You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > COSMETIC SURGERY Rhinoplasty, Saddle NoseArticle Last Updated: Aug 11, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 13
  Author: A John Vartanian, MD, MS, Assistant Clinical Professor, Division of Head and Neck, Department of Surgery, University of California Los Angeles David Geffen School of Medicine; Instructor, Department of Otolaryngology-Head and Neck Surgery, University of Southern California Keck School of Medicine A John Vartanian is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association Coauthor(s): J Regan Thomas, MD, Head Professor, Department of Otolaryngology-Head and Neck Surgery, University of Illinois at Chicago Medical Center Editors: S Valentine Fernandes, MBBS, MB, BS, BSc(Hons), MCPS, FRCSEd, FRACS, FACS, Conjoint Senior Clinical Lecturer, Department of Otorhinolaryngology, Newcastle University; Senior Consultant Surgeon, Department of Otorhinolaryngology-Head and Neck Surgery, John Hunter, Toronto Private and Kurri Hospitals, Australia; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; David W Stepnick, MD, Associate Professor, Departments of Plastic Surgery and Otolaryngology-Head and Neck Surgery, Case Western Reserve University School of Medicine, University Hospitals of Cleveland Case Medical Center; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: saddle nose deformity, saddle-nose deformity, pug nose, boxer's nose, nasal reconstruction, Wegener granulomatosis, relapsing polychondritis, leprosy, Hansen disease, syphilis, ectodermal dysplasia, polyamide mesh, Mersilene, silicone-based implants, Silastic, expanded polytetrafluoroethylene, ePTFE, Gore-Tex, porous high-density polyethylene, PHDPE, Medpor, nasal deformity, plastic surgery, nose job, facial plastic surgery, rhinoplasty, Advanced Rhinoplasty, revision rhinoplasty, esthetic surgery, reconstructive surgery, nose surgery, saddle nose rhinoplasty INTRODUCTIONSection 2 of 13
  History of the ProcedureThe oldest recorded text on the diagnosis and treatment of nasal deformities can be found in the Edwin Smith surgical papyrus from ancient The science and art of rhinoplasty, as understood by most surgeons, remained essentially stagnant until the 19th century. In the 1840s, approaches to correcting nasal dorsal concavities were used by early pioneers, including Dieffenbach, who used a buried forehead flap to cover the nasal dorsum. The first paper on the treatment of the saddle nose can be attributed to John Orlando Roe's original article in 1887, "The deformity termed 'Pug-Nose' and its correction, by a simple operation."1 In 1892, Robert F. Weir published his techniques for correcting the saddle nose.2 In 1896, ProblemAnatomic deformities can affect both the aesthetic and functional qualities of the nose. A saddle-nose deformity is most visibly characterized by a loss of nasal dorsal height. This deformity has also been described as a pug nose or boxer's nose, both of which refer to various degrees of nasal dorsal depression. This often accompanies a shortened nose and compromised nasal support structures (see Images 1-4). The descriptive definition of the saddle-nose deformity represents a wide range of severity. Other features commonly observed in patients with significant saddle-nose deformities include the following:
FrequencyThe prevalence of saddle-nose deformities is difficult to assess. The prevalence is higher in population groups prone to facial trauma (ie, boxers, criminals, athletes), in persons with a history of intranasal cocaine use, and in individuals with a history of nasal surgery (eg, radical submucous septal resection, reductive rhinoplasty). A flat or concave nasal dorsal contour can resemble a saddle nose and is more prevalent in certain familial and racial groups. Some saddled noses may be more subtle, owing to thickened nasal skin soft-tissue envelope. EtiologyA saddle-nose deformity can be congenital or acquired. Various degrees of nasal dorsal depression can be noticed as a part of individual, familial, syndromic, and racial characteristics. Most saddle-nose deformities are acquired. A common theme in all acquired saddle-nose deformities is a structural compromise of the nasoseptal cartilage leading to decreased dorsal nasal structural support. The most common causes of saddle-nose deformities are traumatic and iatrogenic. Trauma Direct trauma to the nose can fracture the cartilaginous and/or bony septum, hence compromising important support structures. Nasal bone depression due to trauma can also lead to a depressed dorsum. An unrecognized posttraumatic septal hematoma may become infected, causing irreversible cartilage damage and loss of support. In a study by Jalaludin, saddling was noted in 14% of patients with unrecognized or untreated septal abscesses.3 In that study, the leading