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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4366_Библиотеки_им_академика_М_И_Перельмана
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Chapter Achieving Aesthetic Balance of the Infratip Lobule 385
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In situations in which the lateral crus is slightly overrotated because of suture
placement for tip projection or tip sculpting, an alar contour gra or lateral crural
strut gra can correct the rim position.
,
e need for alar rim support is based
on the trajectory of the lateral crus. Adequate alar rim support and preservation
of the normal alar-columellar relationship ensure that the perceived lobular projection equals the actual projection.
Adequate alar rim support and preservation of the normal alar-columellar relationship ensure that the perceived lobular projection equals the actual projection.
CASE ANALYSES
is patient had a mildly prominent caudal septum (type V extrinsic deformity).
On the frontal view, her nostril apex was cranial to the midpoint of the lobule,
and she had mild alar retraction. ese ndings were consistent with a type III
deformity with lower lateral malposition and abnormal rotational orientation of
the lower lateral cartilage. Additionally, she had a dorsal hump, no supratip break,
and a slight hanging tip. Intraoperatively she was noted to have a long (type I)
and wide (type II) middle crus with very convex lower lateral cartilages.
e operative goals included the following:
■
Reduce the dorsal hump.
■
Re-create symmetrical dorsal aesthetic lines.
■
Correct the caudal septal deviation.
■
Improve tip denition and balance.
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Primary open approach
3 mm dorsal reduction
Lower
lateral crural
turnover flap
6mm
Tip Sutures
Interdomal
Intercrural
Transdomal
Alar contour graft
Alar contour grafts
Turnover
flap
Surgical Plan
1. Perform an open approach with a stair-step transcolumellar incision and bilateral infracartilaginous extensions
2. Reduce the dorsal hump by mm in component fashion.
3. Resect the caudal septum.
4. Apply lower lateral crural turnover aps, and preserve a mm alar rim strip.
5. Place a columellar strut gra.
6. Place intercrural, interdomal, and transdomal sutures.
7. Perform low-to-low percutaneous perforated lateral osteotomies.
8. Place alar contour gras.
Chapter Achieving Aesthetic Balance of the Infratip Lobule 387
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Postoperatively the patient has symmetrical dorsal aesthetic lines, a corrected
dorsal hump, a narrowed bony base, and a rened tip. e basal view shows narrowing of the nasal tip and improvement of the caudal septal deviation.
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is patient had a tension tip and prominent caudal septum (type V extrinsic
deformity). e frontal and lateral views showed a mildly retracted ala and an
abnormal alar-columellar relationship, suggesting lower lateral cartilage malposition and abnormal rotational orientation, which indicated a type III deformity.
Additionally, she had a reverse-C–shaped dorsal deviation, a large dorsal hump,
caudal septal deviation, and an overprojected tip. Intraoperatively her middle
crus was long (type I) and wide (type II).
e operative goals included the following:
■
Reduce the dorsal hump.
■
Straighten the nose.
■
Create symmetrical dorsal aesthetic lines.
■
Correct the caudal septal deviation.
■
Decrease projection of the tension tip.
■
Improve tip denition and balance.
Chapter Achieving Aesthetic Balance of the Infratip Lobule 389
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Primary open approach
7 mm dorsal reduction
6mm
Tip sutures:
Interdomal
Intercrural
Transdomal
Alar contour grafts
Swinging
door flap
Depressor septi release
Surgical Plan
1. Perform an open approach with a stair-step transcolumellar incision and bi-
lateral infracartilaginous extensions.
2. Reduce the dorsal hump by mm in component fashion.
3. Harvest septal cartilage, preserving an L-strut.
4. Reposition the caudal septum onto the anterior nasal spine.
5. Perform transnasal release of depressor septi nasi muscle.
6. Perform cephalic trim, maintaining a mm alar rim strip.
7. Apply bilateral spreader gras.
8. Place a columellar strut gra.
9. Use intercrural, interdomal, and transdomal sutures.
10. Perform low-to-low percutaneous perforated lateral osteotomies.
11. Place alar contour gras.
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Eighteen months postoperatively, the patient demonstrates a straight dorsum,
symmetrical dorsal aesthetic lines, a corrected dorsal hump, and decreased projection and renement of the tip. Her basal view shows narrowing of the nasal
tip and correction of the caudal septal deviation.
CONCLUSION
e infratip lobule is central to the lower third of the nose. Establishment of
an algorithm and endpoints for the variety of surgical maneuvers is essential
for consistent and predictable results. Our method of medial to lateral stepwise
correction provides aesthetic results when used in conjunction with our overall
surgical philosophy in rhinoplasty.
Chapter Achieving Aesthetic Balance of the Infratip Lobule 391
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KEY POINTS
■
e infratip lobule is the area of the nose bounded by the tip-dening points
superiorly, the columella caudally, and the so triangles and the apices of the
nostrils laterally.
■
e trajectory, length, and strength of the middle crura of the lower lateral cartilages dene the shape, contour, and projection of the infratip lobule.
