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Decreasing Tip Projection
Lateral crura complex strength and stability play
-
ral complex that is strong and rmly adherent to
the piriform aperture resists posterior movement
nated by undermining the vestibular skin from the
cally transecting the cartilages to allow overlapping
and posterior movement. Suture xation is used to
secure the region of overlap and reestablish support
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Intercartilaginous
incision
Complete transxion incision
Decreasing nasal tip projection is accomplished by weakening or eliminating
the elements that support the tip. Several of these supports are violated with
routinely used surgical incisions. A complete transxion incision violates the
broelastic connections between the medial crura and caudal septum. is allows greater posterior migration of the medial crural footplates toward the anterior nasal spine. e shorter the medial crura and the less so tissue present
that prevents posterior motion, the more the tip will deproject. Placement of an
intercartilaginous incision, release of the lateral crura from the upper lateral cartilages at the scroll area, or cephalic trim of the lower lateral cartilage violates the
brous attachments suspending the lateral crura from the upper lateral cartilages
and decreases tip support. Additionally, division of the suspensory ligament that
spans the domes will weaken tip support.
Intercartilaginous incision
Cartilage transected
and overlapped
Complete transxion incision
a pivotal role in tip support and should be consid
ered when decreasing tip projection. A lateral cru
of the tip.
deep surface of the lateral crural complex and verti
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Resistance may be reduced or elimi
of the lateral alar wall.
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In some cases, a lateral crural strut gra may be required for adequate support
aer transection and overlap of the lateral crus.
Cartilage transected
and overlapped
Vertical transection with overlap and suture xation of the medial crura may also
be performed. is maneuver is employed when the medial crura are elongated
and resist posterior movement of the tip. Transection is typically completed midway between the tip-dening points and the columellar-lobular angle following
vestibular skin undermining. Any folding of the vestibular skin is concealed by
the skin of the so tissue triangle.
Decreasing tip projection should follow a graduated approach. Disruption of so
tissue support is performed with reassessment of tip position. If greater deprojection is needed vertical transection of the lateral and/or medial crura with
cartilage overlap allows posterior displacement of the tip and may be required.
Deprojecting the nasal tip may produce aring of the alae. In a long, narrow nose
this may improve overall nasal aesthetics, but noses with normal or preexisting alar aring require assessment and possibly surgical intervention to correct.
Flaring results from alar rim skin and lateral crural complex rigidity that resists
compression. Treatment for the lateral crural complex, as discussed earlier, is with
vertical transection, whereas alar skin excess is treated with alar base excision.
Decreasing tip projection can be accomplished incrementally by elevation of skin
envelope, violation of tip-supporting brous attachments, addressing the dorsal
septum, and then transection and overlap of lateral and/or medial crura.
Chapter Basic Nasal Tip Surgery: Anatomy and Technique 337
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Alar aring does not always result from decreasing tip projection. Occasionally,
the overprojected nose is associated with the appearance of the alar base being
pulled away from the underlying face and skeleton. Such a nding is usually seen
in those patients with a class II skeletofacial deformity and a high septal angle
producing a tension tip nose. In these patients, lowering the tip allows the base
to settle back into the appropriate location and does not exhibit aring on the ala
until a point is reached where settling is complete and aring begins.
Bowing of the columella in a downward direction may also occur when the nasal
base meets resistance from the maxilla. Such movement can result in increased
infratip lobular show and/or increased columellar show. Correction requires
transection, overlapping, and suture xation of the medial or middle crura and/
or resection of the membranous columella with a small portion of caudal septum,
allowing wound closure and pulling of the columella cephalad.
e relationship between nasal projection and the alar base is crucial to understand. In cases where alar base resection is performed due to a wide lower third,
tip projection can be eected. To further explain, the absolute tip position is not
altered but the alar-cheek junction is advanced toward the tip giving an appearance of decreased projection.
Altering Tip Rotation
e tripod concept also applies to altering of tip rotation. Moreover, understanding the anatomic structures that support the nasal tip is important as such structures may limit tip rotation.