cause of a nasal septal abscess was trauma. Birth-related nasoseptal trauma can also appear with various degrees of nasal deformity that may be erroneously labeled as being congenital. Surgical causes Changes made to the nose after rhinoplasty or submucous resection of septal cartilage can result in a number of undesirable deformities, including a saddle-nose deformity. Tzadik and colleagues noted that, depending on the surgeon's skill, saddling rates varied from 0% to 2.6% (average, 0.4%) in patients who had undergone submucous resection of the nasal septum.4 Overresection of septal cartilage can lead to collapse of the middle vault and saddling. Removing too much septal cartilage can compromise the structural integrity of the dorsal L-shaped strut and increase the probability of postoperative or traumatic saddling of the nasal dorsum. No cartilage should be resected anterior to an imaginary vertical line drawn from the rhinion (osseocartilaginous junction) to the nasal spine. During septal cartilage resection, leaving a minimum of a 10-mm dorsal-caudal L-shaped margin of cartilage is important. Arching the incisions, instead of creating right-angled corners, can also impart slightly greater structural integrity to the dorsal L-shaped strut. Surgical overreduction of a nasal dorsal hump can produce an overly concave nasal dorsum. Additionally, an unidentified open roof deformity can further contribute to middle vault depression. Disharmonious changes in the nasal contour (eg, an overly projected nasal tip, an exaggerated supratip break) can also impart the impression of saddling. Inadequate support of the upper lateral cartilages and the middle vault may lead to its settling and relative saddling of the middle vault with time. Medical causes A number of medical conditions affecting the nose can result in damage to the septum and cartilaginous structures. The common pathway is damage to the cartilage; compromise in the structure; and various degrees of subsequent nasal dorsal saddling, as clinically observed. A number of conditions can affect the nasal septum and lead to a saddle-nose deformity.
Intranasal cocaine use leading to large septal perforation and cartilage loss can also produce saddling of the nose. Wegener granulomatosis is characterized by necrotizing granulomas and vasculitis of the upper and lower respiratory tracts, including the nasal septum. The cycle of necrotizing granulomatous lesion and microabscess formation leads to cartilage destruction. In relapsing polychondritis (see Images 3-4), recurrent episodes of autoimmune cartilage inflammation and destruction result in damage to the cartilaginous structure of the ears, nose, larynx, trachea, and peripheral joints. In this rare disease, fibrotic tissue replaces collagen, elastin, and other matrix proteins found in normal cartilage; this process leads to the loss of healthy cartilage. Overall, Hansen disease, or leprosy, is rare in the Syphilis can cause intranasal ulcerative lesions that can lead to osteochondritis; cartilage damage; and, eventually, saddle-nose deformity. PathophysiologyPatients with saddle-nose deformities may have various degrees of nasal obstruction. Middle vault collapse is commonly observed in moderate-to-severe saddle noses. The inferomedial collapse of the upper lateral cartilages and corresponding narrowing of the internal nasal valve can produce significant obstruction that impairs nasal breathing. Large septal perforations often result in nasal saddling. Saddle-nose deformities with septal perforations can appear with nasal crusting, nasal obstruction, and whistling upon nasal airflow. In individuals in whom nasal airway compromise is noted, nasoseptal reconstruction should address important functional, as well as aesthetic, deficits of the patient's nose. An exact understanding of the deformity and dysfunction can allow for the proper selection of the best reconstructive option. Classification Regardless of the etiology, categorizing the severity of the saddle nose is helpful. The authors use a simplified system that classifies saddle-nose deformities on the basis of the anatomic deficits (see Image 5), as follows:
Most patients with a type 2, 3, or 4 saddle-nose deformity have functional nasal airway obstruction. A practical classification method described by Tardy divides saddle-nose deformities into 3 categories, as follows:
