Preface

Chapter 8 **Sutures or Resection of the Protruding End of**

Daniel G. Moina and Gabriel M. Moina

Chapter 9 **Medical Rhinoplasty – The Treatment of Mimical Patients 85**

Chapter 11 **Five Fluorouracil, Hyaluronidase, and Triamcinolone in the**

Diego Schavelzon, Guillermo Blugerman, Gabriel Wexler and

Guillermo Blugerman, Diego Schavelzon and Gabriel Wexler

Guillermo Blugerman, Diego Schavelzon, Gabriel Wexler and

**Medial Crura 69**

**VI** Contents

**Section 2 Non Surgical Techniques 83**

Alessio Redaelli

Lorena Martinez

Roberto Schale

Alessio Redaelli

Chapter 14 **Nonsurgical Rhinoplasty 165** Alexander Z. Rivkin

**Nasal Region 113**

Chapter 12 **Auxiliary Procedures in the Nasal Skin 125**

Chapter 13 **Medical Rhinoplasty – Profile Correction with**

**Resorbable Fillers 149**

Chapter 10 **Botulinum Toxin in the Nasal Area 99**

Facial harmony and aesthetics often depend on small individual characteristics in propor‐ tions, volumes and angles, requiring understanding of art and perfection in treatment, which is critical in rhinoplasty. It is an artistic procedure to give the highly demanded pro‐ portions and angles, as well as properly localized volumes as an aesthetic part of the whole face, which is the goal of beautification. Patient's age, sex, skin quality, ethnicity should be considered. Nasal tip position has great importance in all cases of rhinoplasty and especially in cases of long, short or non-proportional noses.

Over the past decades surgical and medical techniques have greatly progressed to im‐ prove and correct appearance and breathing. In recent years, due to the dynamic modern lifestyle, there is diminishing in numbers of extended traumatic rhinoplasty operations. Many mini-invasive surgical and non-surgical techniques were introduced to be more atrau‐ matic and to prevent cartilages from iatrogenic trauma and devascularization, thus permit‐ ting faster healing and a more stable result.

There is an increasing patient and doctor interest in procedures without trauma or scars. Pro‐ longed surgery, downtime, and absence from work and social life have provoked a notable development in mini-invasive techniques. Nowadays minimally invasive surgical and nonsurgical procedures have been indicated and available for the treatment of asymmetries, smaller irregularities, post-surgical defects and even airflow problems. In many primary and secondary cases, aesthetic problems exist, which do not need an open rhinoplasty and the full armament of bone-cartilage treatment that can be more traumatic than necessary.

> **Dr Nikolay Serdev, MD, PhD** Medical Center "Aesthetic Surgery, Aesthetic Medicine" Bulgaria

**Section 1**

**Surgical Techniques**

#### **Chapter 1**

## **T-Excision for Nasal Tip Rotation**

#### Nikolay P. Serdev

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/62061

#### **Abstract**

Authors "T-excision" for nasal tip rotation is used to reduce long noses as an independ‐ ent procedure or as a part of primary or secondary rhinoplasties. It consists of "en bloc" excision of the cephalic part of the greater alar cartilages and elongated caudal septum, using: 1) total retrocolumellar incision, prolonged in transcartilaginous incisions, through opposite nostrils, leaving only skin intact; 2) septal incision, perpendicular to dorsum to form correct dorsum length, prolonged into intercartilaginous incisions, through opposite nostrils, leaving only skin intact. Thus, the cephalic strip resection is done en bloc with the unnecessary excessive and prolonged septum and soft tissue. Two, three mattress transmucosal septocolumellar sutures for 2–3 weeks are enough to support healing. The T-excision technique is mini-invasive, nearly bloodless, and time-saving. It is safe; welltolerated by patients; there is no pain after surgery; no need of plaster, tampons, and ban‐ dages. Patients can return next day to social life and work.

**Keywords:** Rhinoplasty, long nose, T-excision en bloc, mini-invasive technique, elongat‐ ed septum, primary or secondary, retrocolumellar incision, transcartilaginous incision, intercartilaginous incisions, perpendicular to dorsum septal incision, no downtime

#### **1. Introduction**

Facial analysis is critical in rhinoplasty. This procedure is not an operation of a separated nose; it is an artistic surgery to give aesthetic proportions and angles, as well as properly localized volumes as an aesthetic part of the whole face, which is the goal of beautification. Patient's age, sex, skin quality, ethnicity should be considered. Nasal tip position has great importance in all cases of rhinoplasty and especially in cases of long and nonproportional nose. Cephalic strip resection of the lower lateral cartilages is performed to achieve upward tip rotation. The "en bloc" T-excision technique for adjustment of nasal tip involves new understanding of wellknown incisions, based on anatomical knowledge and specific surgical skills. It minimizes trauma, it is nearly bloodless, achieving acceptable beautifying postoperative result with no

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

downtime for the patient, requiring no plaster, no tampons, and nearly immediate return to work and social life. This technique prevents cartilages from iatrogenic trauma and devascu‐ larization and thus permits faster healing and a stable result. It includes cephalic strip resection and septal shortening (caudal septum and/or retrocolumellar mucosal elongation) en bloc.

