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Chapter Basic Nasal Tip Surgery: Anatomy and Technique 345
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sion is made by incising vestibular skin along the caudal margin of the lateral
crura. e incision begins laterally just beyond the location where the caudal rim
of the lateral crus diverges from the alar rim to move cephalad. It continues medially, following the caudal rim of the lateral crus and medial crus, nally ending at the columellar-lobular junction. e incision may be extended further on
both ends to facilitate cartilage delivery.
An intercartilaginous incision is created beginning at the lateral end of the limen
vestibuli and extends medially mm caudal and parallel. e incision is then
curved into the membranous septum anterior to the valve region where it meets
the transxion incision. Skin is then separated from the cartilage starting at the
infracartilaginous incision, ceasing at the lateral and medial extensions of the
incisions. Such undermining connects the intercartilaginous and infracartilaginous incisions, while creating a bipedicled ap of cartilage lined with vestibular
skin. It is then delivered from the nostril to expose the supercial surface of the
cartilages.
On delivery, the cartilage is oen distorted as the ends are tethered. A rightangle hook placed in the apex can help more accurately identify the dome area
aer delivery. With the hook secured the cartilage is pulled out the nostril and
the dome marked. With dicult delivery, the incisions are extended as needed
and so tissue undermined to improve access. Following adequate delivery and
marking of the domes, cartilage modication is performed.
e cartilage delivery technique permits direct exposure of the lower lateral cartilages, providing greater exibility compared with cartilage-splitting technique.
e foremost disadvantage of the cartilage delivery technique is the associated
distortion of delivered cartilage making it dicult to conceptualize the nal cartilage shape once returned deep to the skin. Placing the cartilage back into the
appropriate location and suturing the caudal rim back into original position is
problematic if crosshatching is not used for alignment. Inaccurate incisions and
suturing may result in alar rim notching and obliteration of so tissue facets.
Distortion of the delivered cartilage is the primary disadvantage with the cartilage delivery technique.
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e Open Approach
Infracartilaginous
incision
Trans-
columellar
incision
Opening the nose uses a transcolumellar incision connected to bilateral infracartilaginous incisions to elevate the nasal skin envelope.
from nasal cartilage and bone, exposing the complete tip and majority of the dorsum. e transcolumellar incision may be designed as in inverted-V or stairstep
pattern. e anking infracartilaginous incisions are designed and completed
in the same method described for the cartilage delivery technique. e incisions
cease medially where the medial crura footplates begin to are.
,
So tissue is elevated
e open approach allows comprehensive diagnosis of existing deformity and
optimizes surgical intervention as a result of maximal exposure. Inspection of
the cartilages in their natural anatomic position and determining the subsequent inuence on tip appearance is more easily accomplished through the open
approach.
Advantage of the open approach is optimal visualization of the undisturbed nasal
infrastructure providing a more accurate diagnosis and treatment.
Furthermore, it is easier to observe the inuence that each maneuver has on the
overall cartilaginous framework. e nal modied framework can be acurately
assessed before the conclusion of surgery. e skin envelope is redraped and the
entire nose is once again inspected and palpated to ensure the desired result.
Liing the skin envelope and making the appropriate changes can easily address
any irregularities.
Chapter Basic Nasal Tip Surgery: Anatomy and Technique 347
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Additional advantages of the open approach include the following:
■
Enhanced ability to use both hands
■
Improved control of bleeding limiting postoperative edema
■
Greater ease of contouring and suturing existing structures
■
More accurate placement and xation of gras
■
Optimal for teaching rhinoplasty
Open approach rhinoplasty has enjoyed great popularity because of the optimal
exposure for diagnosis and surgical intervention. It is extremely useful in patients
with unusual deformities of the nasal tip, for secondary rhinoplasty or posttraumatic noses, and for nasal deformities associated with cle lip.
Disadvantages to the open approach include the transcolumellar scar and potential for greater postsurgical edema. A closed approach with broad undermining
would produce similar edema. e incision should be placed at the narrowest
portion of the columella, typically where the medial crura begin to are. Straight
line incisions are avoided to prevent scar contracture and notching of the scar at
the transition from the external to internal columellar skin. Instead, an invertedV or stairstep pattern is recommended. With accurate closure, a ne, narrow scar
is produced on the undersurface of the nose that is imperceptible. Critics of open
rhinoplasty have reported prolonged tip edema, extended operating time, and
an inability to create small gra pockets.
