Contracted Short NoseCorrection

CHAPTER | 10

I. What is a contractured nose?

II. Causes of contracture

III. Correction of a contractured short nose

ASIAN RHINOPLASTY

I. What is a contractured nose?

Contracture is a state that causes deformity internally and externally of the nose due to contraction of scar tissue

or capsule formation. The internal and external deformity caused by contracture is as follows.

1. Deformity due to the contracture of alar cartilage

a. If alar cartilage is pulled up cephallically, the nasal tip is lifted in the forehead direction and the nose length

becomes short. At the same time, the nostrils are excessively seen. This is called deformity of an upturned

nose (Fig. 10-1).

b. In case of depression due to contracture at one or both alar cartilages, it causes pinched tip and in severe

cases, the external or internal valve is collapsed, which may cause nasal obstruction(Fig. 10-2).

2. Deformity due to the contracture of the soft tissue of nasal dorsum

In cases where contracture forms along both edges of the silicone implant of nasal dorsum, both edges of the

implant are shown to be in an 11-shape(Fig. 10-3). In various fields of rhinoplasty, correction for a contracted

upturned nose is considered to be one of the most technically demending surgery. Followings are the reasons that

make this surgery difficult (Fig. 10-4).

a. Presence of excess scar tissue inside the nose

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Contracted Short Nose Correction

ASIAN RHINOPLASTYCHAPTER | 10

II. Causes of contracture

1. Multiple previous surgery

Among Asians, many patient have had multiple rhinoplasty operations. In those patient, scar tissues are

excessively generated and can develope to contracture.

2. Infection

A single infection implies possibility of causing more serious contracture than that of several past surgeries.

3. Effects from patient’s personal constitution

There are some patients who have contracture even without previous history of infection or multiful surgeries. In

such case, they are considered to have tissue properties that generate excessive scar tissue and contracture.

III. Correction of a contractured short nose

1. Timing of surgery

It is recommended to conduct the surgery at least 1 year after the previous surgery. However, earlier surgery is

promoted in the following cases.

a. A case that progresses more contracture with time

b. A case having risk of implant extrusion

c. A case accompanying infection

d. A case where earlier surgery is needed as the patient shows severe avoidance in social life

2. Anesthesia

In general, surgery is executed under intravenous sedation. Propofol, Dormicum, Ketamine are used, and the

type and volume of the drug are decided by the preference and experience of the surgeon. Under sedation, local

anesthetics is injected to the nose. 2% lidocaine mixed with 1: 100,000 epinephrine is used but in case of a surgery

that takes longer hours, 0.5% bupivacaine is also mixed. The injection should be administered extensively

throughout all surgical fields including the columella, nasal dorsum, nasal septum, etc. (Fig. 10-5).

Contained epinephrine reduces bleeding in the operation field, and extends the duration of action of local

anesthetics. Also, it effectively reduces systemic effect of the anesthetics. If the operation is expected to take

excessively long hours or needs to harvest costal cartilage, general anesthesia may be considered.

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b. Damaged structures due to previous surgeries or infection

c. Difficulty of lengthening the contractured skin or mucosa

d. Limited type of extractable graft cartilage as cartilages were used up from previous operators.

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Fig. 10-1 Contracted nose : upturnedshort nose with excess nostril visibility

Fig. 10-2 Contracted nose : external valve contracture Fig. 10-3 Contracted nose: visibleimplant contour

Fig. 10-4 Three enemies of rhinoplasty surgeons dealing withcontracted short nose a: scar tissue around the cartilage framework, b: tight skin due to scar/capsule adhesion, c: graft handicap

a b

c

4. Dissection

Dissection on alar cartilage and scar tissue has to be done after the incision of nasal columella and intranasal

cavity. Due to the adhesion of severe scar tissue, this process of dissection is very challenging and takes a long time.

Nonetheless, it is the most important process for the correction of a contractured nose; thus, dissection must be fully

conducted patiently.

