Summary :
External Transcolumellar Approach
Other surgical approaches
Deviated noses
Augmentation rhinoplasty
Functional graft
Graft of the nasal tip
Secondary rhinoplasties
CH I - Introduction

FIG. 1 There is no magic formula , and in rhinoplasty as in other procedures of aesthetic surgery , it is important to think in terms of equilibrium : it is not so much the volume which is important , but the harmony of volumes .One can consider the nasal pyramid as being composed of the juxtaposition of different "sub-units" which are : the radix , the dorsum, the supra-tip area , the lobule , the columella , the alar lobules , and the lateral walls.

These sub-units or "volumes " should be in balance not only between themselves but with the other volumes of the face which are the forehead , the cheek bones , the lips , and the chin.

In order to obtain proper equilibrium , one must perform appropriate modifications of each of these volumes which might often consist in combination of reduction and augmentation of each of these.

Fig. 1

fig. 2 Preoperative planning on photograph
FIG. 2 The clinical examination starts with a psychological evaluation which helps in understanding the patient's motivation . It is particularly important to ask the patient to be precise about the types of changes he desires and to wait before suggesting a nose which in our mind would be suitable for him .

One should respond to a desire of reasonable modifications and should moderate demands of excessive one . After examination of the other structures of the face for assessement of proportions and harmony , the skin conditions constitute a crucial factor to be appreciated by inspection and palpation .. One can schematically describe three types of skin.

Photographs are indispensable not only for preoperative study , but also in the operating room where they are displayed near the surgeon so that he can refer to them at any moment he wishes to.

Computerized video is utilized by numerous surgeons . This method has been criticized for its spectacular aspects , but in the same way as on the picture modifications , it allows the surgeon demonstrate the limits of the procedure where the patient is too demanding .
Structures of the nasal pyramid -Surgical Anatomy

The bony vault
The bony vault has a function of protection as the most solid portion of the nasal pyramid ; . It also provides support for the cartilaginous middle vault , which is weaker . It is often altered by the procedure , but any alteration carried out at this level should be considered as a function of the morphology of the adjacent areas and of the planned alterations of these areas.

The upper lateral cartilages
The middle vault support is provided by the upper lateral cartilages thanks to their attachements to the nasal bones and anterior septal border ; the septum becomes wider anteriorely and presents a structural histologic continuity with the anterior border of the upper lateral cartilages .

Fig. 3 The alar cartilages

FIG. 3 The alar cartilages
The alar cartilages play a major role in the aesthetic appearance of the nasal tip and also in the nasal valve function .A precise analysis of these cartilages taking account of their shape , thickness , elasticity , and dimensions is essential , since all of the changes of the nasal tip will depend on the maneuvers which have been performed on the alar cartilages : incisions , resections , sutures and grafts . The variation in the shape of the lateral crura are numerous and have morphological and sometimes functional repercussions.

Soft tissue characteristics
The thickness and the quality of the soft tissue envelope have an important relation both to the aesthetic result and to the functional result .
The thickness of the covering tissues varies in the different areas of the nose

The doctors AIACH and DURON are surgeon specialist nose