KEY POINTS
■
Surgery of the nasal tip requires a comprehensive knowledge of nasal anatomy
and support.
■
When operating on the nasal tip it is best to follow a graduated approach with
constant reassessment before each maneuver.
■
To rotate the nasal tip, the surgeon must identify and remove anatomic structures resisting upward rotation.
■
Open rhinoplasty provides optimal exposure to the nasal framework. Such
exposure allows comprehensive diagnosis and greater accuracy in surgical execution.
■
Fibrous attachments of the lower lateral cartilages to the upper lateral cartilages, piriform aperture, and caudal septum are responsible for nasal tip support and position.
■
e tripod concept facilitates an understanding of how surgical modications
to the medial and lateral crura inuence tip position.
■
Suturing ared medial crura together provides a small increase in nasal tip
projection.
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■
If changes in the shape of the columella, alteration of the alar-columellar relationship, and/or columellar-labial transition are desired, this pocket can be
dissected closer to the columellar skin.
■
Open approach placement of a columellar strut provides superior control and
a greater increase in tip projection.
■
Lateral crural steal involves advancing the lateral crura medially and using horizontal mattress sutures to create new tip-dening points on each lateral crus.
■
A graduated approach to increasing tip projection includes placement of a
columellar strut gra, followed by lateral crural steal with xation to the strut,
and if necessary, tip graing may also be used to achieve greater tip projection.
■
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.
■
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.
■
Increasing rotation of the nasal tip requires evaluation of each factor that may
limit upward rotation. e result of such assessment guides surgical decision
making.
■
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 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.
■
Creating supratip break places the tip-dening points to mm above the
septal angle; varying on skin thickness dierences between the dorsum and tip.
■
Distortion of the delivered cartilage is the primary disadvantage with the cartilage delivery technique.
■
Advantage of the open approach is optimal visualization of the undisturbed
nasal infrastructure providing a more accurate diagnosis and treatment.
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REFERENCES
1. Gunter JP, Hackney FL. Basic nasal tip surgery: anatomy and technique. In Gunter JP, Rohrich RJ,
Adams WP Jr, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters, ed . St Louis: Quality Medical Publishing, .
2. Rohrich RJ, Ahmad J. Rhinoplasty. Plast Reconstr Surg :e-e, .
3. Janeke JB, Wright WK. Studies on the support of the nasal tip. Arch Otolaryngol :-, .
4. Anderson JR. A reasoned approach to nasal base surgery. Arch Otolaryngol :-, .
5. Gunter JP, Yu YL. e tripod concept for correcting nasal-tip cartilages. Aesthet Surg J :-,
.
6. Ghavami A, Janis JE, Acikel C, Rohrich RJ. Tip shaping in primary rhinoplasty: an algorithmic approach. Plast Reconstr Surg :-, .
7. Petro MA, McCollough EG, Hom D, et al. Nasal tip projection: quantitative changes following
rhinoplasty. Arch Otolaryngol Head Neck Surg :-, .
8. Tardy ME Jr, Walter MA, Patt BS. e overprojecting nose: anatomic component analysis and repair. Facial Plast Surg :-, .
9. Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg :-, .
10. Unger JG, Lee MR, Kwon RK, Rohrich RJ. A multivariate analysis of nasal tip projection. Plast Reconstr Surg :-, .
11. Rohrich RJ, Kurkjian TJ, Hoxworth RE, et al. e eect of the columellar strut gra on nasal tip
position in primary rhinoplasty. Plast Reconstr Surg :-, . Erratum in Plast Reconstr
Surg :, .
12. Rohrich RJ, Hoxworth RE, Kurkjian TJ. e role of the columellar strut in rhinoplasty: indications
and rationale. Plast Reconstr Surg :e-e, .
13. Sheen JH. Achieving more nasal tip projection by the use of a small autogenous vomer or septal
cartilage gra. A preliminary report. Plast Reconstr Surg :-, .