In primary short nose correction, moving the alar cartilage toward the caudal direction of the nose by fully

dissecting it from upper lateral cartilage is the most important process of the opertion. However, it is difficult to

expect a good outcome for a contractured nose only through mere dissection of alar cartilage and movement of its

position. It is because short nose correction is completed as the skin is fully extended as in lengthening the alar

cartilage, but in a contractured nose, the scar tissue adheres to the skin and makes the skin lengthening difficult.

Thus, it is very important to fully separate the scar tissue from the skin. The dissection of the scar tissue must be

conducted by dual plane dissection (Fig. 10-9).

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3. Incision

The operation for a contracted nose always has to be done throught open rhinoplasty incision. Horizontal

incision is made at the narrowest area of the columella. The shape of the horizontal incision can be inverted V-

shape or stair-shape, but the author prefers inverted V- shape (Fig. 10-6). In case of previous a scar in the columella

caused by a past surgery, incision is conducted along the existing scar(Fig. 10-7). Sometimes, incision has to be

made in the caudal position away from the existing incision scar if the incision along the previous scar is inappropriate.

Such case implies potential risk of tissue necrosis between the new and old incision lines; thus, in such a case, it is

advised to conduct surgery at least 1 year after the previous incision.

Incision line of the columella is extended into the nostril. It is necessary not to damage the soft triangle of the

nose. If incision is made directly to the soft triangle, there is a possibility of deformity or asymmetry of the nostrils

due to notching. Therefore, incision should be placed about 2~3mm inside from the alar rim not to directly damage

the soft triangle. The incision line inside the nasal cavity is extended along the inferior border of lateral crus up to

the area of the hinge complex(Fig. 10-8). The longer the incision line in the nasal cavity is, the more the extension of

the skin and alar cartilage is possible.

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Fig. 10-5 Local anesthetics infiltration

Fig. 10-6 Inverted V-incision Fig. 10-7 Incision along the previous open rhinoplasty scar

Fig. 10-8 Incision extended upto the hinge complex

Dissection starts from the end of skin-scar(capsule) flap. Dissection of the scar tissue or capsule tissue from the

skin layer must be carefully conducted not to injure the skin integrity and dermal circulation. Dissection should be

as wide as possible to maximize mobility of the skin. Once superficial plane dissection is completed, skin flap and

scar-capsule flap are separated to form two flaps(Fig. 10-12).

3) Alar cartilage release

Once dual plane dissection is completed, alar cartilage is separated from upper lateral cartilage. The connective

tissue between the two cartilages and cicatrix tissue are fully disconnected. By doing so, alar cartilage is fully

separated from the upper lateral cartilage to enable lengthening(Fig. 10-13).

The scar tissue that limits the movement of alar cartilage in a contractured nose always exists even in the

membranous septum, and this area should be fully dissected to release the scar tissue. Otherwise, there is difficulty

in moving caudally and thus lengthening the alar cartilage; therefore, dissection of this area is considered to be very

important. It is necessary to fully dissect all cicatrix tissue, leaving a thin membrane(Fig. 10-14). To disconnect the

accessory ligament after dissecting around the hinge complex helps the movement of alar cartilage (Fig. 10-15).

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1) 1st stage of dual plane dissection: deep plane dissection

Dissection starts from the incision line of nasal columella. The dissection is progressed toward the nasal tip while

separating and lifting the skin and scar tissue from medial crus of the alar cartilage. It is relatively easy to conduct

dissection at the starting area but as it reaches to nasal tip, dissection becomes difficult due to the scar tissue

adhesion caused by various surgical manipulations on the tip in the past. However, when the dissection is patiently

and carefully conducted, it is possible to separate the scar tissue from the alar cartilage and elevate the scar

tissue/skin envelope as one block.

After separating scar-capsule tissue from the alar cartilage, dissection is progressed towards a more cephalic

direction to the upper lateral cartilage and then radix forming a wide pocket under the scar tissue-capsule. This is

called deep plane dissection. By doing so, the dissected and elevated flap contains both skin envelope and capsule-

scar tissue as one block(Fig. 10-10).