ClinicalComplete history taking and physical examination is an important first step in evaluating the patient with a saddle-nose deformity. In particular, the history should include an investigation of the suspected etiology of the deformity, any history of nasal airway obstruction, any history of antecedent nasal trauma, the number of previous nasal surgeries, and any history of any autoimmune diseases. The use of intranasal cocaine or heroin should be investigated in patients with nasoseptal perforations. Upon physical examination, the degree and location of saddling, the state of the nasal septum, the status of the internal and external nasal valves, and the structural integrity of the nasal support structures must be evaluated. A higher rate of septal perforations is found in patients who have a saddle noses. Endoscopic nasal examination can facilitate an accurate survey of all endonasal structures. The standard series of photographs should be obtained prior to surgical planning for rhinoplasty. INDICATIONSSection 3 of 13
Indications for nasal reconstruction must be tempered by patient selection, the surgeon's experience, and the etiology of the deformity. Indications for surgery can be functional, aesthetic, or, most commonly, both. Examples are as follows:
RELEVANT ANATOMYSection 4 of 13
In-depth knowledge of the nasal anatomy is essential. The morphologic changes observed in a saddle nose are due to the loss of nasal skeletal support structures. These pathologic processes are discussed in the Pathophysiology section. The osseocartilaginous support framework includes the nasal bones, the upper and lower lateral nasal cartilages, the septum, the premaxilla, and their attachments to each other (see Image 6). The nasal septum plays a robust role in supporting the middle and lower thirds of the nose (see Image 7). CONTRAINDICATIONSSection 5 of 13
Persons with contraindications for repairing a saddle-nose deformity include the following:
Patients with relative contraindications include the following:
WORKUPSection 6 of 13
Imaging Studies
Diagnostic ProceduresEndoscopic nasal examination can facilitate an accurate survey of the endonasal structures. TREATMENTSection 7 of 13
Medical therapyMedical treatment applies only to limiting the progression of those disease states that lead to cartilage destruction and eventual saddling. Diseases such as Wegener granulomatosis and relapsing polychondritis should be managed with the help of medical specialists (rheumatologists). In most individuals with saddle-nose deformities, treatment is aimed at surgical reconstruction of functional and aesthetic deficits. Surgical therapyDepending on the degree of saddling, different reconstructive options can be used. Decisions regarding nasal reconstruction are concerned both with the choice of materials to be used and the type of reconstruction needed. The history of nasal reconstruction is full of nasal implants and grafts taken from a variety of sources. The interesting list of grafts and implants used in reconstructing the nose seems almost limitless. Some historic grafts and implants used in the human nose include the following:
Variable rates of success and failure have been noted with different implants and grafts. The selection of material in nasal reconstruction should center on balancing long-term biocompatibility, infection rates, extrusion rates, graft resorption rates, graft harvest site morbidity, and material availability. The ideal implant's profile satisfies all of these concerns. The ideal nasal implant has yet to be developed. The ideal nasal implant should have certain characteristics, as follows:
Autogenous materials Autogenous materials are always preferred to alloplastic implants as far as infection rates, extrusion rates, and biocompatibility issues are concerned. Septal cartilage is the best choice but is often not present in sufficient quantity. Secondary sources of autogenous cartilage include auricular and rib cartilage. Cartilage harvested from the ear is especially well suited for use in the nose. Bone grafts harvested from calvarial, iliac, and tibial bone sources can be used. Autogenous soft tissue materials include dermis and fascia. Homografts Homografts are harvested from healthy screened donors. Irradiated cartilage and sheets of pooled acellular dermal allografts (AlloDerm; LifeCell Corp, Alloplasts Synthetic implants offer the advantages of ready availability. However, in the nose, alloplasts have a tendency to behave like foreign bodies, with higher rates of infection, extrusion, and inflammatory reactions, as compared with those of autogenous grafts. Moreover, although alloplasts are well suited as filler material, most do not provide significant structural support to the nose. Commonly available alloplasts include polyamide mesh (Mersilene; Ethicon, Proponents of alloplasts note that autogenous cartilage grafts are fraught with problems that must be considered. As mentioned before, septal cartilage is often of low quantity or nonexistent. Auricular cartilage is available; however, it is curved, it can potentially warp with time, it is of limited quantity, and it involves the morbidity of a second operative site. Rib cartilage is susceptible to warping and involves the morbidity of a second operative site. Also, some