Augmenting the nasal tip using the open approach and sutures

Augmenting the Nasal Tip Using the Open Approach and Sutures using permanent mattress irst, I want to make clear that I am specifically sutures. I have not found that addressing techniques for primary rhinoplasty. simply mobilizing the soft tisWhen I discuss the use of sutures versus grafts, sues of the medial crura weakI want to distinguish the techniques for primaens them. If the length of either ry rhinoplasty from those for secondary procedures, crus or the columella lobule because I believe tip grafts are definitely a logical first angle is not what I want, then I option in secondary rhinoplasty, in which normal fashion control columella anatomy is not present. But in my opinion, tip grafts are John B. Tebbetts, MD struts, which I u s e a s a jig, Dallas, 13( not the most logical first option in primary rhinoplasty, bending the medial crura and because placing a tip graft introduces at least nine varithe middle crus to match the shape that I've defined to ables that I can think of: malposition, displacement, the strut. I stabilize this with needles and use internal warping, resorption, visible irregularities, infection, horizontal mattress sutures to anchor the strut and bend extrusion, soft-tissue deformation and soft-tissue atrothe crura to fit the strut. This provides a very stable and phy. The techniques that I've tried to focus on are exactly shaped complex. unique in several principal respects: each preserves the The most common deformistructural integrity of the ty in the lateral crus is the alar cartilage and thus sup~The surgeon h a s t h e luxury lateral alar convexity, or the port of the tip; each can be bulge that is encountered in applied incrementally in a O f not having to be right the a box tip, and I correct this controlled manner; and each with a horizontal mattress is reversible. In addition, the ~st t i m e a n d i s a b l e to a v o i d suture called a lateral crural combination of suture techpermanently compromising spanning suture, which niques and nonvisible spans the supratip dead grafts that is, those that struclllre... ~ space. With all of these don't contact the soft-tissue sutures, it is critical to envelope enables the surunderstand that they can geon to achieve very good produce deformity to the tip shaping and positioning without grafts in at least 90 same extent that they correct it. Most surgeons who use percent of primary cases. sutures overtighten them, and this disrupts normal anatomic relationships, so it is critical to tighten the The sequence in which I approach the tip is vital. It sutures just enough to correct the deformity. Sutures are begins with soft-tissue skeletonization to create struca means of applying incremental, very precise forces to turally symmetrical, rim-stripped elements. In stage two, change the shape of the existing anatomy. I try to unify the medial crura and create basic dome height projection symmetry. Next, I shape the lateral One of the major differences between these techniques crura and domes. Now I have a symmetric unified tip and others is that these allow a lot of mobility in the complex, which is then moved anteriorly or posteriorly unified tip complex. This complex can be moved within for projection, and then in a cephalad caudal arch for a range of at least five millimeters anteriorly or posterirotation relative to the osseocartilaginous vault and orly without producing any substantial distortions anyfacial plane. The suture shaping of the tip should be where else. I've used these techniques for well over ten done toward the end of the rhinoplasty to avoid disruptyears now, and there's no question in my mind that they ing all of the precise and delicate changes that have been work and will last if they are applied properly. The surproduced in the tip. geon has the luxury of not having to be right the first time and is able to avoid permanently compromising Before I place the sutures and adjust the alar cartilages, I structure or introducing variables before knowing establish symmetry of the alar cartilages. If the shape of whether he or she is right. 9 the medial crura--that is, the length of the medial crus, the length of the middle crus and columella lobule Contributor acknowledges having some financial interest in angle is good, then I simply stabilize this relationship related products.

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AESTHETIC

SURGERY

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WINTER

1995

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