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DR BECKER IS NOW TREATING RHINOPLASTY PATIENTS BY TELEHEALTH.

During the COVID-19 state of emergency, in order to protect our patients and staff, but in order to communicate with patients and plan for the future, Dr Becker will communicate with potential rhinoplasty patients by Telehealth. Telehealth appointments may be scheduled on the phone (our operators our working remotely). Visits will be performed by audio or video discussion.

Becker Rhinoplasty Center
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856-772-1617
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  • Meet the Doctor
  • Procedures
    • Rhinoplasty
    • Revision Rhinoplasty
  • Photos
    • Bulbous Tip
    • Droopy Nose
    • Ethnic Rhinoplasty
    • Finesse Rhinoplasty
    • Nasal Bump
    • Nasal Fracture
    • Narrow Nose
    • Overprojected
    • Revision Rhinoplasty
    • Saddle Nose
    • Twisted Nose
    • Underprojected
    • Unique Issues
    • Upturned Nose
    • Wide Nose
  • Testimonials
    • Patient Reviews
    • Testimonial Videos
  • Videos
    • Testimonial Videos
    • Educational Videos
  • Patient Education
    • Nose Form & Function
    • A Patient’s Guide
    • Books & Publications
    • Revision Rhinoplasty Textbook
    • Rhinoplasty Education
    • Rhinoplasty Dissection Manual
  • Locations
    • Sewell Office
    • Voorhees Office

Revision Rhinoplasty Textbook Page 5

Special Challenges Continued

Alar batten grafts are the first line treatment of alar retraction and nasal valve collapse (Fig. 18-5).10,11,16 Batten grafts have been very well described in the literature. Alar retraction may be treated by cartilage batten grafts in less severe cases (1-2 mm).10 The area of retraction is marked before injection, and a small marginal incision allows dissection of a precise pocket. (If an open approach is elected, a precise pocket may still be created for the batten graft, but suture fixation also may be required.) A contoured cartilage graft (commonly of auricular or septal cartilage) may be inserted into the precise pocket, which should extend inferiorly to the sesamoids and should be wide enough to simulate the normal shape of the lateral crus at the dome.

Nasal Valve Collapse
Fig. 18-5

Figure 18-5 Nasal valve collapse may be apparent on normal inspiration, (A) Patient at rest. (B) Patient at normal inspiration. (C) Patient after placement of alar batten grafts. Alar batten grafts may be placed via an external rhinoplasty approach or into a precise pocket made through an endonasal incision, as shown here (D,E). This graft is nonanatomic and is typically placed caudal to the lateral crura, where there is maximal collapse of the lateral nasal wall and supra-alar pinching. If alar batten grafts are placed too far cephalic, excessive fullness over the middle vault will be noted. Patients should be told that there will be temporary fullness in the area of the graft. This fullness will typically decrease over 2 to 3 months. For maximal support, the alar batten graft should extend over the bone of the pyriform aperture.

Auricular composite grafts are commonly used in more severe cases (Fig. 18-6).22,23 It has been my experience that the skin and cartilage of the anterolateral surface of the ear, just inferior to the inferior crus, of the opposite ear (example, left ala, right ear) provides the best donor site and the best contour. An incision several millimeters from the nostril rim is followed by careful dissection with freeing of adhesions, creating a defect and displacing the alar rim inferiorly. Volume and support must be restored to hold the nostril rim in position; this role is fulfilled by the composite graft. The fashioned composite graft is carefully sutured into place.22,23 Typically, I use 5-0 chromic suture. I place a cotton ball or other light dressing intranasally to apply light pressure for 1 to 3 days.

Before and Afters
Fig. 18-6 a
Composite Graphs
Fig. 18-6 b

Composite grafts are easiest to place when undertaking a limited, precise pocket approach. When more extensive rhinoplasty is being performed, with wider elevation undertaken, the surgeon may be concerned that the composite graft will not stay in position. However, I have not found this to be the case. Composite grafts may be used in conjunction with alar batten grafts.

Alar-Columellar Disproportion

An alar-columellar disproportion may be caused not only by alar retraction but also by a hanging columella or a combination of both (Fig. 18-7).10,25 Retrodisplacement of the columella may effectively address the columellar contribution to the abnormality. Depending on the anatomy encountered, the medial crura may be retrodisplaced onto the caudal septum. Alternatively, excision of excessive caudal septum may be appropriate in selected cases.
When redundant septal mucosa exists, excision and suture
reapproximation also can be effective.

Alar-columellar
Fig. 18-7

Figure 18-7 (A) Alar-columellar disproportion, treated with alar batten grafts to address the alar retraction and retrodisplacement of the columella in “tongue-in-groove” fashion to address the columellar component of the abnormality. (B) One year postoperative.

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"Dr. Daniel Becker is the sweetest most caring person. It’s almost a year since I had a really bad nose bleeds and he was there for us, came to hospital in the snow on a Sunday just to fix me. He is so very special and always there when you need him. Love him!!!"

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