2) 2nd stage of dual plane dissection: Superficial plane dissection (Fig, 10-11)

After completing deep plane dissection, superficial plane dissection is conducted. Superficial plane dissection is

a procedure that separates between the skin and scar tissue combined in a single flap. When failure to do so, the

skin cannot be fully extended as much as the length of the extended alar cartilage due to scar tissue holding the skin

envelope.

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Fig. 10-9 Contracted short nose correction including dual plane dissection of the skin-scar tissue envelopeb: deep plane dissection, c: alar cartilage release, d: deep plane dissection, e: septal extension graft

a b c

d e

Fig. 10-10 Deep plane dissection

Fig. 10-11 Superficial plane dissectiona: scar-capsule tissue grasped with forceps, b: dissection between the scar-capsule and skin envelope, c: dissection progressed to the cephalic direction

a b c

skin

scar / capsuletissue

alar cartilage

4) Dissection of nasal septum

When correcting a contractured nose, the entire nasal septum has to be exposed for septal extension graft. For the

nasal septum dissection, refer to Chapter 1 and Chapter 6.

5) Harvest of septal cartilage

If the nasal septum was harvested and used up in the past, the use of other cartilages, such as costal cartilage,

should be considered. But if septal cartilage can be harvested, it should be used for septal extension graft for

maximal results. The method of septal cartilage harvest is introduced in Chapter 1. It is suggested to harvest a

sufficient amount of nasal septal cartilage; however, at least 8~10mm width of L-strut must be left to prevent

saddle nose.

6) Fixation of extended alar cartilage

In order to maintain the extended position, the alar cartilage re-positioned toward the caudal direction of the nose

away from the upper lateral cartilage needs to be fixed by using autogenous cartilage. For such purpose, septal

extension graft and derotation graft are frequently used.

(1) Septal extension graft

This procedure fixes autogenous cartilage graft to the caudal septum or dorsal septum and then fixes the dome

area of alar cartilage at the end of the cartilage graft. For autogenous cartilage, septal cartilage is the most

recommended, but in cases of having difficulty using septal cartilage, costal cartilage may be used.

There are two methods of septal extension graft (Fig. 10-16). First is the batten type septal extension graft that

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Fig. 10-14 Medial crus release from the membranous septum

Fig. 10-15 Dissection of the nasal hinge complex a: dissection of right side accessory ligament, b: after detachment of accessory ligament

a b

Fig. 10-12 Scar-capsule flap is separated from skin envelope. Fig. 10-13 Alar cartilage release from the upper lateral cartilage

Fig. 10-16 Two main types of septal extension graft for short nose correction

Extended spreader type

Batten type

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fixes cartilage graft to the caudal septum. Second is the extended spreader type septal extension graft that fixes

the graft to the dorsal septum. Batten type is relatively easy even for beginners and presents good outcome; thus,

it is a more common method; the writer also prefers this method (Fig. 10-17). The graft is positioned by

overlapping about 1cm in the nasal septum and is fixed to the caudal septum or throughout the caudal and dorsal

septum. However, in cases where deviated nose has to be corrected simultaneously, extended spreader type that

fixes the graft between upper lateral cartilage and dorsal septum may be very useful (Fig. 10-18). When fixing the

graft cartilage to septum, #5-0 PDS suture is used in 4 - 5 areas.

When fixing alar cartilage at the end of the graft cartilage, the dome area of the alar cartilage is primarily fixed

(Fig. 10-19) and then, lateral crus or medial crus sometimes can be fixed. For fixation, #5-0 PDS suture is used.

(2) Derotation graft

If alar cartilage is not very small and the force acting on the alar cartilage toward the forehead is not big, it is

possible to use a derotation graft. In general, conchal cartilage is used (Fig. 10-20). In case of weak medial crus,

the tip defining point tends to be lower as the alar dome is pressed by the derotation graft, causing extended

nose but pressed look of the nasal tip. In such a case, it is necessary to add a columella strut graft.