#### **2. Anatomy**

The **greater alar cartilages** (**lower lateral cartilages**) are situated below the upper lateral nasal cartilages, forming the columella and the wings of the nostrils. The medial crura are loosely connected with the corresponding portion of the opposite cartilage. Together with the septum they stabilize the columella. In Caucasians, the columella is stable, unlike Asians, Afro-Americans, and Latino-Americans.

The author's observations in Caucasian, Asian, and Afro-American noses show that the proper dorsocolumellar angle is very near to 900 . Angles different from the right angle change the aesthetic proportions and disbalance the beauty triangle [1-9].

#### **3. Tip rotation**

Using the tripod concept, a long nose has longer superior legs (lateral crura of greater alar cartilages) and shorter central leg (medial crura and columella). Thus, the shortening of the lateral crura (cephalic strip resection of the lower lateral cartilages) gives upward tip rotation. (**NB**: Projection of the nasal tip is described by the author in the chapter, "Columella Sliding for Nasal Tip Projection.")

Tip rotation is also related to "position of the tip to the alar crease." The angle at the nasal tip has been described as the wide angle between the vertical line passing through the alar crease and a second line that is drawn from the alar crease to the nasal tip, on lateral view. The ideal tip angle is described to be 105º in females and 100º in males [7-9].

The author's opinion is that such description can hardly guide a surgeon during the process of operation. His observation is that angles that are too different from the right angle at the nasal tip disrupt the aesthetic proportions and the "beauty triangle" composed of both cheeks and chin (Figures 17, -11). If the angle is more acute, the nose appears to be long and dispro‐ portional to the whole face, and the nasal tip (when seen enface) hangs into the area of the upper lip. If the tip angle is obtuse, the nose appears short and over-rotated, as in some Asian and Afro-American noses.

#### **4. Patient consent**

If the tip angle is correct, the nostrils in enface aspect are slightly visible. Usually, patients with long noses, who have never seen their nostrils, have difficulty in accepting that nostrils should be a bit visible in frontal aspect. It should be clearly explained that in order for the nostrils to be invisible, the tip angle should be sharp (about 700 ), which is not appropriate and the nose looks long in relation to the face (Figure 1). Patients should be informed, confident, and motivated for this change. 4. Patient consent If the tip angle is correct, the nostrils in enface aspect are slightly visible. Usually, patients with long noses, who have never seen their nostrils, have difficulty in accepting that nostrils should be a bit visible in frontal aspect. It should be clearly explained that in order for the nostrils to be invisible, the tip angle should be sharp (about 70°), which is not appropriate and the nose looks long in relation to the face (Figure 1). Patients should be informed, confident, and motivated for this change.

Table 1. A. Correct aesthetic proportions and angles. The nose is proportional – 1/3 of the face. Correct 30° dorsoprofile angle and nasal tip angles. Nostrils should be a bit visible from a frontal view. B. Visibly incorrect length, angles, and lack of aesthetic section of nose and face. The nostrils are not visible from a frontal view. Long nose. 4.1. Design of the T-Excision Technique **Figure 1. A.** Correct aesthetic proportions and angles. The nose is proportional – 1/3 of the face. Correct 300 dorsopro‐ file angle and nasal tip angles. Nostrils should be a bit visible from a frontal view. **B.** Visibly incorrect length, angles, and lack of aesthetic section of nose and face. The nostrils are not visible from a frontal view. Long nose.

#### Excision of the cephalic part of the greater alar cartilages, including unnecessary prominent caudal part of septum, permits rotation of the tip, i.e., shortening the length of the nose. The T-excision technique described below is made en bloc, using a closed **4.1. Design of the T-excision technique**

downtime for the patient, requiring no plaster, no tampons, and nearly immediate return to work and social life. This technique prevents cartilages from iatrogenic trauma and devascu‐ larization and thus permits faster healing and a stable result. It includes cephalic strip resection and septal shortening (caudal septum and/or retrocolumellar mucosal elongation) en bloc.

The **greater alar cartilages** (**lower lateral cartilages**) are situated below the upper lateral nasal cartilages, forming the columella and the wings of the nostrils. The medial crura are loosely connected with the corresponding portion of the opposite cartilage. Together with the septum they stabilize the columella. In Caucasians, the columella is stable, unlike Asians, Afro-

The author's observations in Caucasian, Asian, and Afro-American noses show that the proper

Using the tripod concept, a long nose has longer superior legs (lateral crura of greater alar cartilages) and shorter central leg (medial crura and columella). Thus, the shortening of the lateral crura (cephalic strip resection of the lower lateral cartilages) gives upward tip rotation. (**NB**: Projection of the nasal tip is described by the author in the chapter, "Columella Sliding

Tip rotation is also related to "position of the tip to the alar crease." The angle at the nasal tip has been described as the wide angle between the vertical line passing through the alar crease and a second line that is drawn from the alar crease to the nasal tip, on lateral view. The ideal

The author's opinion is that such description can hardly guide a surgeon during the process of operation. His observation is that angles that are too different from the right angle at the nasal tip disrupt the aesthetic proportions and the "beauty triangle" composed of both cheeks and chin (Figures 17, -11). If the angle is more acute, the nose appears to be long and dispro‐ portional to the whole face, and the nasal tip (when seen enface) hangs into the area of the upper lip. If the tip angle is obtuse, the nose appears short and over-rotated, as in some Asian

If the tip angle is correct, the nostrils in enface aspect are slightly visible. Usually, patients with long noses, who have never seen their nostrils, have difficulty in accepting that nostrils should

. Angles different from the right angle change the

**2. Anatomy**

4 Miniinvasive Techniques in Rhinoplasty

**3. Tip rotation**

for Nasal Tip Projection.")

and Afro-American noses.