surgeons may be uncomfortable with the possible risks related to the thoracic surgical site. Bone grafts have been reported to undergo resorption. They are hard and can also result in donor-site morbidities. At times, because of a number of factors, including strong patient preference against a second operative site, alloplastic implants may be used. ePTFE has been in use for a number of years, and positive reports have encouraged their wider use. Outcomes pertaining to synthetic implants are discussed in the Outcome and Prognosis section. PHDPE implants have pore sizes of 125-250 µm, which allow access to immune cells and fibrovascular ingrowth. Sclafani, Thomas, and colleagues (1997) demonstrated the ingrowth of fibrovascular tissue into these porous implants, which confers increased resistance toward implant infection.5 This ingrowth also anchors the implant to the surrounding native tissue. Despite several promising reports, the long-term viability of these implants has yet to be evaluated. Alloplasts must be recommended only as a last resort and not as a convenient substitute for autogenous grafts. One significant disadvantage of nasal implants includes the changes to the surrounding tissue (scarring, skin atrophy), which may render less-than-optimal results in subsequent rhinoplasties. The authors' hesitancy to use any foreign materials in the nose is based on the authors' and other colleagues' experience with the removal of displaced, infected, or extruding nasal implants placed by other surgeons. Intraoperative detailsNasal dorsal reconstruction using autogenous materials For patients with no nasal airway obstruction and minor-to-moderate nasal dorsal saddling, onlay grafting techniques can be used. These grafts can be fashioned from septal cartilage or auricular cartilage. Onlay grafting can be used to augment the dorsum or to camouflage localized areas of depression. As Tardy described, auricular cartilage grafts can be individually placed as morselized pieces or as laminated or layered grafts. Small-to-medium dorsal depressions can also be camouflaged by using layers of laminated, or sandwiched, ear cartilage placed on the dorsum. Such layered or sandwiched grafts can be used to reconstruct not only the dorsum but also the caudal septum (see Image 8). Grafts can be placed via endonasal or external (transcolumellar) rhinoplastic approaches. The precise creation of the subperiosteal pocket can help stabilize the graft placement site. Transcutaneous suture fixation can be used to prevent graft migration. The aesthetic look and the dorsal tactile regularity of the nose can be improved by morselizing the graft edges and by placing a layer of acellular dermis (AlloDerm) on top of the grafts. AlloDerm can be used for camouflaging small dorsal imperfections by providing a layer of cushioning. Alternatively, a layer of crushed cartilage or fascia can also provide a smoother reconstructed dorsum. A properly performed targeted osteotomy can result in the elevation of flat or depressed nasal bones. Larger defects and deformities affecting the middle vault or the nasal dorsum require a more structural reconstructive approach. Fundamental to reconstructing the moderate-to-severe saddle nose is restoring middle vault function, reversing any internal valve narrowing, and reinforcing nasal tip and dorsal support mechanisms. The placement of spreader grafts is usually sufficient to address the internal nasal valve and middle vault collapse (see Image 9). More substantial dorsal augmentation (too great for placement of conchal or septal cartilage grafts) can be achieved by using a boat-shaped onlay graft fashioned from rib cartilage (see Image 10). The cartilage is carved from the central core of the rib (as opposed to peripheral area) to minimize warping. Adams et al have demonstrated this phenomenon in their elegant studies measuring cartilage warping with time and location of harvest.6 The sculpted graft is placed in a precise pocket and can be suture fixated for additional stability. If nasal tip projection and support structures are deficient, new support structure must be reconstructed. L-shaped strut reconstruction The reconstitution of dorsal-caudal and tip support structures can be achieved using the concept of the dorsal L-shaped strut. The L-shaped strut refers to the L-shaped dorsal-caudal nasoseptal support structure that should be present in the nose. An intact septum in the normal nontraumatized nose sufficiently serves this function. In the structurally compromised nose, new support structures must be constructed. A number of methods can be used to reconstruct a dorsal L-shaped strut. The patient's own septal cartilage is readily available and well suited for reconstructing caudal and dorsal septal deficits. In patients lacking adequate septal cartilage, other