Management of the middle third in revision rhinoplasty

The middle nasal vault is composed of the upper lateral cartilages and the nasal septum. Although not as common as lower third or nasal tip problems, middle nasal vault abnormalities can be particularly disfiguring and contribute significantly to patient dissatisfaction. Failure to properly address the middle nasal vault in primary rhinoplasty can contribute to bony dorsum and pollybeak deformities, pinched supratip, uneven or wide upper lateral cartilages, and midnasal asymmetry. The authors discuss evaluation of the patient, etiologies of middle nasal third problems, deformities of the middle nose, saddle nose deformity, pollybeak deformity, narrow middle nasal vault/inverted V deformity, open roof deformity, crooked nose deformity, and the treatment of the deformities.