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Fig. 10-17 Batten type of septal extension graft

Fig. 10-18 Extended spreader type of septal extension graft a: Hockey stick-shaped graft has been made from septal cartilage., b: septal extension graft between dorsal septum & left upper lateral cartilage

a b

Fig. 10-19 Fixation of alar cartilage dome to the tip of septal extension graft

Fig. 10-20 Derotation graft

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7) Manipulation of the separated scar-capsule flap

The scar-capsule that is separated through dual plane dissection should be removed in the following cases(Fig. 10-21).

a. Severely irregular surface

b. Presence of infected granulomatous tissue

c. Accompanied calcification

However, the author believes that it should not be removed if possible in case of healthy tissues without fore-

mentioned conditions and well preserved to utilize it as an independent soft tissue. In other words, it is used to

cover a new implant by spreading the scar-capsule tissue and by doing so, it is possible to reduce the implant-

transparency phenomenon while deriving identical effect as a surgical method that inserts an implant by wrapping it

with temporal fascia or dermis. Even in cases without using an implant, it is believed that it displays an effect to

reinforce the thin-layered skin as a healthy tissue by leaving it inside the nose(Fig. 10-22). Fig. 10-23, Fig. 10-24,

and Fig. 10-25 are the cases of a contractured short nose before and after the surgery.

8) How to overcome troublesome conditions

Troublesome conditions that a surgeon may face when conducting a contracted short nose correction are as

follows.

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Fig. 10-21 Capsule that should be removeda: irregular thick capsule, b: infected capsule, c: calcified capsule

a b

c

Fig. 10-22 Capsular flap a: Capsular flap has been divided longitudinally and stretched outward. B: Capsule covers the new implant(Gore-Tex).

a b

Fig. 10-23 Contracted short nose Case I. Septal extension graft(extended spreader type) with septal cartilage, Implant changea,b,c: preop.view, d,e,f: postop. 3 months, Both short nose with visible nostril and deviated nose with oblique columella are all corrected.

a b c

d e f

Fig. 10-24 Contracted short nose Case II. Septal extension graft(batten type) with septal cartilage, Implant change a,b: preop. view, c,d: postop. view

a b c d

(2) In case of deviated or twisted graft

Problems regarding deviated cartilage can be solved by positioning the end of deviated graft at the center (Fig.

10-28). However, sometimes the deviated cartilage has to be straightened and it can be solved by two methods.

First, straighten the deviated cartilage by symmetrically adding a layer of septal cartilage to it(Fig. 10-29).

Second, directly straighten the deviated cartilage by using horizontal double mattress suture (Fig. 10-29).

(3) In case that is impossible to harvest septal cartilage graft

There are some cases where harvesting septal cartilage is not possible due to several reasons. Following are

such cases.

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a. In case of too small or weak septal cartilage graft

b. In case of deviated or twisted septal cartilage graft

c. In case that is impossible to harvest a septal cartilage

d. In case of deviated or twisted caudal septum where the graft is fixed

e. In case of lost L-strut where the graft is fixed

It is said that the acquisition of techniques to well overcome such difficult situations is the gate toward a high-

level rhinoplasty surgeon. Thus, solutions for each case are described.

(1) In case of too small or weak graft

The proper length of the graft for septal extension graft should be more than 1.5 - 2cm. However, in case when

the harvested septal cartilage is too small or its thickness is too thin that it is difficult to support force, it can be

overcome by implementing two layers at the both sides of the nasal septum. In case of a small graft, the area

that contacts the septal cartilage becomes very limited if where sufficient length of the graft is needed extend to

beyond the caudal septum; thus, it may be difficult to support the alar cartilage well. In such case, the

supported power can be reinforced by adding cartilage on the other side. For the cartilage on the other side, it is

possible to use ear cartilage or IHCC besides septal cartilage (Fig. 10-26). In case that is difficult to provide

enough support due to too thin a cartilage, it is also possible to add strong power by adding one more layer on

the other side (Fig. 10-27).

