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Structure approach in rhinoplasty
CONTEMPORARY TECHNIQUES: AN UPDATE WITH THE MASTERS
1064–7406/02 $15.00 ⫹ .00
STRUCTURE APPROACH IN RHINOPLASTY Dean M. Toriumi, MD
Over the past decade, rhinoplasty techniques have moved away from excisional methods and focused more on repositioning and restructuring existing tissues. These changes in surgical technique were made in part because of some of the untoward long-term changes noted in noses that were treated with excisional techniques. Patients who undergo aggressive resection of the lateral crura tend to develop alar retraction, supra-alar pinching, lateral wall weakness, and nasal valve collapse. Aggressive excision of the middle nasal vault without appropriate reconstruction tends to result in inferomedial collapse of the upper lateral cartilages and nasal valve collapse. Excessive excision of the caudal margin of the septum can result in foreshortening of the nose and postoperative loss of tip projection. The incidence of many of these complications is greater in patients with certain nasal anatomy. It is the responsibility of the surgeon to identify these anatomic variants and make necessary adjustments in surgical technique to avoid complications. The effect of performing cephalic trim of the lateral crura is noted over the lifetime of the patient. When these patients are followed, supra-alar pinching can begin soon after surgery and become much more pronounced 10 to 15 years later.6 At the time of surgery, a reduction
in fullness in the supra-alar region is noted after performing cephalic trim of the lateral crura. Then, after surgery, scar contracture acts on the weakened lateral crura, creating continued narrowing of the supra-alar region. If excessive cephalic trim was performed, the lateral crus can contract superiorly, creating alar retraction. Even if conservative cephalic trim is performed, scar contracture will tend to create narrowing in the supra-alar region. Patients with thin skin, narrow lateral nasal walls, and preoperative prominence of the supra-alar crease are at much higher risk for continued collapse of the supra-alar region postoperatively. In these patients, alar batten grafts or lateral crural strut grafts are placed at the time of the primary surgery to help prevent this complication. Recognition of variant nasal anatomy, alteration of techniques, and placement of grafts to avoid complications will maximize the aesthetic and functional outcomes in rhinoplasty.
CONTROLLING NASAL TIP PROJECTION Success in rhinoplasty is in part related to the surgeon’s ability to control nasal tip projection. When the surgeon has control of
From the Department of Otolaryngology–Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, University of Illinois at Chicago, Chicago, Illinois
FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA VOLUME 10 • NUMBER 1 • FEBRUARY 2002
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nasal tip projection, variables related to healing are decreased and a favorable tip/supratip relationship can be preserved. If adequate tip projection can be attained, the patient’s nasal dorsum can be left higher or raised to provide more favorable lateral wall shadowing and definition. By increasing tip projection, the surgeon can project a favorable shaped tip or dome structure into the nasal tip skin to improve tip shape. This concept is particularly important in patients with thick nasal tip skin. Increasing tip projection will act to narrow the nasal base and open the nasolabial angle. Adequate control of nasal tip projection also requires preventing postoperative loss of nasal tip projection. Postoperative loss of nasal tip projection can result in a supratip polybeak as the tip drops below the supratip. Lack of control of nasal tip projection forces the surgeon to anticipate where the tip will settle. This leads to potential deformities such as a residual dorsal hump, polybeak deformity, or a pronounced tip/supratip relationship. Control of nasal tip projection provides the surgeon with the ability to confidently set intraoperative nasal tip projection and feel confident that the
tip/supratip relationship noted at the time of surgery will be preserved.
STABILIZING THE NASAL BASE Tip projection can be controlled by stabilizing the nasal base before modifying the nasal tip lobule. Anderson1 simplified nasal tip surgery by likening the lower lateral cartilages to a tripod-like structure with the conjoined medial crura making up one leg of the tripod and the lateral crura making up the other two (Fig. 1). The position and stability of the conjoined medial crura greatly influence the position of the nasal tip. Patients who have a poorly supported nasal base are more likely to have an underprojected or dependent nasal tip and acute nasolabial angle. Stabilizing the nasal base in these patients can act to increase nasal tip projection, rotate the nasal tip, and open the nasolabial angle. Maneuvers used to stabilize the nasal base include setting back the medial crura on a midline caudal septum, sutured in place columellar strut, caudal extension graft, or extended columellar strut.
Figure 1. A, Tripod complex of lower third of the nose. The lateral crura make up two legs of the tripod and the third leg is comprised of the conjoined medial crura. Modifications in nasal tip position can be anticipated using the tripod complex of the lower third of the nose. B, Shaded area represents the intermediate crura that diverge to meet the domes.
