A 25-year-old woman has numbness of the nasal tip two years after undergoing cosmetic rhinoplasty through an endonasal approach. Which of the following is the most likely cause of the numbness?

(A) Division of the descending branches of the infratrochlear nerve
(B) Division of the supratrochlear nerve
(C) Injury to the external nasal branch of the anterior ethmoidal nerve
(D) Injury to the external nasal branch of the supraorbital nerve
(E) Retraction injury to the branches of the infraorbital nerve

The correct response is Option C.

This patient has sustained an injury to the external nasal branch of the anterior ethmoidal nerve, a structure that is particularly vulnerable to damage during endonasal rhinoplasty procedures. The nerve emerges from between the nasal bone and lateral nasal cartilage, supplying sensation to the skin of the distal nasal dorsum and tip.

The infraorbital nerve supplies sensory innervation to the lower lateral half of the nose and columellar skin, while the infratrochlear nerve supplies the cephalic portion of the nasal side walls and the skin overlying the radix. The supraorbital nerve also innervates the skin of the radix. The supratrochlear nerve supplies sensation to the forehead skin.

References
1. Daniel RK, ed. Aesthetic Plastic Surgery: Rhinoplasty. Boston, Mass: Little, Brown & Co; 1993:3-39.
2. Zide BM. Nasal anatomy: the muscles and tip sensation. Aesthetic Plast Surg. 1985;9:193.

A 37-year-old man has partial airway obstruction on inspiration and a "caved-in" alar rim after undergoing cosmetic rhinoplasty for correction of a bulbous deformity of the nasal tip. Which of the following is the most appropriate management?

(A) Placement of transdomal sutures anchored to the caudal septum
(B) Septoplasty
(C) Use of alar grafts
(D) Use of cranial bone grafts, morselized and placed subcutaneously
(E) Use of middle nasal vault spreader grafts

The correct response is Option C.

In this patient who has a pinched nasal tip, the most appropriate surgical technique is insertion of alar grafts. A pinched nasal tip can result from excessive resection of the lower lateral alar cartilages and may lead to airway obstruction secondary to compromise of the external nasal valve. To correct the deformity, alar cartilage can be obtained from the auricle or nasal septum and then placed between and deep to the remaining lateral crura to oppose the forces leading to nasal valve collapse.

Transdomal sutures can be used to decrease nasal projection and transdomal width but not to correct a pinched nasal tip. Septoplasty would not typically improve this patient's deformity. Cranial bone grafts are used for correction of saddle nose deformity. Spreader grafts are stick-like strips of cartilage placed in the middle nasal vault following resection of cartilage and bone to prevent internal nasal valve collapse.

References
1. Gunter JP, Rohrich RJ. Correction of the pinched nasal tip with alar spreader grafts. Plast Reconstr Surg. 1992;90:821.
2. Sheen JH. Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg. 1984;73:230-239.