The photographs shown above are of a 62-year-old man who sustained a nasal septal fracture in a high-speed motor vehicle collision five days ago. Following reduction of the fracture, which of the following grafts is most appropriate for correction of the deformity?

(A) Alloplastic graft
(B) Columellar strut graft
(C) Shield graft
(D) Spreader septal graft
(E) Umbrella graft

The correct response is Option D.

Fractures of the nose can occur in three zones. Fractures of the upper vault of the nose involve the nasal bones, ethmoid, vomer, and cephalic septal border. Fractures of the middle vault involve the upper lateral cartilages, septum, and maxilla. In patients with fractures of the lower vault of the nose, the alar cartilages and inferior septum are affected. This patient has fractures involving both the upper and middle vaults of the nose. Following reduction of the septum and nasal bones, spreader grafts should be inserted to provide support to the septum.

Compared with autologous tissues, alloplastic grafts have higher rates of exposure and infection and are relatively contraindicated in a patient with recent trauma to the nose and multiple mucoperichondrial lacerations.

Columellar strut, shield, and umbrella grafts are used for correction of deformities in the lower vault of the nose.

References
1. Gunter JP, Rohrich RJ. Management of the deviated nose: the importance of septal reconstruction. Clin Plast Surg. 1988;15:43.
2. Lupo G. The history of aesthetic rhinoplasty: special emphasis on the saddle nose. Aesthetic Plast Surg. 1997;21:309-327.
3. Menick FJ. Anatomic reconstruction of the nasal tip cartilages in secondary and reconstructive rhinoplasty. Plast Reconstr Surg. 1999;104:2187-2201.
4. Rohrich RJ, Adams WP Jr. Nasal fracture management: minimizing secondary nasal deformities. Plast Reconstr Surg. 2000;106:266-273.

Which of the following is the most likely adverse effect of performing infracture of the nasal bones?

(A) Development of an open roof deformity
(B) Development of a supratip deformity
(C) Narrowing of the internal nasal valve
(D) Narrowing of the nasal tip
(E) Retraction of the columella

The correct response is Option C.

Infracture of the nasal bones is performed to narrow the nasal dorsum. However, because the upper lateral cartilages are attached to the nasal bones, this technique may lead to an excessively acute angle (less than 10 degrees) between the upper lateral cartilages and the septum. Narrowing and occlusion of the internal nasal valve can result, causing breathing difficulties.

Infracture is also a method of correcting an open roof deformity.

Supratip deformities are generally caused by inadequate resection of the dorsal spine or excessive resection of the nasal dorsum.

The nasal tip and columella are relatively unaffected by infracture.

References
1. Constantian M. Primary rhinoplasty: basic techniques. In: Cohen M, ed. Mastery of Plastic and Reconstructive Surgery. Boston, Mass: Little, Brown & Co; 1994;2:1999-2020.
2. Sheen JH, Sheen AP. Problems in secondary rhinoplasty. In: Aesthetic Rhinoplasty. Saint Louis, Mo: Quality Medical Publishing; 1998:1135-1406.

The internal nasal valve is comprised anatomically of the septum and which of the following structures?

(A) Caudal edge of the upper lateral cartilage and pyriform aperture
(B) Inferior turbinate and nasal floor
(C) Nasal floor and caudal edge of the upper lateral cartilage
(D) Pyriform aperture and vomer
(E) Vomer and inferior turbinate

The correct response is Option C.

The internasal nasal valve is a triangular shaped passage that is comprised of the septum, the nasal floor, and the caudal portion of the upper lateral cartilage. Patency of the internal nasal valve is crucial for breathing. The normal angle of the internal nasal valve is 10 to 15 degrees; if the angle is less than 10 degrees, airway occlusion at the internal nasal valve may result. Insertion of spreader grafts, which are stick-like strips of cartilage, is recommended to open the angle and improve the airway. The grafts are placed submucosally between the dorsum of the septum and the upper lateral cartilage. In contrast, infracture of the nasal bones will only narrow the angle and worsen breathing.