14. Sheen JH, Sheen AP. Aesthetic Rhinoplasty, ed . St Louis: Quality Medical Publishing, .
15. Arden RL, Crumley RL. Cartilage gras in open rhinoplasty. Facial Plast Surg :-, .
16. Constantian MB. Distant eects of dorsal and tip graing in rhinoplasty. Plast Reconstr Surg :; discussion -, .
17. Peck GC. e dicult nasal tip. Clin Plast Surg :-, .
18. Peck GC. e onlay gra for nasal tip projection. Plast Reconstr Surg :-, .
19. Peck GC. Techniques in Aesthetic Rhinoplasty. New York: ieme-Stratton, .
20. Gibson T, Davis WB. e distortion of autologous cartilage gras: its cause and prevention. Br J
Plast Surg :-, .
21. Johnson CM, Wyatt CT. A Case Approach to Open Structure Rhinoplasty, ed . Philadelphia: Elsevier, .
22. Byrd HS, Andochick S, Copit S, et al. Septal extension gras: a method of controlling tip projection
shape. Plast Reconstr Surg :-, .
23. Ha RY, Byrd HS. Septal extension gras revisited: -year experience in controlling nasal tip projection and shape. Plast Reconstr Surg :-, .
24. Rohrich RJ, Hoxworth RE, ornton JF, Pessa JE. e pyriform ligament. Plast Reconstr Surg
:-, .
25. Lee MR, Geissler P, Cochran S, Gunter JP, Rohrich RJ. Decreasing nasal tip projection in rhinoplasty. Plast Reconstr Surg (in press).
26. Rich JS, Friedman WH, Pearlman SJ. e eects of lower lateral cartilage excision on nasal tip projection. Arch Otolaryngol Head Neck Surg :-, .
27. Fredricks S. Tripod resection for “Pinocchio” nose deformity. Plast Reconstr Surg :-, .
28. Gunter JP, Friedman RM. Lateral crural strut gra: Technique and clinical applications in rhinoplasty. Plast Reconstr Surg :-; discussion , .
29. Goldman IB. e importance of the medial crura in nasal-tip reconstruction. Arch Otolaryngol
:-, .
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30. Tardy ME Jr, Patt BS, Walter MA. Transdomal suture renement of the nasal tip: long-term outcomes. Facial Plast Surg :-, .
31. Tebbetts JB. Shaping and positioning the nasal tip without structural disruption: a new, systematic
approach. Plast Reconstr Surg :-, .
32. Gruber RP. Suture correction of nasal tip cartilage concavities. Plast Reconstr Surg :-,
.
33. Daniel RK. Rhinoplasty: a simplied three-stitch, open tip suture technique. Part I: Primary rhinoplasty. Plast Reconstr Surg :-, .
34. Daniel RK. Rhinoplasty: a simplied, three-stitch, open tip suture technique. Part II: Secondary
rhinoplasty. Plast Reconstr Surg :-, .
35. McKinney P, Stalnecker M. Surgery for the bulbous nasal tip. Ann Plast Surg :-, .
36. Webster RC, White MF, Courtiss EH. Nasal tip correction in rhinoplasty. Plast Reconstr Surg :, .
37. Rohrich RJ, Adams WP Jr. e boxy nasal tip: classication and management based on alar cartilage suturing techniques. Plast Reconstr Surg :-; discussion -, .
38. Rohrich RJ, Grin JR. Correction of intrinsic nasal tip asymmetries in primary rhinoplasty. Plast
Reconstr Surg :-; discussion -, .
39. Guyuron B, Behmand RA. Nasal tip sutures Part II: e interplays. Plast Reconstr Surg :; discussion -, .
40. Rohrich RJ, Liu JH. Dening the infratip lobule in rhinoplasty: anatomy, pathogenesis of abnormalities, and correction using an algorithmic approach. Plast Reconstr Surg :-, .
41. Gunter JP, Rohrich RJ. External approach for secondary rhinoplasty. Plast Reconstr Surg :-,
.
42. Rohrich RJ, Lee MR. External approach for secondary rhinoplasty: advances over the past years.
Plast Reconstr Surg :-, .
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18
Advanced Suture Techniques
Ronald P. Gruber Aaron J. Berger Edwin Kwon
Rhinoplasty is considered by most to be the most dicult of all aesthetic
plastic procedures. For many years the nasal tip was considered to be the most
complex part of rhinoplasty. e broad, bulbous, round nasal tip was treated
with much cartilage resection, scoring, and bruising, all in an attempt to reduce
its size and bring about a normal shape. Unfortunately, postoperatively, very few
nasal tips were of very high quality. It was eventually recognized that destructive
techniques simply were not working and that remodeling and remolding with
sutures would be the best way to achieve controllable and replicable results.