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Fig. 10-25 Contracted short nose Case III. Septal extension graft(batten type) with septal cartilage, Implant removal and dermofat graft ondorsum a,b,c: preop.view, d,e,f: postop. 6 months

a b c

d e f

Fig. 10-26 Graft handicap: small graft

Fig. 10-27 Graft handicap: thin and weak graft

b. Use of IHCC (Irradiated homologous costal cartilage)

Some patients do not want to use his or her own rib cartilage. They are concerned of the surgery becoming too

complicated or reluctant to leave a scar in the chest. In such case, it is possible to use irradiated homologous

costal cartilage (IHCC) instead of autogenous rib cartilage (Fig. 10-33). Increased number of surgeons are

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a. Harvest of the septal cartilage in the past

b. Previous submucosal resection or septoplasty

c. Fractured nasal septum

d. Presence of septal perforation

If it is impossible to harvest septal cartilage, Derotation graft using ear cartilage can be an alternative way (Fig.

6-125) but if the situation demands septal extension graft, use of autogenous rib cartilage or cadaver’s costal

cartilage can be an alternative measure.

a. Use of autogenous rib cartilage

The harvest method of costal cartilage is described in Chapter 1 in detail. Several thin slices of costal

cartilages are prepared by slicing the rib cartilage to 1mm thickness in a longitudinal direction (Fig. 10-31).

Warping of costal cartilage appears immediately after slicing and may progress 2 weeks after the surgery.

However, since warping nearly completes in 1 hour in most cases, it is necessary to wait for 30 minutes to 1

hour after slicing in order to use the costal cartilage. By symmetrically adding the deviated costal cartilage

on both sides of the caudal septum to eliminate the curved vector, it is possible to make a straight septal

extension graft (Fig. 10-32).

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Fig. 10-30 Graft handicap: deviated graft cartilage 3 Double mattress suture for the straightening of curved cartilage graft

Fig. 10-31 Graft handicap: septal cartilage not availabe 1, Autogenous rib cartilage Preparation of rib cartilage

a b

Fig. 10-32 Bilateral septal extension graft with autogenous rib cartilage

Fig. 10-33 IHCC(irradiated homologous costal cartilage)

Fig. 10-28 Graft handicap: deviated graft cartilage 1 Fig. 10-29 Graft handicap: deviated graft cartilage 2

of alar cartilage fixation can occur (Fig. 10-35). In order to avoid avulsion fracture, the end of the graft that

fixes alar cartilage should be implemented at an area with density and a needle with round cross section

must be used for fixation.

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recently using IHCC in Korea; however, there is controversial regarding its feasibility. The author has used

this material for quite some time and have reported research regarding its use. Thus, the application of IHCC

is described.

Homologous costal cartilage graft was first reported in 1961 by Dingman and Grabb, and has been used for

a long period of time. Since all cells, bacteria, and virus are destroyed through the production process of the

homologous costal cartilage, along with cell membrane destruction by use of osmotic pressure, protein

denaturation by use of H2O2 or alcohol, and radiation, it is safe against contagious diseases.

The major issues raised regarding the use of homologous costal cartilage have been about resorption and

infection.

There are many studies that reported its use in rhinoplasty through various applications, including the

correction of the depressed nasal dorsum. In general, low absorption and satisfactory shape are reported

with good outcomes and common resorption is reported to be about 1-30%. In such extent, it is considered

to have no difference compared to the resorption rate of autogenous cartilage and reported that there is no

difference in infection rate in comparison to that of autogenous cartilage.

My opinion on the resorption of homologous costal cartilage (Graft rejection) is that the antigenic proteins

of homologous costal cartilage are understood to be nearly fully deactivated through the chemical treatment

and radiation and the chondrocyte itself is protected inside the lacunae, which is an immune previliged area

from attack of macrophage or antibody. Thus, it is thought that graft rejection can be ignored. Of course,

some undestroyed antigen may be exposed during surgery as the lacunae in the portion that was cut in the

process of carving the homologous costal cartilage is exposed. Although immune reaction is present due to

this, it is limited to the surface. As a consequence, fibrosis shall be limited only to the surface due to

rejection and resorption and its progress to the inside should be limited. The fibrous tissue itself will serve

the role of limiting membrane that blocks further immune attack. Eventually, resorption will be limited only

to the surface and complete resorption of the entire graft is thought to be theoretically unrealistic.