**4. Patient consent**

Americans, and Latino-Americans.

dorsocolumellar angle is very near to 900

aesthetic proportions and disbalance the beauty triangle [1-9].

tip angle is described to be 105º in females and 100º in males [7-9].

Excision of the cephalic part of the **greater alar cartilages,** including unnecessary prominent caudal part of septum, permits rotation of the tip, i.e., shortening the length of the nose. The T-excision technique described below is made en bloc, using a closed rhinoplasty approach.

rhinoplasty approach.

**Figure 2.** T-excision drawing. A. Schematic excision of 3 triangles – 2 lateral triangle excisions and one medial triangle excision perpendicular to the nasal dorsum. **B.** Result after tip rotation gives correct tip position and angles.

The initial local infiltration of anesthesia should not deform the nasal tip. 5.1. First Incision **Figure 3.** A. Schematic pyramid in a long nose. **B.** T-excision en bloc, including cephalic part of the greater alar carti‐ lages and elongated caudal septum. **C.** Tip of the nose rotates easily. **D.** Two to three transmucosal mattress sutures of columella to caudal septum are enough to hold the tip in position and guarantee good fixation for healing. Stitches are removed after 2–3 weeks.

### **5. T-excision: Surgical technique**

The initial local infiltration of anesthesia should not deform the nasal tip.

#### **5.1. First incision**

**A total retrocolumellar incision** is performed to separate the columella from the septum. In cases of dropping columella, this incision should follow a desired design. To remove dropping columella, the incision should leave an equal thickness along the length of the columella. Any other form should be previously designed according to patient's desire and informed consent. The **retrocolumellar incision** is then **prolonged into transcartilaginous incision**, which separates the lateral wing of the greater alar cartilage in cephalic and distal parts. In the past, the author used methylene blue dye to mark the transcartilaginous incision, but it is not always easy to exactly reflect the line that has been drawn on the external skin. Actually, this is not totally necessary, because the transcartilaginous incision is a prolongation of the retrocolu‐ mellar incision in each nostril, parallel to the nostril border. The transcartilaginous incision is performed in each nostril through the opposite nostril, using the opening of the retrocolumellar incision – this gives better visibility to the surgeon and permits for better orientation. This incision cuts mucosa and cartilages, leaving the skin intact. To be precise, both alae nasi are held with thumb and index of the other hand, feeling the scalpel below the skin with the fingertips. Transcartilaginous incisions should be located 4–5 mm cephalic to the caudal margin of the lateral crus of the lower cartilages. Finishing both transcartilaginous incisions and leaving only the skin intact, one has separated the lateral wings of the greater alar cartilage in cephalic and distal parts, whereupon the cephalic parts will be removed with the T-excision en bloc.

#### **5.2. Second incision**

The reduction of the length of the nose in the caudal septum region is selective. The second incision line is a **"90o-to-dorsum" septal incision**, starting from a selected dorsum point in a downward direction, perpendicular to the nasal dorsum to meet the retrocolumellar incision (forming the medial excision triangle), which usually happens above the nasal spine. This incision is total, including caudal septum and both sides of mucosa at once (or, in many cases, only elongated mucosa). The "90o -to-dorsum" septal incision is then prolonged into intercar‐ tilaginous incisions in both nostrils, each one through the opposite nostril using the opening of the "90o -to-dorsum" septal incision. The intercartilaginous incision should be placed minimum 2 mm caudal to the valve on the lateral crura side, in order to prevent nasal valve stenosis. The intercartilaginous incision in this technique leaves intact only the skin under the fingertips of the guiding hand, as described above. Intercartilaginous incisions meet the transcartilaginous incisions laterally, forming the 2 lateral triangles of the T-excision. Thus, cephalic parts of greater alar cartilages are separated together with the unnecessary elongated septum (or only mucosa), forming 3 triangles of the "T-excision en bloc": two lateral triangles in the nostrils and one medial triangle in the septal retrocolumellar part. The tissue of the "T-

6

excision en bloc" is still fixed to the alar skin from which it will be separated and removed by using blunt tip scissors, guided by the other hand to prevent the alar skin from trauma.

**5. T-excision: Surgical technique**

6 Miniinvasive Techniques in Rhinoplasty

**5.1. First incision**

en bloc.

of the "90o

**5.2. Second incision**

only elongated mucosa). The "90o

The initial local infiltration of anesthesia should not deform the nasal tip.

