This nose was featured by some of the most difficult technical challenges one can meet in the structure rhinoplasty field; to begin with the dorsum was angled and divergent, with a very prominent supratip and a very low or sunken radix, requiring a seesaw effect by means of lowering the supratip hump and raising the radix using an onlay graft of cartilage and camouflage perichondrium spared from the cartilaginous supratip hump, suitably tailored to fit such extremely hollow radix; the dorsum received an atypical hump shave in decrease, aggressive at the supratip, moderate in center, slight at the high dorsum and nothing but a filler graft at the radix.
The septum was very short, abnormally short and retracted, which lead to a poorly supported and upturned tip and columella, nostrils exposure, a wide nasolabial angle and, indirectly and associated with the divergent dorsum, a supratip prominence or polly beak deformity; to correct this issue a deep septum cartilage window of graft was harvested and mounted as caudal septal extension graft, one on one modality, and using this neo septum as strut by the principles of the tongue in groove maneuver the tip and the medial cruras were assembled and secured to it, acting then as pure extended columellar strut.
It is strongly recommended a close up view of the lateral cruras deformity, they were concave or inverted unlike the orthodox convex or flat, therefore a eversion plasty with cross location was employed to correct such sunken alae at both sides of the tip; the firmness of the lateral cruras made unnecessary any reinforcements with batten or strut grafts on them.
Finally the tip was deprojected and the domes received plasties, plication and an onlay infratip lobule and columella graft to treat the bifidness between the medial cruras.
Regarding the chin it had three spatial issues, a very short vertical height, a lack of anterior projection and also a very sharp or tapered narrow horizontal width which had a keel's shape thus running the risk, once suitable projected, to end in a witch's chin; therefore the patient needed a three dimensional augmentation of the chin's bone to massively increase in the vertical axis and thus boost his masculine facial balance, significantly project forward to balance the profile and moderately broaden to achieve a square or boxy chin which so handsome features provided to his look.
This was accomplished by an oblique osteotomy performed following meticulous preoperative planning in order to achieve augmentation in height and projection by means of inserting a quite large interpositional bone graft harvested from the iliac bone of the hip and suitably sculpted to match the anatomy of the chin; then the chin fragment was split into two halves and broadened inserting a cubic chip of bone graft to space it laterally; finally steel wiring allowed the assemble and fixation of the osseous puzzle.
The chin massively increased and created a new and optimal facial balance, stretching the soft tissues of the face and neck, thus producing a facelift effect on the cheeks, jowls, perioral tissues, the double chin and the neck, creating the well known rejuvenation side effect of augmentation genioplasties.
The final comprehensive outcome of both procedures is, literally, a whole brand new face; this is indeed one of the most difficult cases which can be met in facial plastic surgery.
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