38-year-old female presenting today in consultation regarding aesthetic nasal concerns. Patient desires dorsal hump reduction, increased tip rotation for a ptotic nasal tip, tip refinement. She underwent a Primary cosmetic preservation septorhinoplasty with septal cartilage grafting (left ANSA banner). An inverted V columellar incision and marginal incisions were marked out and incised. The soft tissue envelope was lifted off the cartilage and bony framework. The periosteum over the nasal bones was incised and elevated. An incision was then made along the pyriform aperture and the skin and soft tissue were elevated off the maxilla and nasal bones to prepare for osteotomies. The Piezo saw was then used to make low-low-high osteotomies as well as a horizontal osteotomy at the nasion. The dorsal roof remained intact. Small segments of nasal bone were removed at the pyriform aperture to allow for let down of the dorsal hump.

The medial crura were separated sharply. The anterior septal angle was identified. A left mucoperichondrial flap was elevated. Dissection proceeded anteriorly around the caudal end of the septum allowing elevation of a mucoperichondrial flap on the right.

Next, a modified through and through dorsal cartilage z plasty incision was performed along with an osteotomy through the perpendicular plate of the ethmoid bone to allow for let down of the dorsal hump. At this point, the nasal dorsum was fully let down. A 5-0 prolene was placed around the excised septal cartilage segment to hold the let down dorsal hump in position. An inferior oblique incision is then carried caudally through to the anterior septal angle to level of cartilaginous dorsum.

Inferior septal cartilage was harvested in one piece with care taken to maintain greater than 1.5 cm L strut. The anterior left upper lateral cartilage was released from the septum. Cephalic trims were performed leaving 8mm wide lower lateral cartilages and releasing the scroll. An ANSA banner graft was fashioned from the harvested septal cartilage and secured to the maxillary crest and left side of the native septum with 4-0 PDS and 5-0 prolene. 5-0 prolene dome spanning and lateral crural tensioning sutures were placed to create new domes and increase rotation, securing the lower lateral cartilages to the septal extension graft. The skin was elevated off the medial crura. A tongue-and-groove procedure was performed and the medial crura were sutured to the caudal septum with 5-0 prolene. Medial crural fixation sutures were placed to secure the medial crura together and narrow the columella.