**A total retrocolumellar incision** is performed to separate the columella from the septum. In cases of dropping columella, this incision should follow a desired design. To remove dropping columella, the incision should leave an equal thickness along the length of the columella. Any other form should be previously designed according to patient's desire and informed consent. The **retrocolumellar incision** is then **prolonged into transcartilaginous incision**, which separates the lateral wing of the greater alar cartilage in cephalic and distal parts. In the past, the author used methylene blue dye to mark the transcartilaginous incision, but it is not always easy to exactly reflect the line that has been drawn on the external skin. Actually, this is not totally necessary, because the transcartilaginous incision is a prolongation of the retrocolu‐ mellar incision in each nostril, parallel to the nostril border. The transcartilaginous incision is performed in each nostril through the opposite nostril, using the opening of the retrocolumellar incision – this gives better visibility to the surgeon and permits for better orientation. This incision cuts mucosa and cartilages, leaving the skin intact. To be precise, both alae nasi are held with thumb and index of the other hand, feeling the scalpel below the skin with the fingertips. Transcartilaginous incisions should be located 4–5 mm cephalic to the caudal margin of the lateral crus of the lower cartilages. Finishing both transcartilaginous incisions and leaving only the skin intact, one has separated the lateral wings of the greater alar cartilage in cephalic and distal parts, whereupon the cephalic parts will be removed with the T-excision

The reduction of the length of the nose in the caudal septum region is selective. The second incision line is a **"90o-to-dorsum" septal incision**, starting from a selected dorsum point in a downward direction, perpendicular to the nasal dorsum to meet the retrocolumellar incision (forming the medial excision triangle), which usually happens above the nasal spine. This incision is total, including caudal septum and both sides of mucosa at once (or, in many cases,

tilaginous incisions in both nostrils, each one through the opposite nostril using the opening

minimum 2 mm caudal to the valve on the lateral crura side, in order to prevent nasal valve stenosis. The intercartilaginous incision in this technique leaves intact only the skin under the fingertips of the guiding hand, as described above. Intercartilaginous incisions meet the transcartilaginous incisions laterally, forming the 2 lateral triangles of the T-excision. Thus, cephalic parts of greater alar cartilages are separated together with the unnecessary elongated septum (or only mucosa), forming 3 triangles of the "T-excision en bloc": two lateral triangles in the nostrils and one medial triangle in the septal retrocolumellar part. The tissue of the "T-



The surrounding skin is slightly undermined with the scissors in 2–3 mm distance to permit rotation of the nasal tip and skin adaptation. to permit rotation of the nasal tip and skin adaptation.

Figure 4: T-excision en bloc of 3 triangles: A. Transcartilaginous and intercartilaginous incisions form the 2 lateral triangles of the T-excision. The retrocolumellar and the "90<sup>o</sup> -to-dorsum" septal incision form the medial triangle of caudal septum excision. The 2 lateral triangles should include the cephalic strip of greater alar cartilages. B. Scheme of excised tissue. C. Excised T-formation en bloc. This particular T-excision en bloc includes caudal septum in the medial triangle and cephalic part of the greater alar cartilages in the lateral triangles. D. Humpectomy and T-excision will give the new profile form of the nose. **Figure 4.** T-excision en bloc of 3 triangles: **A.** Transcartilaginous and intercartilaginous incisions form the 2 lateral tri‐ angles of the T-excision. The retrocolumellar and the "90o -to-dorsum" septal incision form the medial triangle of cau‐ dal septum excision. The 2 lateral triangles should include the cephalic strip of greater alar cartilages. **B.** Scheme of excised tissue. **C.** Excised T-formation en bloc. This particular T-excision en bloc includes caudal septum in the medial triangle and cephalic part of the greater alar cartilages in the lateral triangles. **D.** Humpectomy and T-excision will give the new profile form of the nose.

T-excision could be used separately in long noses, or as a part of rhinoplasty with hump removal and other additional techniques. The operation is ambulatory, under local anesthesia. The author uses additional IV sedation. The procedure is almost bloodless and atraumatic. Two to three transmucosal mattress sutures are used to fix columella to septum. Stitches are removed after 2–3 weeks, if not absorbed. There is no need of any bandages or tampons. Patients return to their social life almost immediately.

A. B. In aesthetics, there is another important aspect – the "beauty triangle," forming the mid and lower face beauty. It includes the two cheekbones and the chin. The tip of the nose should not disrupt the upper line of the triangle connecting the projection of the two cheekbones, i.e., its prominence has to be on the line between the two cheekbones. Thus, the nasal tip presents an important aesthetic facial volume, forming a straight line together with the volume of the cheekbones (Figure 7).

Table 5. A. Total retrocolumellar incision. B. The retrocolumellar incision is prolonged into intercartilaginous incisions both sides through the opposite nostril, using the opening of the retrocolumellar incision. C. Second septal perpendicular to dorsum incision. It will be prolonged into 2 intercartilaginous incisions. D. The T-Excision en bloc is separated from the dorsal skin with a blunt tip scissor. E The T-excision is separated and removed, F. The transmucosal mattress suture is performed horizontally if the dome is symmetric (or parallel to the asymmetry). G. The **Figure 5. A.** Total retrocolumellar incision. **B.** The retrocolumellar incision is prolonged into intercartilaginous inci‐ sions both sides through the opposite nostril, using the opening of the retrocolumellar incision. **C.** Second septal per‐ pendicular to dorsum incision. It will be prolonged into 2 intercartilaginous incisions. **D.** The T-Excision en bloc is separated from the dorsal skin with a blunt tip scissor. **E** The T-excision is separated and removed, **F.** The transmucos‐ al mattress suture is performed horizontally if the dome is symmetric (or parallel to the asymmetry). **G.** The transmu‐ cosal septocolumellar suture is ready to be knotted. **H.** Transmucosal domal suture of medial crura for tip refinement. **I.** Result after atraumatic, nearly bloodless T-excision procedure for nasal tip rotation.

