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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 A Predictable and Algorithmic Approach to Tip Renement and Projection 445
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e nasolabial angle and alar-columellar relationship should be evaluated using
previously established criteria, and are also best evaluated on the lateral view.
,
Maneuvers that increase tip projection will frequently aect the nasolabial and
columellar-labial angles.
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2/3
Nostril-tip proportion should be evaluated on the basal view. e ideal nostriltip relationship should be approximately :. An imbalance can produce either
an illusionary or a true nostril-tip disproportion, with tip overprojection if the
nostrils are short and an insucient nasal tip if the nostrils are long.
,
Inadequate tip projection may manifest in a number of clinical scenarios. e inadequately projected tip may demonstrate increased alar are, a short columella,
or incorrectly shaped and inclined lower lateral cartilages.
Aer a systematic nasal analysis, surgical goals are established, and the plan is
reviewed with the patient.
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MANAGEMENT ALGORITHM
Assessment of tip projection/refinement and nostril-to-tip balance
◾
Analytical (0.67 3 Ideal nasal length)
◾
Aesthetic (50%-60% anterior to upper lip vertical)
◾
Aesthetic nostril-to-tip ratio (2:1)
No operative intervention
Inadequate tip projection/refinementNormal tip projection
Cephalic trim Lower lateral crural
turnover flap
Invisible/nonpalpable techniques
◾
Columellar strut graft
◾
Septal extension graft
Medial crural suture
Transdomal suture
Interdomal suture
Medial crural septal suture
Invisible tip grafts
Lateral crural malposition
◾
Alar contour graft
◾
Lateral crural strut graft
Reassess tip projection/refinement
Adequate Inadequate
Complete
(intraoperatively)
and nostril-tip balance
Visible tip grafts
◾
Visible/palpable techniques
(if there is adequate tip projection
and/or refinement)
◾
Nostril-shaping techniques
(if there is nostril-tip imbalance)
and/or
Our algorithmic approach for tip renement and increasing projection is outlined above. Although tip sutures and other maneuvers in rhinoplasty can produce a multitude of dynamic changes, only those that pertain to nasal tip projection and tip renement will be described.
Chapter A Predictable and Algorithmic Approach to Tip Renement and Projection 447
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Invisible/Nonpalpable Techniques at Inuence Tip Renement
and Projection
Technique Tip Renement Tip Projections
Cephalic trim
Columellar strut gra
Septal extension gra
Medial crural suture
Transdomal suture
Interdomal suture
Medial crural septal suture
Alar base resection Neutral
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1
1
1
1
6
1
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/
/
Approach
If minimal modications of the nasal tip are required, the closed approach with
cartilage delivery may be used. If a closed approach is used, great care should be
taken to preserve existing anatomic integrity and so tissue attachments of tipsupporting structures. For example, a Killian incision instead of a hemitransxion or full transxion incision may help preserve some so tissue attachments
that support the nasal tip. For major modications of the nasal tip, including
middle vault alterations and all secondary rhinoplasties, we prefer the open approach: it allows direct visualization and accurate assessment of all tip-supporting
structures, and it facilitates precise, controlled, predictable maneuvers.
Great care should be taken to preserve or restore the anatomic integrity of the
tip-supporting structures.
Intraoperative Analysis
Each element responsible for tip support is analyzed aer adequate exposure.
e lower lateral cartilages are assessed for any subtle asymmetries and contour
irregularities. e degree of the convexity/concavity, length/width dimensions,
position, rotational orientation, and symmetry are closely inspected. Analysis of
the length of the medial crura is critical for tip projection and denition. Medial
crura that are long and stable are less likely to contribute to loss of tip projection
postoperatively. Short and/or weak medial crura can lead to a loss of supratip
denition as a result of a decrease in the dierential between dorsal height and
domal peak.
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e domes are characterized in terms of the domal arch width, angle of divergence, and the degree of symmetry.
,
It is important to relate the lateral, middle,
and medial crura together in the analysis because modications made to one will
commonly aect the others.