cartilage sources can be used. Costochondral (rib) cartilage from the patient (harvested at the time of nasal reconstruction) can be used to re-create a dorsal L-shaped strut. This L-shaped strut usually has 2 components: a dorsal boat-shaped graft (for dorsal profile) and a columellar support pillar or strut (for nasal tip support; see Image 11). The placement of a notch in the dorsal graft to fit the columellar strut can stabilize this connection. The 2 components are suture fixated together. The rest of the nose is reconstructed based on this new support structure. In a similar manner, bone can also be used for reconstruction. Gerow et al and others describe using bone harvested from a rib to reconstruct the dorsal L-shaped strut and to augment the premaxilla.7 Irradiated cartilage homografts can also be used to reconstruct articulated dorsal and caudal nasal support structures, although long-term resorption may be encountered with irradiated cartilage (as reported by Welling et al).8 As such, the use of irradiated cartilage may be more appropriate in older patients in whom long-term resorption may be less of an issue. The flying buttress graft combines a single or paired spreader grafts with a columellar strut. In this manner, the newly created L-shaped support structure can address middle vault collapse and internal valve incompetency and can increase tip and dorsal projection. This technique, combined with dorsal onlay grafting, may be used to fix slight-to-moderate middle vault defects along with improving nasal function. Naficy and Baker (1998) describe the use of the flying buttress in lengthening the short nose (a condition often present in the saddle-nose deformities).9 Remember that the nasoseptal reconstruction must be sufficiently strong and stable to last the entire lifetime of the patient. These goals can be realized in a higher percentage of patients by reinforcing structural and soft tissue elements of the nose in ways that correspond to the defects present and respond to predictable forces of long-term scarring. COMPLICATIONSSection 8 of 13
Complications encountered after saddle-nose reconstruction can be categorized as medical, functional, or aesthetic. Complications vary with the amount and duration of surgery, the surgical approach to the nose, the amount of dissection, the number of previous surgeries, the use and choice of reconstruction materials, and the intrinsic patient factors.
OUTCOME AND PROGNOSISSection 9 of 13
Long-term outcomes at 10 years or longer are the standards by which rhinoplasty and nasoseptal reconstruction procedures should be judged and evaluated. Most available studies are limited by short follow-up, small numbers of patients, outcomes influenced by the surgeon's experience with a particular approach or technique, variability in intrinsic patient factors, and patient selection. Nevertheless, reviewing the available, albeit imperfect, data on the use alloplasts and the application of autogenous grafts is useful. Alloplasts The infection and extrusion rates of synthetic implants are of prime concern regarding their wider nonselective use in rhinoplasty. Most published studies reveal alloplast infection rates of 2-4%. True implant extrusion rates are difficult to ascertain because of variable patient follow-up intervals, patients lost to follow-up, and the lack of substantial long-term studies. On the basis of available studies, implant extrusion rates range from 0% to 9%. Conrad and Gillman evaluated the use of ePTFE implants in 189 patients undergoing rhinoplasty.10 Follow-up intervals varied from 3 months to 6 years (average, 17.5 mo) with 5 cases (2.6%) of implant removal secondary to infection. Two implants were removed because of chronic inflammation and soft tissue reaction. No cases of implant extrusion, migration, or resorption were reported. Godin et al reviewed 309 patients who received ePTFE implants for a 10-year period.11 With an average follow-up of 40.4 months (range, 5 mo-10 y), 10 implants (3.2%) were removed secondary to infection. Niechajev's review of 23 nasal reconstructions using PHDPE nasal implants revealed successful aesthetic outcomes in all patients, with a mean follow-up of 2 years (range, 1-3 y).12 In this study, 2 implant extrusions (9%) were treated with minor revision surgery, and 1 case of implant infection (4%) was treated with antibiotics. Turegun et al used PHDPE implants in reconstructing the noses of 36 individuals with saddle-nose deformities and reported that no cases required implant removal.13 However, the follow-up in this study was generally short (8-18 mo), and the aesthetic and functional outcomes were poorly defined. Romo et al used PHDPE nasal implants in 15 saddle-nose reconstructions and noted 1 major complication because of a twisted dorsal implant at 1-year follow-up. Of the 15 