atraumatic, nearly bloodless T-excision procedure for nasal tip rotation.

atraumatic, nearly bloodless T-excision procedure for nasal tip rotation.

transmucosal septocolumellar suture is ready to be knotted. H. Transmucosaldomal suture of medial crura for tip refinement. I. Result after

In aesthetics, there is another important aspect – the "beauty triangle," forming the mid and lower face beauty. It includes the two cheekbones and the chin. The tip of the nose should not disrupt the upper line of the triangle connecting the projection of the two cheekbones, i.e., its prominence has to be on the line between the two cheekbones. Thus, the nasal tip presents an important Table 6. A. The unnecessary length of septum will be resected. B. The nasal tip is rotated and a correct tip angle is obtained, adapting the nose into 1/3 of the length of the face. T-excision could be used separately in long noses, or as a part of rhinoplasty with hump removal and other additional techniques. **Figure 6. A**. The unnecessary length of septum will be resected. **B.** The nasal tip is rotated and a correct tip angle is obtained, adapting the nose into 1/3 of the length of the face.

aesthetic facial volume, forming a straight line together with the volume of the cheekbones (Figure 7).

The operation is ambulatory, under local anesthesia. The author uses additional IV sedation. The procedure is almost bloodless and atraumatic. Two to three transmucosal mattress sutures are used to fix columella to septum. Stitches are removed after 2–3 weeks,

Table 7. A case of a long nose. A. Before. The long nose causes incorrect facial proportions. The beauty triangle is disrupted, forming 2 incorrect triangles. The facial features of the patient's face are nice but nearly invisible because of the long and disproportional nose. B. After T-excision for nasal tip rotation and columella sliding for tip projection. The nose is shortened to fit into 1/3 of the face. Correct aesthetic proportions (three equal parts of the face), correct 30° dorsoprofile angle, and nasal tip volume on the line of the cheekbone prominence. The tape is not necessary – it was requested by the patient (a ballerina) to make the operation visible and thus protect her from trauma at work. The result is beautification of the face by correct proportions and angles and visible beauty triangle. **Figure 7.** A case of a long nose. **A.** Before. The long nose causes incorrect facial proportions. The beauty triangle is disrupted, forming 2 incorrect triangles. The facial features of the patient's face are nice but nearly invisible because of the long and disproportional nose. **B.** After T-excision for nasal tip rotation and columella sliding for tip projection. The nose is shortened to fit into 1/3 of the face. Correct aesthetic proportions (three equal parts of the face), correct 300 dorsoprofile angle, and nasal tip volume on the line of the cheekbone prominence. The tape is not necessary – it was requested by the patient (a ballerina) to make the operation visible and thus protect her from trauma at work. The re‐ sult is beautification of the face by correct proportions and angles and visible beauty triangle. A. B. Table 7. A case of a long nose. A. Before. The long nose causes incorrect facial proportions. The beauty triangle is disrupted, forming 2 incorrect triangles. The facial features of the patient's face are nice but nearly invisible because of the long and disproportional nose. B. After T-excision for nasal tip rotation and columella sliding for tip projection. The nose is shortened to fit into 1/3 of the face. Correct aesthetic proportions (three equal parts of the face), correct 30° dorsoprofile angle, and nasal tip volume on the line of the cheekbone prominence. The tape is not necessary – it was requested by the patient (a ballerina) to make the operation visible and thus protect her from trauma at work. The result is beautification of the face

by correct proportions and angles and visible beauty triangle.

#### **6. Clinical cases**

A. B.

8 Miniinvasive Techniques in Rhinoplasty

C. D.

E. F.

G. H.

I.

**I.** Result after atraumatic, nearly bloodless T-excision procedure for nasal tip rotation.

Table 5. A. Total retrocolumellar incision. B. The retrocolumellar incision is prolonged into intercartilaginous incisions both sides through the opposite nostril, using the opening of the retrocolumellar incision. C. Second septal perpendicular to dorsum incision. It will be prolonged into 2 intercartilaginous incisions. D. The T-Excision en bloc is separated from the dorsal skin with a blunt tip scissor. E The T-excision is separated and removed, F. The transmucosal mattress suture is performed horizontally if the dome is symmetric (or parallel to the asymmetry). G. The **Figure 5. A.** Total retrocolumellar incision. **B.** The retrocolumellar incision is prolonged into intercartilaginous inci‐ sions both sides through the opposite nostril, using the opening of the retrocolumellar incision. **C.** Second septal per‐ pendicular to dorsum incision. It will be prolonged into 2 intercartilaginous incisions. **D.** The T-Excision en bloc is separated from the dorsal skin with a blunt tip scissor. **E** The T-excision is separated and removed, **F.** The transmucos‐ al mattress suture is performed horizontally if the dome is symmetric (or parallel to the asymmetry). **G.** The transmu‐ cosal septocolumellar suture is ready to be knotted. **H.** Transmucosal domal suture of medial crura for tip refinement.

Immediately after operation, local anesthesia and postoperative edema raise the dorsum and make the nasolabial angle obtuse, which gives an impression of over-rotation of the nasal tip.

demonstrated.