Factors that resist upward rotation of the nasal tip include the following:
■
Fibrous attachments connecting the lateral crura to upper lateral cartilage
■
A cephalic abutment of the lateral crural complex against the piriform
aperture
■
A prominent caudal septum
■
Lengthy upper lateral cartilages
■
High septal angle
■
Skin adherence to the lateral crura, upper lateral cartilages, and nasal
bones
Increasing rotation of the nasal tip requires evaluation of each factor that may
limit upward rotation. e result of such assessment guides surgical decisionmaking.
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Either placement of an intercartilaginous incision or resection of the cephalic
lateral crura eliminates resistance from the brous attachments connecting the
lateral crura to upper lateral cartilages. If rotation is desired, a portion of the
cephalic margin of the lateral crura is resected. Following resection, the lateral
crura are typically free to be moved upward.
High
abutment
Low
abutment
If the lateral crural complex abuts the piriform in a more cephalic direction, it
will prevent upward tip rotation. Elimination of this force is as previously described, with vertical transection of the cartilage and overlap with suture xation.
Placement of a columellar strut is occasionally needed to maintain tip rotation
and avoid posterior movement of the medial crura.
If rotation of the tip is still limited aer these maneuvers, the caudal septum
should be assessed as it may interfere with upward movement of the medial
crura. Loose connective tissue between the medial crura feet and caudal septum
typically allow rotational movement. When greater rotation is needed these connections may cause tethering and need to be released usually with caudal septal
Chapter Basic Nasal Tip Surgery: Anatomy and Technique 339
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resection. Elongated upper lateral cartilages are typically addressed during cephalic resection of the lateral crura. It is important to reconstruct the dorsum
appropriately so that midvault collapse is avoided.
Determining which portion of the septum should be resected depends on the
columellar-labial angle.
If the angle is normal then resection should be isolated to the anterior portion
of the caudal septum. When the angle is displaced down and out, more cartilage
is resected from the posterior caudal septum and adjacent to the anterior nasal
spine. is type of problem is seen more commonly in patients with class II skeletofacial deformities with short upper lips. Resection to any signicant degree
of the caudal septum is typically accompanied by similar resection of membra
nous septum.
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Presence of a high septal angle may resist upward rotation of the nasal tip if the
suspensory ligament remains intact. Either lowering of the septal angle or divid
ing the suspensory ligament will address this. Skin adherent to the underlying
cartilage can also obstruct upward tip rotation. To correct such a problem, the
skin should be undermined and redraped aer cartilage movement.
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A more challenging problem is derotation of the tip combined with lengthening
the nose. is is covered in Chapters and .
Improving Tip Denition
Decreasing the width between tip-dening points can be best accomplished with
interdomal suture placement to closer approximate the domes.
method to accomplish this task is through cephalic trim of the lateral and middle
crura of the domes. Typically, as the lower lateral cartilages transition from dome
to columella, they are so that the caudal margins are separated. Resection of
the cephalic margins improves alignment and allows the tip-dening points to
shi medially.
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An additional
Chapter Basic Nasal Tip Surgery: Anatomy and Technique 341
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Narrowing the angle of divergence and medializing the tip-dening points is accomplished by tip suture techniques and/or by cephalic trim of the lower lateral
cartilages.
Reducing Tip Fullness
Fullness of the nasal tip is seen rather frequently and requires partial cartilage resection, weakening of the lateral crura, or suture reshaping of the lateral
crura.
while the remaining caudal segment continues to are, resulting in a bulbousappearing nose.
-
Cephalic trim of the lower lateral cartilages will reduce tip fullness
To reduce this caudal lateral crura are, a horizontal mattress suture is placed in
the dome area. Angulation of the dome is increased with tightening and tying of
the suture. Suture placement is completed bilaterally with one suture being le
long and eventually tied to the contralateral suture then tightened to the desired
level, acting as an interdomal suture. When fullness is the result of severe lateral crura convexity, lateral crural strut gras are the preferred method used to
straighten the lateral crura. Lower lateral crural turnover aps may also be used
to correct shape while decreasing tip fullness. Both of these techniques are discussed in Chapters and .