■
In type I infratip lobular deformities, the excess vertical height of the middle
crus is limited by its surroundings, causing it to buckle or bow outward inferiorly. is results in excess infratip lobular projection.
■
In type II infratip lobular deformities, a wide middle crus pushes on the infratip
lobule, causing overprojection.
■
Type III infratip lobular deformities most oen relate to the angle of departure
between the lateral crus and the alar rim or to the rotational orientation of the
lateral crus with respect to its cranial and caudal edges.
■
e surgical approach to the correction of excess infratip lobular projection
treats each type of deformity in a stepwise fashion from medial to lateral.
■
e junction of the middle and lateral crura is set using an interdomal suture.
■
e endpoint of transdomal suturing is a straight and at lateral crus and
proper rotational orientation.
■
Alar rim position corresponding to a rotational level in which the cephalic
and caudal edges are on the same plane will provide an ideal infratip lobular
projection.
■
Adequate alar rim support and preservation of the normal alar-columellar relationship ensure that the perceived lobular projection equals the actual projection.
REFERENCES
1. Gunter JP, Rohrich RJ, Adams WP Jr. Dallas Rhinoplasty: Nasal Surgery by the Masters, ed . St
Louis: Quality Medical Publishing, .
2. Rohrich RJ, Liu JH. Dening the infratip lobule in rhinoplasty: anatomy, pathogenesis of abnor-
malities, and correction using an algorithmic approach. Plast Reconstr Surg :-, .
3. Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg :-, .
4. Ghavami A, Janis JE, Acikel C, Rohrich RJ. Tip shaping in primary rhinoplasty: an algorithmic ap-
proach. Plast Reconstr Surg :-, .
5. Gunter JP, Friedman RM. Lateral crural strut gra: technique and clinical applications in rhino-
plasty. Plast Reconstr Surg :-; discussion -, .
6. Rohrich RJ, Raniere J Jr, Ha RY. e alar contour gra: correction and prevention of alar rim de-
formities in rhinoplasty. Plast Reconstr Surg :-; discussion -, .
7. Guyuron B. Dynamics of rhinoplasty. Plast Reconstr Surg :-; discussion , .
8. Sheen JH, Sheen AP. Aesthetic Rhinoplasty, ed . St Louis: Quality Medical Publishing, .
9. Daniel RK. e nasal tip: anatomy and aesthetics. Plast Reconstr Surg :-, .
10. Anderson JR. A reasoned approach to nasal base surgery. Arch Otolaryngol :-, .
11. Gunter JP, Yu YL. e tripod concept for correcting nasal-tip cartilages. Aesthet Surg J :-,
.
12. Gunter JP, Rohrich RJ, Friedman RM. Classication and correction of alar-columellar discrepan-
cies in rhinoplasty. Plast Reconstr Surg :-, .
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20
Structural Graing of the Nasal Tip
Nazim Cerkes
F or a rhinoplasty to be successful, the nasal tip must be well dened and project
properly. is requires accurate preoperative diagnosis of the nasal tip’s structural deformities.
e lower third of the nose has a tripod-like support structure that is made up
of the conjoined medial crura and lateral crural complex based bilaterally on the
piriform aperture (see Chapter ). e medial crura together form one leg of
the tripod, and the lateral crura make up the other two legs. e middle crura
act as a transition between the dierent planes of the lateral and medial crura
and contribute to the double break and infratip lobule. In rhinoplasty, the tripod should be maintained and/or restored to provide tip support and a normalappearing nasal tip shape.
393
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e lower third of the nose has a tripod-like support structure that is made up of
the conjoined medial crura and lateral crural complex based bilaterally on the
piriform aperture. Reconstructing a stable tripod structure supports the nasal tip,
strengthens the alar sidewalls, and provides an aesthetically pleasing nasal tip.
Major tip support mechanisms must be understood and respected in both primary and secondary rhinoplasty.
-
e main components of tip support include
the length and the strength of the lower lateral cartilages, the attachment of the
cephalic margin of the lateral crura to the caudal margin of the upper lateral cartilages, and the ligamentous attachments between conjoined medial crura and
caudal septum. If any of these support mechanisms is interrupted, various surgical maneuvers must be used to reinforce the tip support.
Airway obstruction resulting from nasal valve collapse is usually attributed to
lateral nasal wall weakness. Nasal functional problems aer rhinoplasty include
internal and external nasal valve collapse. External nasal valve dysfunction is
caused by medial displacement of alar rims during forced inspiration. is problem is caused by the structural weakness of the alar rims. e alar rims need to
be supported with cartilage gras for treatment of external nasal valve collapse.
Adequate tip projection is dened as the presence of % to % of the tip lying
anterior to the most projecting point of the upper lip. One of the vital steps of
a rhinoplasty operation is to control the nasal tip projection and position. e
length and strength of the medial crura is critical for tip projection and denition. e shape and stability of the lateral crura are additional important factors
for aesthetic and functional outcomes.
A 50%-60%
of AB
A
B
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