By Enrico Robotti, MD

Dr. Robotti performs six surgeries as part of the 2021 Live Surgery Open Rhinoplasty Course. Step-by-step operative technique from markings to closure and dressing is included in each case, supplemented with clinical photos, and analysis of cone-beam CT and 3-D renderings. Viewers will benefit from technical pearls regarding the combined or alternative use of power tools and piezo for osteoplasty, osteotomy, septoplasty, and turbinoplasty. Emphasis is placed on various techniques for managing the dorsum, including Dr Robotti’s cartilaginous push-down technique to rebuild or preserve natural and aesthetic dorsal lines. The use of various new instruments is also shown. Complete details of finesse rib grafting for secondary reconstruction are fully demonstrated in three cases, especially including Dr. Robotti’s SPF (Sandwich of Perichondrium and rectus Fascia) and SPLF (Sandwich of Perichondrium, rib Lamina, and rectus Fascia) techniques for precise and aesthetic dorsal reconstruction. Dr. Robotti’s comments throughout the surgeries and Q&A between surgeon and audience enhance the educational value of this video collection.

Case 1
Primary, 27-year-old female patient, volumetrically large nose, wide nasal bones, mild hump, mildly drooping tip, deviation. 
Subperichondrial-subperiosteal plane, bony cap reduction by power burrs, osteoplasty by burrs and piezo, piezo osteotomies and transosseous sutures, piezo-assisted septoplasty and turbinoplasty, modified dorsal split cartilaginous push-down technique, spreader flaps for precise middle vault reshaping, interdomal ligament sling, lateral crural cranial slide-under, vertical and horizontal scroll-reestablishing sutures, 3-point compartmentalization sutures, tip triangulation and sidewall definition by lateral crural steal, medial crural transaction and overlap, columellar strut, alar contour grafts, Pitanguy ligament suturing for supratip break definition, diced cartilage.

Case 2
Primary, 18-year-old female patient, major hump, depressed radix, drooping tip, ill-defined tip with weak cartilages, infratip excess.
SubSMAS and subsequent subperichondrial-subperiosteal plane, bony cap reduction with Stryker saw, piezo osteotomies, transosseous sutures, piezo septoplasty and piezo turbinoplasty, modified dorsal split cartilaginous push-down technique, septal extension graft, interdomal ligament sling, cranial lower lateral crural turn-under, lateral crural mini-transposition, articulated grafts, vertical and horizontal scroll-reestablishing sutures, 3-point compartmentalization sutures, multiple tip defining sutures, columellar strut, Pitanguy ligament resuture, diced cartilage.

Case 3
Primary, 19-year-old female patient, deviated nose with tip/dorsum disproportion, hump, short and drooping tip. 
Subperichondrial-subperiosteal plane, bony cap reduction by Stryker saw, osteoplasty by piezo and burrs, bilateral piezo osteotomies, transosseous sutures, septoplasty and turbinoplasty, modified dorsal split cartilaginous push-down technique, middle vault spreader stabilization, interdomal ligament sling, mini-septal extension graft, lateral crural cranial slide-under and mini-transposition, vertical and horizontal scroll-reestablishing sutures, 3-point compartmentalization sutures, mini-alar contour grafts, tip sutures, columellar strut, Pitanguy ligament reapproximation, diced cartilage.

Case 4
Secondary, 41-year-old female patient, following two previous rhinoplasties, deviation, severe tip asymmetry, tip collapse, dorsum irregularities, columellar deformity, severe functional obstruction. 
Rib harvesting and finesse lamination, subtotal L-strut septal reconstruction with multiple rib laminations, rib septal extension graft, posterior septoplasty with correction of residual deviation, piezo turbinoplasty, burr and piezo osteoplasties, piezo osteotomies, total lateral crural and medial crural reconstruction, finesse lateral crural rib laminations for extended struts, mini-alar contour grafts, SPLF construct for aesthetic dorsal reconstruction and augmentation.

Case 5
Secondary, 32-year-old female patient, following two previous rhinoplasties, multiple dorsum irregularities, synechiae, bony collapse, tip overshortening and overrotation, retracted nostrils, saddling, severe functional obstruction. 
Rib harvesting and finesse lamination, septoplasty of residual posterior deviation, complete septal L-strut reconstruction with multiple rib laminations and extended rib spreader grafts, septal extension graft, piezo turbinoplasty, burr osteoplasties and asymmetric piezo osteotomies, tip domal reconstruction and sidewall reconstruction with extended lateral crural struts from finesse rib laminations, lateral crural transposition and stabilization, medial crural reconstruction, SPLF construct for correction of saddling and optimal dorsal contouring, perichondrium and fascia onlay graft to tip.

Case 6
Secondary, 33-year-old female patient, following two previous rhinoplasties, asymmetric bulbous tip with synechiae, pinching, external valve collapse, crooked nose, septal deviation, functional obstruction. 
Rib harvesting and finesse lamination, septoplasty and turbinoplasty, L-strut septal reconstruction with rib laminations, tip reconstruction with lateral crural rib laminations extended struts, medial crural reconstruction, osteoplasties and asymmetric osteotomies, SPLF graft for dorsal aesthetic contouring, perichondrium patch to tip.