Augmenting the nasal tip using the closed approach and grafts

Augmenting the Nasal Tip Using the Closed Approachand Grafts dome, then I will deliver the alar he shape of the tip lobule is one of three cartilages. I close the incisions as determinants that help me to plan a rhinoI place the grafts. The tip grafts plasty. The other two are the thickness of are placed last. I first try to fill the skin and the relationship between the out the superior part of the lobsize of the base and the height of the bridge. To achieve ule as much as necessary and good nasal tip aesthetics, the most projecting point of then add more grafts to the the tip should be rather high, the supratip should be anterior lobule, either in contiflat and the mass of the tip lobule should fall caudal to Mark B. Constantian, MD nuity or in a separate pocket. the most projecting point--not cephalad to it. I look at Nashua, NH a tip and determine the areas that need subtraction of I have always used the closed skeletal support and the areas that need addition of approach. The main advantage of performing a closed skeletal support. Septal cartilage would be my first rhinoplasty is that I rarely have to fix the grafts, choice for graft material if it were available, because because I can control the dimensions in the pocket, it's the most plastic substance. My second choice, if particularly in the tip. I can, therefore, still correct septal cartilage weren't problems for patients available, would be ear in whom good graft cartilage. Costal cartilage material isn't available can be used, but not as *~The and use grafts that easily. The majority of the would otherwise be is that I can apply these same time, I use multiple grafts unsuitable if I had to that have been crushed suture them through an principles to both primary and slightly. open approach. In terms of subtraction, I I am not a critic of the determine the areas of the open approach; it is alar cartilages that need fine if the surgeon is reduction or interruption capable and pays close of the arch if the vertical attention to detail. But or transverse dimensions are too large, and then augI don't think a surgeon should select the open approach ment the deficient areas. If the superior lobule is flat or because he or she thinks it's going to be easier, because the point of projection needs to be raised, then I will I don't think that it is. Not only c a n you suture grafts, place grafts into these areas. The advantage of this but you often m u s t suture them. Second, the dissection approach is that I can apply these same principles to of the columella to create the open approach to the tip both primary and secondary rhinoplasty procedures, separates that very densely adherent skin from the because the parameters depend on soft tissue contours, medial crura, which destabilizes the medial crura to not skeletal structure. some degree. I think in many situations, this creates the need for a columella strut to support the base so that The problems that I have encountered have been either the tip can be fixed in the desired location, thereby making the grafts too small, placing them too caudally, increasing graft requirements. Finally, just as you can't using too few grafts, or using grafts that are too stiff; I limit the pocket, you can't use tiny scraps or crushed have discovered that it is paradoxically simpler to use cartilages to fill out a tip as easily using the open multiple, rather than single grafts, and I don't anchor approach, because they must be suture-fixed, which is the tip grafts. Most of the problems with tip grafting difficult or impossible. The putative advantage of the are technical, and therefore diminish with practice; they open approach--that you can see anatomical details are not idiosyncratic. that would otherwise be hidden--is more theoretical If I have to make only minimal modifications to the than real. If the underlying anatomy is not distorting alar cartilages, I will do so through an intercartilagithe surface or obstructing the airway, I ignore it. [] nous incision. If I need to do something more to the alar cartilages such as remove a wedge to narrow the

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advantage of this approach

secondary rhhloplasty procedures..."

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WINTER

1995