patients, 14 (93%) were pleased with their aesthetic outcomes (follow-up duration unknown). Despite attempts at precise contouring of the implant prior to its placement, the investigators noted demarcation of the lateral borders of a number of implants placed on the dorsum. In another study, Romo et al applied PHDPE implants in 121 cases involving revision rhinoplasty and in 66 platyrrhine noses.14 In most cases, the implant was used to augment the dorsum and reinforce the columella. From a total of 187 cases, 5 implants (2.7%) needed to be removed because of 3 early and 2 delayed implant infections. Beekhuis' report of 70 patients with various degrees of nasal dorsal saddling who were all treated with rhinoplasty and polyamide mesh placement revealed 3 cases (4%) of implant removal (all because of infection).15 Autogenous material In a review article about surgical correction of the saddle-nose deformity, Tardy describes his 20-year experience in using various autogenous grafts in nasal reconstruction with gratifying results and no major complications.16 Infection rates with autogenous cartilage are low, and infections can be successfully treated with antibiotics. Rates of auricular cartilage warping are variable but approximately 4-7%. Cartilage extrusion rates are less than 5%, with most cases of extrusion resolving spontaneously. Sherris treated 21 patients requiring caudal and dorsal septal reconstruction by using only autogenous material. Material used included septal cartilage; autogenous rib grafts; ethmoid bone; and, in one case, calvarial bone grafts. With an average follow-up of 19.8 months (range, 12-29 mo), no cases of infection, graft extrusion, or warping were noted. He noted one case (5%) of partial (rib) graft exposure, which resolved spontaneously without any sequelae, and one case (5%) in which (calvarial bone) graft resorption in the nasal tip area had been noted at 2-year follow-up. Aesthetic outcomes were "much improved" in 76% of the cases and "improved" in the remaining 24%. Murakami et al used irradiated rib cartilage to reconstruct 18 saddle-nose deformities.17 With a follow-up of 1-6 years (mean, 2.8 y), no cases of infection, extrusion, or noticeable resorption were noted. One (6%) graft had to be removed secondary to warping, and 2 (11%) displaced caudal struts had to be repositioned under local anesthesia. Long-term evaluation of irradiated cartilage grafts by Welling et al revealed progressive graft resorption with time.8 Animal studies by Donald have also demonstrated the steady resorption of irradiated cartilage with time.18 This resorption may discourage the use of irradiated cartilage in younger patients, in whom long-term resorption may limit the lifespan of the nasal reconstruction. Adams et al have demonstrated decreased rib cartilage warping rates when the cartilages were carved from central portion rather than peripheral portions of the harvested cartilage.6 Gunter and colleagues significantly reduced their postoperative cartilage warping rates by internally stabilizing rib cartilage grafts by using Kirschner wires (K-wires).19 Toriumi describes minimizing the risk of long-term warping by performing adequate symmetric carving of the graft, by not leaving any perichondrium on the graft, and by dissecting a precise subperiosteal graft insertion pocket.20 In the study by Gerow et al, the use of rib bone grafts for 16 saddle-nose reconstructions yielded good aesthetic results with no significant complications.7 Some of the cases described had continued good aesthetic results at long-term follow-up (7-10 y). Bone absorption was noted in all cases, but in no cases did the deformities recur. FUTURE AND CONTROVERSIESSection 10 of 13
The future of nasoseptal reconstruction continues to evolve on the basis of long-term results, the introduction of new techniques, and the use of increasingly biocompatible homografts and implants. The ideal alloplasts are yet to be found, but the search for new compounds may facilitate the development of an ideal alloplast. Future developments in bioengineering may allow the production of autologous soft tissue products (eg, cartilage). This advancement will eliminate the importance of material as a limiting factor in complicated nasal reconstructions. Until then, the intelligent and creative use of autogenous grafts can allow the surgeon to address an almost limitless array of nasal deformities, including the saddle nose. ACKNOWLEDGMENTSSection 11 of 13
The author acknowledges his mentors (Dr. Dean Toriumi, Dr. Gene Tardy, Dr. Frank Kamer, Dr. Gary Burget, and Dr. J. Regan Thomas) for their gift of knowledge and practical surgical know-how. MULTIMEDIASection 12 of 13
REFERENCESSection 13 of 13
Rhinoplasty, Saddle Nose excerpt Article Last Updated: Aug 11, 2008 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