It is a false impression. With the diminishing of the edema in the first 5–7 days, the correct angle takes shape and the tip falls into place. 6. Clinical cases Immediately after operation, local anesthesia and postoperative edema raise the dorsum and make the nasolabial angle obtuse,

7 days, the correct angle takes shape and the tip falls into place.

which gives an impression of over-rotation of the nasal tip. It is a false impression. With the diminishing of the edema in the first 5–

Table 8. T-excision for nasal tip rotation. Immediate result in a case of a long and disproportional nose. A. Before. Long nose with hanging columella, resulting in a disproportional face, containing some nice features, nearly invisible to observers. B. After. Immediate result, a few minutes after T-excision, nasal tip and lower third refinement by transcutaneous Serdev Sutures®. Swelling could be visible to specialists but not to the public. Aesthetic proportions (three equal parts of the face) are present. The result is beautification of the face – previously invisible beauty is now demonstrated. **Figure 8.** T-excision for nasal tip rotation. Immediate result in a case of a long and disproportional nose. **A.** Before. Long nose with hanging columella, resulting in a disproportional face, containing some nice features, nearly invisible to observers. **B.** After. Immediate result, a few minutes after T-excision, nasal tip and lower third refinement by trans‐ cutaneous Serdev Sutures®. Swelling could be visible to specialists but not to the public. Aesthetic proportions (three equal parts of the face) are present. The result is beautification of the face – previously invisible beauty is now demon‐ strated. A. B. Table 8. T-excision for nasal tip rotation. Immediate result in a case of a long and disproportional nose. A. Before. Long nose with hanging columella, resulting in a disproportional face, containing some nice features, nearly invisible to observers. B. After. Immediate result, a few minutes after T-excision, nasal tip and lower third refinement by transcutaneous Serdev Sutures®. Swelling could be visible to specialists but not to the

visible – nasal tip on the line of the cheekbone prominence. The result includes: proper aesthetic proportions of the face (three equal parts of the face); tip is correctly rotated; and the nose is proportional. The tip is projected to fit to the proper 30°dorsoprofile angle; the chin is augmented using her own collected tissue, without foreign materials; jaw line and submandibular line are stretched; lower face proportions are corrected: lip to chin ratio (incl. lower lip) is 1:2; straight noble profile is present. The immediate result presents the beauty of the face. Table 9. Immediate result (Braunol disinfection is still not totally cleaned) after nasal tip rotation by T-excision and chin enhancement by Serdev Suture® in a case of a long nose, small chin (retrognatia), and improper ratio in the lower part of the face (between upper lip and chin); A. Before. The upper face is nice, but the nose is long, the chin is small and disproportional. Straight line of the noble profile is missing. Due to short mandible and reduced skeleton support, surrounding and submandibular tissue is hanging; B. After. Immediate result after T-excision for nasal tip rotation, columella sliding for tip projection and chin augmentation collecting her own tissue using Serdev Suture® volumizing method. Correct volumes are visible – nasal tip on the line of the cheekbone prominence. The result includes: proper aesthetic proportions of the face (three equal parts of the face); tip is correctly rotated; and the nose is proportional. The tip is projected to fit to the proper 30°dorsoprofile angle; the chin is augmented using her own collected tissue, without foreign materials; jaw line and submandibular line are stretched; lower face proportions are corrected: lip to chin ratio (incl. lower lip) is 1:2; straight noble profile is present. The immediate result presents the beauty of the face. **Figure 9.** Immediate result (Braunol disinfection is still not totally cleaned) after nasal tip rotation by T-excision and chin enhancement by Serdev Suture® in a case of a long nose, small chin (retrognatia), and improper ratio in the lower part of the face (between upper lip and chin); **A.** Before. The upper face is nice, but the nose is long, the chin is small and disproportional. Straight line of the noble profile is missing. Due to short mandible and reduced skeleton support, surrounding and submandibular tissue is hanging; **B.** After. Immediate result after T-excision for nasal tip rotation, columella sliding for tip projection and chin augmentation collecting her own tissue using Serdev Suture® volumizing method. Correct volumes are visible – nasal tip on the line of the cheekbone prominence. The result includes: proper

columella sliding for tip projection and chin augmentation collecting her own tissue using Serdev Suture® volumizing method. Correct volumes are

public. Aesthetic proportions (three equal parts of the face) are present. The result is beautification of the face – previously invisible beauty is now

aesthetic proportions of the face (three equal parts of the face); tip is correctly rotated; and the nose is proportional. The tip is projected to fit to the proper 300 dorsoprofile angle; the chin is augmented using her own collected tissue, with‐ out foreign materials; jaw line and submandibular line are stretched; lower face proportions are corrected: lip to chin ratio (incl. lower lip) is 1:2; straight noble profile is present. The immediate result presents the beauty of the face.