BACKGROUND
Suture techniques to control the cartilages of the nose and therefore nasal shape
originated with Jacques Joseph in the s. He developed the basis of today’s
columellar-septal suture when he used sutures to secure the tip complex to the
septum. Modern techniques began in large part with Tardy et al, who applied
a transdomal suture to control dome width in the closed approach. In the s
Daniel introduced his domal denition suture in the open approach. is was
followed by a urry of suture techniques, which became part of the rhinoplasty
evolution and continue to be developed today. Guyuron and Behmand provided
a review of commonly employed suture techniques. A signicant number of surgeons have contributed enormously to this eld.
us to favor the suture techniques discussed in this chapter.
INDICATIONS AND CONTRAINDICATIONS
ere is an indication for suture techniques in rhinoplasty, particularly primary
rhinoplasty, in virtually every case. Any nasal tip that is not normal and that re-
-
Our personal experience led
351
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quires reshaping is likely to benet from the suture techniques described here.
ere are virtually no contraindications.
In a secondary case, suture techniques are used rst to reshape the nasal tip. If
suture techniques do not achieve the result because, for example, the cartilages
are decient or defective, cartilage graing is used to restore the tip. However,
the surgeon will likely select suture techniques as a rst choice, because they are
simple, fast, safe, and save donor cartilage.
Tip contour is controlled largely with various suture techniques.
PREOPERATIVE ASSESSMENT AND PLANNING
e patient for a rhinoplasty is assessed for any tip abnormalities. ese include
bulbosity (broad tip, wide tip, round tip, or boxy tip). When any of these abnormalities is present, the plan is suture tip-plasty. e rst step of that plan is to
convert the tip complex to a tripod in which two of the “legs” are lateral crura
mm wide. Wide lateral crura are relatively easy to control with sutures and can
be relied on not to collapse. Crushing, bruising, scoring, or resection of the lateral crura to a smaller size causes weakness and complications such as rim collapse and alar retraction.
e third leg of that tripod is the paired middle/medial crura. e surgical plan
therefore is to separate the cephalic part of the lateral crus to leave such a tripod
and plan on shaping the tripod to normal anatomy. An anatomic model helps
the surgeon determine what that shape should be rather than trying to memorize
the various angles and dimensions.
e techniques described can all be done, and have been done, using the closed
approach. e tip cartilages have to be delivered with intercartilaginous and marginal incision, and the process is not quite as exacting, but it can be done that way.
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OPERATIVE TECHNIQUE
Suture Tip-plasty
Aer the nose is opened and the tip cartilages exposed, an appropriately wide lateral crus is developed that should be approximately mm wide. A
lateral crus of that width is easiest to manipulate
with sutures and has enough structural integrity
to avoid collapse.
However, the surgeon must decide whether the cephalic component (sometimes
called the cephalic island) needs to be preserved to avoid or minimize alar retraction (see Chapter ). Otherwise, it should simply be excised. Aer that decision
is made, a series of suture techniques are applied as needed to create a normalshaped nasal tip framework.
Transdomal Suture
A - PDS horizontal mattress suture on P- needle is applied to the dome starting at the caudal end so that the knot is not in the supratip region. If the dome
is dicult to identify, the tip cartilages are gently squeezed with forceps, which
causes the dome to become more apparent. e suture is not tied too tight, but
to the appropriate width. Aer that is done, the domes take on an axis, and the
separation between thoses axes is usually about degrees. Some improvement
to the lateral crus convexity also occurs.
e transdomal suture narrows the dome.
Transdomal suture
Hemitransdomal suture
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Hemitransdomal Suture
When eversion of the lateral crus is desired, a hemitransdomal suture is useful and oen replaces the transdomal suture. While the dome is held with a
ceps, a - PDS simple suture is applied to the cephalic side of the dome.
for
is squeezes only the cephalic side, causing the lateral crus to evert and even
straighten slightly.
e hemitransdomal suture narrows the dome and everts it.
Eversion
e two sutures (transdomal and hemitransdomal) can be compared side by side.
is small amount of eversion is important if it is to minimize a pinching of the
domes and a resultant rim concavity.
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