Reducing fullness in the nasal tip is accomplished by cephalic trim of the lower
lateral cartilages, suturing of the domes to increase angulation, and by placement
of lateral crura strut gras to correct severe convexity and correct crura position.
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Creating a Supratip Break
5 to 8 mm
8 to 12 mm
Formation of a supratip break is frequently desired in females. Supratip break
exists when the nasal tip is higher than the dorsum. Creation of a supratip break
is accomplished through creating tip-dening points with good projection and
reducing the dorsum to the desired eect. Long lasting tip support must also be
established or the tip will settle and the break will be lost. In some cases, failure
to provide adequate support to the nasal tip will result in loss of projection and
derotation and a pollybeak deformity. Skin of the supratip region is thicker than
the actual tip and this must be accounted for when determining the nal septal
height. Placement of the septal angle is usually to mm lower than the tipdening points with thin to medium thickness skin, while this may need to be
to mm with thick skin.
Patients with thick skin, which blunts the supratip break or limits tip denition,
may require debulking of tip so tissue. Loose connective tissue on the undersurface of the skin envelope may be removed with forceps. Removal should be
limited to so tissue loosely attached to avoid dermal injury and external dimpling. In the case where the musculoaponeurotic layer is thick, this can be carefully excised, avoiding subdermal defatting, which can lead to scarring and even
compromise of the skin circulation. Use of an absorbable suture can be used to attach the skin to the cartilage at the supratip and can help to obliterate dead space.
Creating supratip break places the tip-dening points 5 to 12mm above the septal
angle; varying on skin thickness dierences between the dorsum and tip.
Chapter Basic Nasal Tip Surgery: Anatomy and Technique 343
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Improving the Alar-Columellar Relationship
Medial crura aberrations in shape and position disrupt nasal harmony between
the columella and alar rims. Correcting this problem usually requires cartilage
modication in the shape or position of the medial crura, tissue excision, or cartilage graing. is is described in detail in Chapter .
SURGICAL APPROACHES TO THE TIP CARTILAGES
Cartilage-Splitting Technique
Intracartilaginous
incision
Transfixion
incision
Use of the intracartilaginous incision is performed when the only modication
needed is removal of lateral crura cephalic margins and/or anterior medial crura
cephalic margins. e goal is to decrease tip bulbosity in the presence of normal
or near normal intercrural distance. Surgical objective is to improve tip denition and create a supratip break.
e incision begins with placement of a double-pronged skin hook inside the
alar rim with the medial hook just medial to the nostril apex. e incision is
connected to the anterior portion of a partial or complete transxion incision.
With the hook used to li the skin, the lateral crus is pressed toward the vestibular opening with the fourth nger, forcing the cartilage caudal margin and
body into prominence. e surgeon estimates the desired caudal segment width
to leave and visually marks that distance from the caudal edge of the cartilage to
determine incision placement.
e incision is made medial to lateral beginning at the anterior end of the transxion incision. e incision curves upward as the incision moves laterally to
remain parallel with the cartilage edge. e incision can be created through the
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vestibular skin only with skin elevated o of the cartilage to its junction with
the upper lateral cartilage. In this manner, the amount of exposed cartilage can
be compared bilaterally to help determine the amount to excise. e cartilage is
transected at the same level on each side, with the cephalic segment separated
from the overlying so tissue and removed. e initial incision can also be made
through both skin and cartilage simultaneously. e disadvantages of this incision are the technical challenges associated with symmetric cartilage harvest
and the limited ability to modify remaining cartilage. e disadvantage of this
approach is that the cartilages are not directly visualized and the amount of remaining cartilage can only be assumed.
Cartilage Delivery Technique
Infracartilaginous
incision
e cartilage delivery technique includes use of an infracartilaginous incision
that joins a partial or complete transxion incision. e infracartilaginous inci-
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