References
1. Peck GP, Peck GP Jr. Secondary rhinoplasty. In: Georgiade GS, Riefkohl R, Levin LS, eds. Plastic, Maxillofacial and Reconstructive Surgery. Baltimore, Md: Williams & Wilkins; 1997:646-656.
2. Sheen JH, Sheen AP. Applied anatomy and physiology. In: Aesthetic Rhinoplasty. Saint Louis, Mo: Quality Medical Publishing; 1998:14.

A 40-year-old woman is to undergo rhinoplasty to increase projection of the nasal tip. In addition to tip grafting, which of the following techniques will provide the greatest tip projection?

(A) Resection of the lateral crura
(B) Resection of the lower lateral cartilages
(C) Resection of the nasal spine
(D) Suturing of the medial crura
(E) Transfixion incision

The correct response is Option D.

Projection of the nasal tip can be increased by applying a cartilage graft to the tip, suturing the medial crura, and placing a strut graft between the medial crura. In addition, the caudal margin of the septum and cephalic alar rim can be resected to rotate the nasal tip and increase its projection subtly.

Tip projection is decreased by resecting the lateral and medial crura and the nasal spine. Complete transfixion incision ultimately decreases projection because it weakens nasal support.

It should be noted that procedures to correct tip projection can lead to a broad-based appearance of the nose. Weir-type alar resection or nasal sill resection is appropriate for rectifying this problem.

References
1. McCarthy JG, Wood Smith D. Rhinoplasty. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders; 1990;3:1804.
2. Sheen JH. Tip graft: a 20 year retrospective. Plast Reconstr Surg. 1993;91:48.
3. Tardy ME Jr, Patt BS, Walter MA. Transdomal suture refinement of the nasal tip: long-term outcomes. Facial Plast Surg. 1993;9:275.
4. Tardy ME Jr, Walter MA, Patt BS. The over projecting nose: anatomic component analysis and repair. Facial Plast Surg. 1993;9;306.

A 30-year-old man is undergoing evaluation for rhinoplasty. He has a 20 pack/year history of cigarette smoking and says that he has difficulty breathing through his nose. Evaluation of this patient’s breathing difficulties should address each of the following anatomic structures EXCEPT the

(A) dorsal nasal hump
(B) internal nasal valve
(C) nasal septum
(D) nasal vestibule
(E) turbinates

The correct response is Option A.

In a 30-year-old man who has breathing difficulties, the internal nasal valve, nasal septum, nasal vestibule, and turbinates should be evaluated. Obstruction can result from collapse or narrowing of the internal nasal valve that occurs as a result of scarring or excessive resection of cartilage. Deviation or perforation of the septum can cause obstruction or turbulent air flow; however, it is common to have significant septal deviation with no obstructive symptoms. The position of the nostrils and nasal vestibule may also affect breathing; ptosis of the nasal tip or an obtuse nasolabial angle can cause turbulent air flow. In addition, the middle and inferior turbinates regulate breathing. Chronic hypertrophy of the inferior turbinate is the most common cause of obstruction in a patient who has had no trauma or previous surgery. If this condition does not resolve with topical administration of decongestant agents, turbinectomy should be considered. Obstruction of the nasal passages may also be caused by vasomotor or allergic rhinitis and exposure to cigarette smoke or other environmental toxins.

The dorsal nasal hump is a bony and cartilaginous prominence that does not affect internal nasal air flow.

References
1. Baker DC, Strauss RB. The physiologic treatment of nasal obstruction. Clin Plast Surg. 1977;4:121.
2. Canady JW. Evaluation of nasal obstruction in rhinoplasty. Plast Reconstr Surg. 1994;94:555.
3. McCarthy JG, Wood Smith D. Rhinoplasty. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders; 1990;3:1804.