It is a false impression. With the diminishing of the edema in the first 5–7 days, the correct

A. B.

**Figure 8.** T-excision for nasal tip rotation. Immediate result in a case of a long and disproportional nose. **A.** Before. Long nose with hanging columella, resulting in a disproportional face, containing some nice features, nearly invisible to observers. **B.** After. Immediate result, a few minutes after T-excision, nasal tip and lower third refinement by trans‐ cutaneous Serdev Sutures®. Swelling could be visible to specialists but not to the public. Aesthetic proportions (three equal parts of the face) are present. The result is beautification of the face – previously invisible beauty is now demon‐

A. B.

A. B.

A. B.

**Figure 9.** Immediate result (Braunol disinfection is still not totally cleaned) after nasal tip rotation by T-excision and chin enhancement by Serdev Suture® in a case of a long nose, small chin (retrognatia), and improper ratio in the lower part of the face (between upper lip and chin); **A.** Before. The upper face is nice, but the nose is long, the chin is small and disproportional. Straight line of the noble profile is missing. Due to short mandible and reduced skeleton support, surrounding and submandibular tissue is hanging; **B.** After. Immediate result after T-excision for nasal tip rotation, columella sliding for tip projection and chin augmentation collecting her own tissue using Serdev Suture® volumizing method. Correct volumes are visible – nasal tip on the line of the cheekbone prominence. The result includes: proper

ratio (incl. lower lip) is 1:2; straight noble profile is present. The immediate result presents the beauty of the face.

ratio (incl. lower lip) is 1:2; straight noble profile is present. The immediate result presents the beauty of the face.

Table 9. Immediate result (Braunol disinfection is still not totally cleaned) after nasal tip rotation by T-excision and chin enhancement by Serdev Suture® in a case of a long nose, small chin (retrognatia), and improper ratio in the lower part of the face (between upper lip and chin); A. Before. The upper face is nice, but the nose is long, the chin is small and disproportional. Straight line of the noble profile is missing. Due to short mandible and reduced skeleton support, surrounding and submandibular tissue is hanging; B. After. Immediate result after T-excision for nasal tip rotation, columella sliding for tip projection and chin augmentation collecting her own tissue using Serdev Suture® volumizing method. Correct volumes are visible – nasal tip on the line of the cheekbone prominence. The result includes: proper aesthetic proportions of the face (three equal parts of the face); tip is correctly rotated; and the nose is proportional. The tip is projected to fit to the proper 30°dorsoprofile angle; the chin is augmented using her own collected tissue, without foreign materials; jaw line and submandibular line are stretched; lower face proportions are corrected: lip to chin

Table 9. Immediate result (Braunol disinfection is still not totally cleaned) after nasal tip rotation by T-excision and chin enhancement by Serdev Suture® in a case of a long nose, small chin (retrognatia), and improper ratio in the lower part of the face (between upper lip and chin); A. Before. The upper face is nice, but the nose is long, the chin is small and disproportional. Straight line of the noble profile is missing. Due to short mandible and reduced skeleton support, surrounding and submandibular tissue is hanging; B. After. Immediate result after T-excision for nasal tip rotation, columella sliding for tip projection and chin augmentation collecting her own tissue using Serdev Suture® volumizing method. Correct volumes are visible – nasal tip on the line of the cheekbone prominence. The result includes: proper aesthetic proportions of the face (three equal parts of the face); tip is correctly rotated; and the nose is proportional. The tip is projected to fit to the proper 30°dorsoprofile angle; the chin is augmented using her own collected tissue, without foreign materials; jaw line and submandibular line are stretched; lower face proportions are corrected: lip to chin

Table 8. T-excision for nasal tip rotation. Immediate result in a case of a long and disproportional nose. A. Before. Long nose with hanging columella, resulting in a disproportional face, containing some nice features, nearly invisible to observers. B. After. Immediate result, a few minutes after T-excision, nasal tip and lower third refinement by transcutaneous Serdev Sutures®. Swelling could be visible to specialists but not to the public. Aesthetic proportions (three equal parts of the face) are present. The result is beautification of the face – previously invisible beauty is now

Table 8. T-excision for nasal tip rotation. Immediate result in a case of a long and disproportional nose. A. Before. Long nose with hanging columella, resulting in a disproportional face, containing some nice features, nearly invisible to observers. B. After. Immediate result, a few minutes after T-excision, nasal tip and lower third refinement by transcutaneous Serdev Sutures®. Swelling could be visible to specialists but not to the public. Aesthetic proportions (three equal parts of the face) are present. The result is beautification of the face – previously invisible beauty is now

7 days, the correct angle takes shape and the tip falls into place.

7 days, the correct angle takes shape and the tip falls into place.

Immediately after operation, local anesthesia and postoperative edema raise the dorsum and make the nasolabial angle obtuse, which gives an impression of over-rotation of the nasal tip. It is a false impression. With the diminishing of the edema in the first 5–

Immediately after operation, local anesthesia and postoperative edema raise the dorsum and make the nasolabial angle obtuse, which gives an impression of over-rotation of the nasal tip. It is a false impression. With the diminishing of the edema in the first 5–

angle takes shape and the tip falls into place. 6. Clinical cases

10 Miniinvasive Techniques in Rhinoplasty

6. Clinical cases

demonstrated.

demonstrated.

strated.

