1973. P. 119.
1851
6. Deneke, H. J., and Meyer, R. Plastic Surgery of Head and
Neck. New York: Springer-Verlag, 1967. P. 102.
7. Aufricht, G. Rhinoplasty and the face. Plast. Reconstr.
Surg. 43: 219, 1969.
8. Joseph, J. Nasenplastik und Sonstige Gesichtsplastic Nebst
Mammaplastik. Oxford, England: Willem A. Meeuws,
1931. P. 141.
9. Sheen, J. H. Aesthetic Rhinoplasty, 1st Ed. St. Louis:
Mosby, 1978. Pp. 26 37.
10. Rogers, B. O. Rhinoplasty. In R. M. Goldwyn (Ed.), The
Unfavorable Result in Plastic Surgery. Boston: Little,
Brown, 1972.
11. Lewis, J. R. Correction of the Supratip Hump. In D. R.
Millard (Ed.), Symposium on Corrective Rhinoplasty. St.
Louis: Mosby, 1976. P. 161.
12. Rees, T. D., and Wood-Smith, D. Cosmetic Facial Surgery.
Philadelphia: Saunders, 1973. Pp. 456 460.
13. Rees, T. D., Krupp, S., and Wood-Smith, D. Secondary
rhinoplasty. Plast. Reconstr. Surg. 46: 332, 1970.
14. Meyer, R. Secondary Rhinoplasty. In W. Berman (Ed.),
Rhinoplastic Surgery. St. Louis: Mosby, 1989. Pp. 223
226.
15. Safian, J. Fact and fallacy in rhinoplasty. Plast. Reconstr.
Surg. 12: 24, 1953.
16. Deneke, H. J., and Meyer, R. Corrective and Reconstruc-
tive Rhinoplasty. New York: Springer-Verlag, 1967. P.
451.
17. Sheen, J. H. Secondary Rhinoplasty Surgery. In D. R.
Millard (Ed.), Symposium on Corrective Rhinoplasty. St.
Louis: Mosby, 1976. Ch. 16.
18. Sheen, J. H. Secondary Rhinoplasty Surgery (Videotape
#9610). Creating the Balanced Nose. Arlington Heights,
Ill.: Plastic Surgery Educational Foundation.
19. Sheen, J. H. A new look at supratip deformity. Ann.
Plast. Surg. 3: 498, 1979.
20. Maliniac, J. W. Rhinoplasty and Restoration of Facial Con-
tour. Philadelphia: F. A. Davis, 1946. Pp. 238 240.
21. Millard, D. R. Adjuncts in augmentation mentoplasty
and corrective rhinoplasty. Plast. Reconstr. Surg. 36: 48,
1965.
22. Falces, E., and Gorney, M. Use of ear cartilage grafts for
nasal tip reconstruction. Plast. Reconstr. Surg. 50: 147,
1972.
23. Sheen, J. H. Achieving more nasal tip projection by the
use of a small autogenous vomer or septal cartilage
graft. A preliminary report. Plast. Reconstr. Surg. 36: 35,
1975.
24. Sheen, J. H. Tip graft: A 20-year retroperspective. Plast.
Reconstr. Surg. 91: 48, 1993.
25. Sheen, J. H. The radix as a reference in rhinoplasty.
Perspect. Plast. Surg. 1: 33, 1987.
26. Sheen, J. H., and Sheen, A. P. Aesthetic Rhinoplasty, 2nd
Ed. St. Louis: Mosby, 1987. Pp. 808 825.
27. Sheen, J. H. Aesthetic Rhinoplasty, 1st Ed. St. Louis:
Mosby, 1978. P. 81.
28. Sheen, J. H. Aesthetic Rhinoplasty, 1st Ed. St. Louis:
Mosby, 1978. Pp. 210 215.
29. Skoog, T. Plastic Surgery. Philadelphia: Saunders, 1974.
Pp. 233239.
30. Sheen, J. H. New Concepts in Rhinoplasty. Presented at
the Annual Meeting of the American Society of Plastic
and Reconstructive Surgeons, Boston, 1976.
1852
31. Sheen, J. H., and Sheen, A. P. Aesthetic Rhinoplasty, 2nd
Ed. St. Louis: Mosby, 1987. Pp. 530 536.
32. Sheen, J. H. Spreader graft: A method of reconstructing
the roof of the middle nasal vault following rhino-
plasty. Plast. Reconstr. Surg. 73: 230, 1984.
33. Sheen, J. H. Spreader graft revisited. Perspect. Plast. Surg.
3: 155163.
34. Gray, H. Anatomy of the Human Body, 28th Ed. Philadel-
phia: Lea & Febiger, 1967. P. 1119.
PLASTIC AND RECONSTRUCTIVE SURGERY, April 2000
35. Sheen, J. H. Aesthetic Rhinoplasty, 1st Ed. St. Louis:
Mosby, 1978. Pp. 432 461.
36. Sheen, J. H., and Sheen, A. P. Aesthetic Rhinoplasty, 2nd
Ed. St. Louis: Mosby, 1987. Pp. 988 1011.
37. Sheen, J. H., and Sheen A. P. Aesthetic Rhinoplasty, 2nd
Ed. St. Louis: Mosby, 1987. Pp. 25 45.
38. Sheen, J. H. Middle crus: The missing link in alar car-
tilage anatomy. Perspect. Plast. Surg. 5: 31, 1991.