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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 Structural Graing of the Nasal Tip 425
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In secondary cases, anatomic reconstruction of the weakened or interrupted
lower lateral cartilages and reconstitution of a stable nasal tip tripod must be
performed for a predictable outcome.
ESTABLISHING TIP PROJECTION AND POSITION
An accurately positioned and stable nasal tip is essential for a successful rhinoplasty. In secondary cases with an overresected nasal skeleton, tip projection is
usually lost and has to be reestablished. Structural gras for tip projection include
the columellar strut gra, the caudal septal extension gra, and tip gras. With
increase in tip projection, a higher dorsum is required, which helps to create a
narrower appearance in wide noses. is is particularly important for patients
with thick skin and overresected nasal cartilages. e typical pollybeak deformity caused by an overresected nasal skeleton can be corrected by adjusting the
tip projection. In the majority of secondary cases in which the nasal skeleton
has been overresected, dorsal augmentation is needed aer nasal tip projection
is increased.
In secondary cases with an overresected nasal skeleton, tip projection is usually
lost and has to be reestablished. Tip projection can be achieved with a columellar strut gra, caudal septal extension gra, or tip gras.
Columellar Strut Gra
e columellar strut gra is the most versatile and powerful tool to stabilize
the columellar base, strengthen the weak medial and middle crura, increase tip
projection, and change tip rotation. It is placed in a pocket between medial and
middle crura, keeping a bed of so tissue between the gra and the anterior nasal
spine. If an increase in tip projection is needed, longer and stronger columellar
strut gras are used and the medial crura are advanced on the columellar strut
gra. In this case, the columellar strut gra is placed in the pocket and the medial
crura are pulled upward in the direction of desired tip rotation and projection.
Needles are passed through the medial crura and the strut to judge whether the
desired eect is obtained and the strut is then xated with - nonabsorbable
nylon sutures to the medial crura.
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e columellar strut gra is a very useful tool for stabilizing the columellar base
and correcting medial crural deformities. A long and strong columellar strut gra
can be used to increase tip projection by advancing medial crura on it.
Caudal Septal Extension Gra
A caudal septal extension gra is a rectangular cartilage that is extended o the
caudal septum and sutured between the medial crura. It is a useful tool for setting the projection and rotation of the nasal tip. To maximize stability and avoid
asymmetries, it should be stabilized to the existing caudal septum with bilateral
spreader gras.
As for xation of the columellar strut gra, needles are passed through the medial crura and septal extension gra to judge the position of the tip, and then the
medial crura are xated to the septal extension gra. If the caudal septal extension gra is prepared from rib cartilage, it can be stabilized to the caudal septum
with PDS plates to avoid extra thickness of the columella.
Chapter Structural Graing of the Nasal Tip 427
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Tip Gras
Tip gras can be used to increase tip projection and improve tip contour. In revision cases, shield-shaped tip gras are preferred to achieve tip denition and
hide tip asymmetries. If the shield gra is prepared from rib cartilage, visibility
of the sharp edges of the cartilage can be a problem in the long term; hence these
gras are camouaged using fascia or perichondrial gras.
Tip gras can be used to increase tip projection and improve tip contour. In secondary cases, shield-shaped tip gras are preferred to achieve tip denition and
hide tip asymmetries. e sharp edges of the cartilage can be camouaged using
fascia or perichondrial gras.
Lateral Crural Reconstruction
Overzealous resection of the lateral crura may result in alar rim collapse because
of severe attenuation or interruption of the alar rim strip. Patients usually present
with narrow nostrils and a pinched tip deformity. In many cases, nasal airway
obstruction resulting from external nasal valve collapse accompany this deformity. Internal nasal valves might also be aected.
Weak, misshapen, malpositioned, or segmentally decient lateral crura must be
reconstructed to achieve a stable nasal tip tripod for an aesthetically pleasing
outcome and functioning external and internal nasal valves. e lateral crural
gra is a versatile tool for reshaping, repositioning, or replacing the missing segments of the lateral crura. e gras can be prepared from septal, auricular, or
rib cartilage.
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e lateral crural gra is a versatile tool for reshaping, repositioning, or replacing the missing segments of the lateral crura and domes.