Table 10.A. Before. Aquiline long nose, short upper lip, and prognatic jaw. B. One year after T-excision for nasal tip rotation, humpectomy, digital fracture instead of lateral osteotomy, caudal septum and nasal spine resection for upper lip elongation, upper lip volumizing by Serdev Suture®. Changes include: proper angles of the nose; it occupies 1/3 of the face, correct aesthetic proportions of the face (three equal parts); the upper lip is elongated and brought forward (thus, the prognatic jaw is included in the correct proportions); proportions of the lower face are in a good ratio; a straight noble profile is present. The result is beautification of the face. **Figure 10. A.** Before. Aquiline long nose, short upper lip, and prognatic jaw. **B.** One year after T-excision for nasal tip rotation, humpectomy, digital fracture instead of lateral osteotomy, caudal septum and nasal spine resection for upper lip elongation, upper lip volumizing by Serdev Suture®. Changes include: proper angles of the nose; it occupies 1/3 of the face, correct aesthetic proportions of the face (three equal parts); the upper lip is elongated and brought forward (thus, the prognatic jaw is included in the correct proportions); proportions of the lower face are in a good ratio; a straight noble profile is present. The result is beautification of the face.

elongated caudal septum resection can rotate the nasal tip to obtain correct proportions of the face. The procedure takes a very short time, even shorter than a medical injection rhinoplasty. It is atraumatic, nearly bloodless, does not require plaster fixation, tampons, and downtime. The results are permanent. **Figure 11.** A disproportionally long nose is shortened by tip rotation via T-excision to obtain 3 equal parts of the face with correct angles of the nose.

very small or lack of trauma to the greater alar cartilages and surrounding tissue.

7.1. In cases of over-rotation or short upper lip

volumes, and angles of the face. The nose cannot be separated aesthetically. T-excision en bloc, including cephalic strip and

Patients return to work and social life almost immediately. There is no bruising. Edema is not visible for observers. Swelling can minimally change the tip position only in the first 5–7 days. After that it becomes natural and in the right position. T-excision is the shortest rhinoplasty procedure to correct long noses and dropping columella, with the most stable and permanent results, due to

#### **7. Conclusion**

Beautification is a work of art. Rhinoplasty, including shortening of a long nose, aims at obtaining exact aesthetic proportions, volumes, and angles of the face. The nose cannot be separated aesthetically. T-excision en bloc, including cephalic strip and elongated caudal septum resection can rotate the nasal tip to obtain correct proportions of the face. The proce‐ dure takes a very short time, even shorter than a medical injection rhinoplasty. It is atraumatic, nearly bloodless, does not require plaster fixation, tampons, and downtime. The results are permanent.

Patients return to work and social life almost immediately. There is no bruising. Edema is not visible for observers. Swelling can minimally change the tip position only in the first 5–7 days. After that it becomes natural and in the right position. T-excision is the shortest rhinoplasty procedure to correct long noses and dropping columella, with the most stable and permanent results, due to very small or lack of trauma to the greater alar cartilages and surrounding tissue.

#### **7.1. In cases of over-rotation or short upper lip**

If the upper lip is shortened by a too long septum or shortening of the whole pyramid of the nose is necessary, the prominent posterior septal angle can be excised, together with the prominence of the anterior nasal spine. This maneuver deepens the nasolabial angle. It elongates the upper lip and can also correct an over-rotated nasal tip (see Chapter 2)

#### **Author details**

Nikolay P. Serdev\*

Address all correspondence to: serdev@gmail.com

New Bulgarian University, Sofia, Medical Centre "Aesthetic Surgery and Aesthetic Medicine," Sofia, Bulgaria

#### **References**


**7. Conclusion**

12 Miniinvasive Techniques in Rhinoplasty

permanent.

**Author details**

Nikolay P. Serdev\*

**References**

Medicine," Sofia, Bulgaria

**7.1. In cases of over-rotation or short upper lip**

Address all correspondence to: serdev@gmail.com

Aires – Argentina, Oct. 31–Nov. 1, 1999

lig Clinic, Caracas, Venezuela, Nov. 1999

Beautification is a work of art. Rhinoplasty, including shortening of a long nose, aims at obtaining exact aesthetic proportions, volumes, and angles of the face. The nose cannot be separated aesthetically. T-excision en bloc, including cephalic strip and elongated caudal septum resection can rotate the nasal tip to obtain correct proportions of the face. The proce‐ dure takes a very short time, even shorter than a medical injection rhinoplasty. It is atraumatic, nearly bloodless, does not require plaster fixation, tampons, and downtime. The results are

Patients return to work and social life almost immediately. There is no bruising. Edema is not visible for observers. Swelling can minimally change the tip position only in the first 5–7 days. After that it becomes natural and in the right position. T-excision is the shortest rhinoplasty procedure to correct long noses and dropping columella, with the most stable and permanent results, due to very small or lack of trauma to the greater alar cartilages and surrounding tissue.

If the upper lip is shortened by a too long septum or shortening of the whole pyramid of the nose is necessary, the prominent posterior septal angle can be excised, together with the prominence of the anterior nasal spine. This maneuver deepens the nasolabial angle. It

elongates the upper lip and can also correct an over-rotated nasal tip (see Chapter 2)

New Bulgarian University, Sofia, Medical Centre "Aesthetic Surgery and Aesthetic

[1] Serdev NP. Principles of Face Beautification. Ier Congreso International De Medicina y Cirugia Cosmetica, The South American Academy of Cosmetic Surgery, Buenos

[2] Serdev NP. Sliding of the Columella by the Serdev Technique. Live Surgery Work‐ shop, The International Academy of Aesthetic Surgery and Aesthetic Medicine, Kru‐