Some reported negative result in which some grafts were completely absorbed; however in such case, the

cartilage was substituted to fibrous tissue to maintain volume. Thus, it is said that there was no change in

the external appearance. But in case of structural graft used for support such as in the contracted upturned

nose, there is an issue if it is possible to maintain the lengthening effect when substitution is made with

fibrous tissue. Nonetheless, it is assumed that it is possible to fully maintain the shape after tissue stabilization

for more than 10 years. Regarding this issue, there should be long-term follow-up on the outcome.

As for the advantages of homologous costal cartilage, there is no scar caused by harvest of autogenous

costal cartilage. Also, the recovery period is short, it is possible to shorten the surgery time, and cost for the

surgery is reasonable (Fig. 10-34).

Regarding the quality of homologous costal cartilage, it varies depending on the age of the donor and

cartilage treatment process of each company. Thus, it is advised to use one with high quality, and the area to

be fixed through suture must be dense without bloating.

A side effect that is sometimes shown in the use of IHCC is fracture of the graft. Due to the production

process of IHCC, it is easier to be broken than autogenous cartilage. Especially, avulsion fracture at the area

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Fig. 10-34 Contracted short nose correction using IHCCThe patient received rhinoplasty 5 times and due to infection, the implant was removed during the last operation. Following that, contracted short nosedeveloped. For the correction of the contracted nose, septal extension graft with IHCC as well as dorsal augmentation with implant were conducted.

a b c d

Fig. 10-35 Avulsion fracture of IHCCa: preop. Contracted short nose, b: postop. 8 months after septal extension graft with IHCC, c: slight shortening of tip (postop. 18 months), d: Dome of alarcartilage is displaced upward from its original position (graft tip) due to avulsion fracture of graft tip, e: avulsion fracture of graft tip

d e

a b c

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(4) In case of deviated or twisted caudal septum where the graft is fixed

If graft is fixed to the caudal portion of the deviated nasal septum (L-strut), the graft moves out of the correct

position and leads to incorrect nasal tip. Therefore, the graft must be fixed after conducting a procedure that

straightens the deviated or twisted caudal septum. There are various patterns of deviated caudal septum (Fig.

10-36). The correction of the deviated caudal septum is closely described in Chapter 8.

Case shown in Fig. 10-37 is a patient with short nose that displays contracture after multiple times rhinoplasties.

The caudal portion of the nasal septum is deviated in a S-shape and the dorsal area is also deviated. The dorsal

septum was straightened through wedge-shaped resection and adding a batten graft. For the deviated caudal

septum, strip resection of about 2-3mm and adding batten graft was done for the correction. After flattening the

L-strut of the nasal septum, short nose was corrected by septal extension graft with costal cartilage.

(5) In case of lost L-strut where the graft is fixed

In case when the L-strut of nasal septum is lost or collapsed due to reasons such as infection, it is impossible to

fix the graft. In such a case, there are two ways to solve the problem.

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Fig. 10-36 Various types of caudal septal deviation

Fig. 10-37 Contracted short nose with twisted caudal septuma,b,c,d: preop. view, e: much scar tissue visible, f: deep plane dissection, g: scar-capsule flap isolated after superficial plane dissection, h: S-shaped deviationof caudal & dorsal septum, i,j: strip resection of the inferior portion of caudal septum and wedge resection of dorsal septum, k,l: batten graft to the dorsalseptum, m: septal extension graft with rib cartilage to the straightened caudal septum, n: fixation of alar dome to the graft tip, o,p: postop. view

m

n o p

i j

k l

e f g

h

a b c d

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a. Derotation graft

Since derotation graft is a surgery that fixes graft by laying it on the upper lateral cartilage regardless of nasal

septum condition, it can be used in case of lost nasal septum. However, it is possible only when the shape of

the upper lateral cartilage is relatively intact without a dent (Fig. 10-38).