If the deformity is not severe, such as attenuated lateral crura or a missing small
segment, replacing or strengthening the deformed segment with a lateral crural
gra is the preferred method of reconstruction to establish the shape and stability of the lateral crura.
If the lateral crura are missing but the medial crura and domes are intact, the vestibular skin is dissected o the undersurface of each dome to xate lateral crural
gras. Long lateral crural gras, prepared from septal or rib cartilage, are then
sutured to the undersurface of each dome to replace the missing lateral crura.
e gras are kept long enough to extend laterally to the piriform aperture.
Chapter Structural Graing of the Nasal Tip 429
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If the domes and lateral crura are missing or severely deformed, a columellar
strut gra is placed to reconstruct the caudal leg of the tripod and it is xated to
the medial crural remnants. Long lateral crural gras are prepared from the rib
cartilage (usually the length of the septal cartilage is insucient) and thinned,
to allow the gra to bend.
e lateral crural gras are xated to the columellar strut gra with two sutures
about to mm below the upper end of the columellar strut gra. en the lateral crural gras are bent and domes are created with dome spanning sutures.
e newly created domes are approximated with a dome equalization suture. is
suture helps create two tip-dening points and supratip break point.
Long lateral crural gras can be prepared from rib cartilage and thinned, allowing the gra to bend and be used to reconstruct the missing domes and the
lateral crura.
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In some patients and the elderly, the rib cartilage is more calcied and rigid, and
it is not usually possible to carve thin lateral crural gras that are pliable enough
to create new domes with spanning sutures. In these cases, the lateral crural gras
are sutured to the tip of the columellar strut to reconstitute the nasal tip tripod.
e gras are extended laterally to the piriform aperture. e angle between columellar strut and lateral crural gra is kept at approximately degrees.
To preserve this angle and for the stability of the lateral
crural gra−columellar strut gra junction, small triangular cartilage gras can be placed between the lateral
crural gras and the columellar strut gra just underneath the suture line
To create the tip-dening points and camouage the
sharp edges of the columellar strut gra and lateral crural gras, a tip gra can be placed on top of the junction.
Case Analyses
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Chapter Structural Graing of the Nasal Tip 431
To camouage the sharp edges of the tip gra, an onlay
rectus fascia gra or a perichondrial gra is placed on
the newly reconstructed dome.
Aer one prior rhinoplasty, this -year-old woman presented with low tip projection, a pollybeak deformity, an inverted-V deformity, and functional nasal
problems. Both lateral crura were missing, and she had weak medial crural remnants.
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e operative goals included the following:
■
Rene the dorsal aesthetic lines.
■
Correct the inverted-V deformity and improve the internal nasal valves.
■
Reduce the dorsal hump.
■
Correct the pollybeak deformity.
■
Increase tip projection and improve the columellar-lobular angle.
■
Reconstruct the missing lateral crura.
Sixth rib cartilage was harvested. Bilateral spreader gras were placed to reconstruct the internal nasal valves. A long columellar strut gra was placed between
the medial crural remnants. e lateral crural gras were sutured to the tip of
the columellar strut gra. A shield-type tip gra was used to achieve extra projection. A piece of rectus abdominis fascia was placed to smooth the sharp edges
of tip gra. A thin, diced cartilage−rectus abdominis fascia gra was placed to
camouage dorsal irregularities.
Chapter Structural Graing of the Nasal Tip 433
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e patient is shown months aer surgery. e nasal tip projection is increased
and a structured nasal tip has been achieved, with functional improvement. e
inverted-V deformity is corrected and the nasal dorsum is smooth.
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Aer one prior rhinoplasty, this -year-old patient presented with tip asymmetry, a hanging columella, an overresected dorsum, septal deviation, and functional problems. On the right side, a segment of the middle crura was missing.
Septal cartilage remained untouched aer the primary surgery but was severely
deviated.
e operative goals included the following:
■
Rene and augment the nasal dorsum.
■
Correct the septal deviation and reconstruct a straight, stable septal L-strut.
■
Correct the hanging columella and support the medial and middle crura.
■
Reconstruct the missing segments of the lower lateral cartilages and correct tip asymmetry.
■
Support the alar rims.
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