,
For example, reducing the vertical height of the
domes using an extended cephalic trim will drop the supratip break on frontal
view and enhance tip denition, and improperly stabilized medial crura will result in loss of tip projection and blunting of the supratip break, which eventually
produces a pollybeak deformity.
,,
It is important to note that at each point
along the algorithm where surgical maneuvers are performed, the eect of each
technique should be reassessed.
Manipulation of Lateral Crura
Cephalic Trim
Only when the domes are bulbous or boxy, causing paradomal fullness, is a cephalic trim indicated. It is important to realize that cephalic trim intrinsically
decreases tip support by disrupting attachments of the upper and lower lateral
cartilages at the scroll area. However, cephalic trim is oen a necessary maneuver to facilitate tip renement with suture techniques.
e cephalic portion of the middle and lateral crura is detached from the underlying mucosa and excised leaving at least a mm alar rim strip. Calipers are
used to accurately measure the planned incision. Preserving strong lower lateral
cartilages is particularly important when applying tip-suturing techniques that
recruit the lower lateral cartilages to enhance the domal shape and height. For instance, transdomal, and to a lesser degree interdomal sutures, medialize the lower
Chapter A Predictable and Algorithmic Approach to Tip Renement and Projection 449
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lateral cartilages and produce a relative concavity lateral to the middle crura. If
these maneuvers are performed in the presence of weakened lower lateral crura,
alar retraction, notching and/or external valve collapse may occur.
Lower Lateral Crural Turnover Flap
Full-thickness
incision
Thin score line
on posterior
surface
Full-thickness
incision
Scored and folded
cartilage
As opposed to cephalic trim of the lower lateral crura, the lower lateral crural
turnover ap can be used to preserve this cartilage and use it to correct concavities/convexities of the lower lateral crus, strengthen the external valve, and op
pose pinching of the tip caused by tip suturing. is exploits intrinsic concavities or convexities of the lateral crus and repositions these forces into opposition
resulting in correction of the deformity. is ap is particularly useful when the
lower lateral cartilages appear weak and will help to reduce tip fullness while
making use of the intrinsic strength of the lower lateral cartilages.
-
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Columellar Strut Gra
e columellar strut gra is used for tip unication, correction of medial crural asymmetry, maintenance of tip projection, and establishment of a foundation for nasal tip renement.
strut gra is usually approximately by mm. Most commonly, the columellar
strut gra is invisible between the medial crura but can be made visible when
increased columellar show and infratip lobular augmentation are required. e
columellar strut gra serves a crucial role in maintaining the additive changes
that result from various tip-suturing techniques.
,
Septal cartilage is preferred and the columellar
Columellar struts are the mainstay in providing a stable and strong nasal base
that will allow more liberal use of other tip-suturing techniques.
ere are two variations of columellar strut gras, oating and xed. e oating
strut gra is most commonly used and is inserted between or caudal to the medial crura. Its posterior portion rests in the so tissue to mm anterior to the
anterior nasal spine to prevent audible or palpable clicking against the maxilla.
e medial crura are secured to the strut gra with - PDS horizontal mattress
sutures at the junction of the medial crura with the middle crura (medial crural
suture). Two additional sutures (interdomal sutures) are oen placed anterior to
the rst suture to x the medial portions of the domes to the strut. ese interdomal sutures help camouage the gra making it invisible and nonpalpable. e
columellar strut gra is then further rened, trimmed, and shaped, depending
on the requirements of the infratip lobule. e oating columellar strut gra can
provide to mm of additional tip projection.
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Septal Extension Gra
When more than mm of tip projection is needed, a
xed strut gra can be used. Commonly this is harvested from rib cartilage, notched at the portion abutting the nasal spine, and can be xed in place using
- PDS sutures to the periosteum.