b. Midvault reconstruction with rib cartilage

The patient shown in Fig. 10-39 has a short nose due to several surgeries. In the photos taken during the

surgery, the nasal septum is shown to be lost. In this case, it is advised to reconstruct the midvalut by using

costal cartilage while correcting the short nose at the same time. Although it requires a high surgical level, it

presents high satisfaction. Also, it can improve not only the shape but also functional aspect. Fig. 10-40 is

another example of the surgery.

9) Dressing

For dressing after a surgery, it is advised to conduct pressure dressing to prevent bleeding and reduce swelling

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Fig. 10-38 Derotation graft for the contracted short nose correction a: preop.view, b: postop. view, c: released alar cartilage, d: derotation graft

c

a

d

b

Fig. 10-39 Midvault reconstruction and contracted short nose correction 1a,b: preop. view, c,d: We can see excess scar inside the nose and absence of L-strut of septal cartilage, e: midvault reconstruction with IHCC, g: IHCC fixed to the preformed wedge-shaped slit of nasal bone, h: columella strut, i: dorsal cartilage fixed to the columella strut cartilage, k,l: postop. view

a b c

d e f

g h i

j k l

(Fig. 10-41). It is convenient to use thermosplint after pressing the operated area with paper tape. For packing to

press the nasal septum, vaseline gauze or Merocele is used. Packing is maintained for about 2 days, but if there is a

risk of bleeding, it can be maintained for about 5 days after the surgery. The pressure dressing and suture are

removed on the 5th -7th day after the surgery.

10) Management after the surgery

The operated area becomes more swollen in 2-3 days after surgery, therefore an ice pack should be applied.

During this period, it is advised to locate the operated area slightly above the heart. To reduce swelling, exposure to

LED with 830nm wavelength may be helpful and in case of severe bruising, Vit K ointment can alleviate the

condition.

In case of hematoma at the nasal dorsum, liquefaction of hematoma occurs 7 days after the surgery; thus, it is

drained by using an injection with an 18G needle after 7 days and pressure dressing is applied for several days (Fig.

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Fig. 10-40 Midvault reconstruction and contracted short nose correction 2a,b: preop. view, c: harvested rib cartilage, d: midvault reconstruction with one pair of rib cartilage, e,f: postop. view

e

c

a

f

d

b

Fig. 10-41 Dressing

a b

c

10-42). For the hematoma in the nasal septum, a 5-10mm length of horizontal incision is made to one side of the

inferior portion of septal mucosa to directly drain hematoma. It is necessary to conduct packing to press the septum.

The incision is not sutured but left as to induce natural drainage of additional hematoma (Fig. 9-21).

References1. Demirkan F, et al. Irradiated homologous costal cartilage: versatile grafting material for rhinoplasty. Aesthetic Plast Surg. 27:

213, 2003

2. Dingman RO, Grabb WC. Costal cartilage homografts preserved by radiation. Plast Reconstr Surg. 28: 562, 1961

3. Gruber JP. Lengthening the short nose. Plast Reconstr Surg. 91(7): 1252, 1993

4. Guyuron B, Behmand, RA. Caudal nasal deviation. Plast Reconstr Surg. 111: 2449, 2003

5. M.H. Paik. Correction of short nose. Arch Aesth Plast Surg. 11. No1: 22-26, 2005

6. M.K. Suh: Contracted short nose correction using irradiated homologous costal cartilage. Arch Aesth Plast Surg. 16(3) 117-

124, 2010

7. Strauch B, Wallach SG. Reconstruction with irradiated homograft costal cartilage. Plast Reconstr Surg. 111: 2405, 2003

8. Welling DB, et al. Irradiated homologous cartilage grafts. Long-term results. Arch Otolaryngol Head Neck Surg. 114: 291,

1988

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Fig. 10-42 Aspiration of hematoma

a b