Paired extended spreader grafts Paired batten grafts Direct extension graft
Dissatisfaction with the control and maintenance of tip projection in cases of
midvault collapse (inverted-V deformity) using columellar strut gras led to
the septal extension gra described by Byrd et al. is gra can be an extended
spreader gra, a batten gra, or a direct septal extension gra. e gra extends
beyond the anterior septal angle into the interdomal space. e upward angle
of the gra is oen degrees, and the length of the tip portion averages mm.
e gra should be xed inferior to the divergence of the middle crura and to a
second point of xation interdomally. Using this gra, the dierential between
the domal height and the nasal dorsum plane (commonly to mm) can be
controlled.
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Guyuron and Varghai described the tongue-and-groove technique as an eective method to create and maintain tip projection when nasal lengthening is also
required. Bilateral extended spreader gras that extend beyond the caudal septum are sutured to the septum and a caudal septal extension gra is positioned
between the groove created by the extended spreader gras. Suturing the medial
crura to the caudal septal extension gra provides stability to the construct.
Medial Crural Suture
Intercrural or medial crural sutures are the rst sutures placed and can be used in
isolation to correct medial crural asymmetries, to reduce aring, and to control
the overall width of the columella. e positioning of the medial crural suture is
dictated by the underlying deformity and intended goal. If aring is to be altered,
the suture should be placed in the region of the footplates. When the goal is to
correct convexities and asymmetries in the columella, then the suture should be
placed at the apex of that convexity to atten it.
Chapter A Predictable and Algorithmic Approach to Tip Renement and Projection 453
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Most commonly, medial crural−columellar strut sutures are placed in the middle
third of the medial crura to secure it to the columellar strut gra. Temporary
straight-needle xation will help ensure accurate suture placement. Fixation to a
columellar strut can increase both tip projection and tip strength simultaneously
as the medial crura are elevated toward the anterior septal angle. ese maneuvers are oen required before other tip sutures are placed because the medial
crural−columellar strut complex acts as a point of stability in the nasal tripod,
and can limit the dynamic eects suture techniques have on the cartilaginous
framework.
,
is process allows a more controlled and incremental approach
to tip renement. As with any tip-suturing technique, the degree of tightening is
proportional to the intensity of the eect.
Transdomal Suture
Transdomal sutures are placed usually aer the nasal base has been stabilized using medial crural suturing with a columellar strut gra. is is a horizontal mattress suture that is placed through the lateral and medial aspects of the domes.
e entry and exit sites of the mattress suture are important—because the suture is placed farther away from the dome apex, greater lateral crural concavity
and tip projection are produced, depending on the amount of suture tightening.
Dierential placement of this suture can be used to correct domal asymmetries
of position and shape. For instance, caudad or cephalad placement of the suture
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will rotate the lateral crura, respectively. e transdomal suture is a powerful
suturing technique, and care should be taken to avoid creating unnecessary tension on the lateral crura, excess concavity adjacent to the domes, and more tip
projection than required.
Suturing techniques should be employed incrementally, starting with the medial
crural−columellar strut suture to secure and stabilize the columellar strut gra.
If a septal extension gra is used, this is secured to the septum rst, before suturing techniques are employed. Transdomal sutures are commonly required and
are a powerful tool in simultaneously controlling tip projection and denition.
Medial crural septal sutures may be placed to aect tip rotation and drooping.
Interdomal Suture
e interdomal suture is a horizontal mattress suture placed between the domal
segments of the middle crura of the lower lateral cartilages. is suture is rarely
indicated without concomitant transdomal sutures, and when used in isolation
can potentially decrease tip projection by attening the domes. Transdomal sutures can be placed rst, because some interdomal narrowing can be achieved.
e suture ends of the transdomal suture can be le long and tied to one another
to duplicate the eect of an interdomal suture, if indicated.
e interdomal suture technique decreases the angle of domal divergence, narrows the tip-dening points, can further camouage a columellar strut gra or
septal extension gra and enhance the infratip lobule, and increases projection.
When the suture is placed in the caudal portion of the domes, this technique can
also rotate the lateral crura caudally. When improperly placed, interdomal sutures can have deleterious eects on tip shape by unifying the tip-dening points,
reducing domal denition, and excessively narrowing the nasal tip.
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