STRUCTURE APPROACH IN RHINOPLASTY
These maneuvers act to increase projection of the medial crural component of the tripod complex. Patients who have an overly long midline caudal septum are good candidates for setting back the medial crura on the caudal septum. This technique is typically used in patients who would otherwise require trimming of the caudal margin of the nasal septum. In this case, the excessively long caudal septum is suture fixated between the medial crura in a tongue-in-groove fashion and the redundant caudal septum is used to support the nasal tip. After dissecting between the medial crura, the caudal septum is identified. Then bilateral mucoperichondrial flaps are elevated, and redundant septal mucosa is moved cephalically, eliminating the need to trim septal mucosa after repositioning the nasal tip (Fig. 2A). The medial crura are repositioned on the caudal septum and then sutured to the septal cartilage with a 5-0 chromic mattress suture (Fig. 2B). If the tip position, rotation, and alar/ columellar relationship is appropriate, a 5-0 PDS suture is placed from the inner surface of both medial crura to the caudal septum. After the tip position is set and all septal work is completed, a running 5-0 plain gut suture on a straight septal needle is used to quilt the septal mucosa and redistribute the septal mucosa along the nasal septum. If not performed properly, the septal mucosa may bunch intranasally. In most cases, this maneuver is used in patients with a tension nose deformity, overprojected nasal tip, or hanging columella (Fig. 3). There are occasions when an under-
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projected nasal tip can be advanced anteriorly on the caudal septum to increase tip projection. When using this technique, it is critical to avoid creating a retracted columella, foreshortened nose, or over-rotated nasal tip. Other potential deformities include an obtuse nasolabial angle or long upper lip. This can be avoided by only setting back the medial crura on an overly long midline caudal septum that otherwise would require reduction. A rectangular shaped columellar strut can be used to stabilize the nasal base and correct buckling of the medial and intermediate crura.3 The strut typically measures 5 mm to 12 mm in length, 3 mm to 6 mm in width, and 1 mm to 3 mm in thickness. The strut is sutured into a pocket between the medial crura and should not extend to the nasal spine. This type of strut typically does not increase tip projection, but it does support the medial crural component of the tripod complex. The caudal extension graft is a cartilage graft that overlaps the caudal margin of the nasal septum and is sutured between the medial crura to stabilize the nasal base and set tip projection and appropriate alar/columellar relationship (Fig. 4).8 A minimum of two sutures should be applied to fixate the caudal extension graft to the septum. The caudal margin of the extension graft should lie in the midline (Fig. 5). The position of the caudal extension graft will determine the position of the nasal tip and the nasolabial angle. If the caudal extension graft is longer posteriorly, it will act to open the nasolabial angle. If the caudal
Figure 2. A, Setting back the medial crura on an overly long midline caudal septum. Dissection between the medial crura to expose the caudal septum. Note that bilateral mucoperichondrial flaps have been elevated. B, Medial crura set-back and fixated on midline caudal septum with a 5-0 plain gut suture on a straight septal needle. A 5-0 PDS suture will be added to provide additional support.
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Figure 3. Patient with a hanging columella and excessively long caudal septum. Preoperative (A, C, E, G) and postoperative (B, D, F, H) lateral, frontal, oblique, and basal views.
extension graft is longer along the anterior margin, it will tend to counter-rotate the nasal tip. The caudal extension graft is also ideal for correction of the retracted columella. The extended columellar strut is different from a conventional columellar strut because it is used to increase nasal tip projection in those patients who have a major deficiency in tip support. Many of these patients have a dependent nasal tip and an acute nasolabial angle. The extended columellar strut is usually carved from costal cartilage and is fixed to the periosteum about the nasal spine (Fig. 6). In some cases, a notch is carved into the base of
the strut to fit over the nasal spine and ensure that the strut remains in the midline. In other cases, the strut can be integrated with a premaxillary graft that is fixated to the nasal spine or premaxilla (Fig. 7). The medial crura are then advanced anteriorly on the costal cartilage strut to increase nasal tip projection and open an acute nasolabial angle (Fig. 8). In some cases, soft tissue over the premaxilla must be dissected to allow the medial crura to be advanced anteriorly. The extended costal cartilage columellar strut increases tip projection by advancing the medial crura anteriorly without expanding the nasal tip lobule (Fig. 9).
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Figure 4. Caudal extension graft sutured to caudal margin of nasal septum and extended between medial crura to set tip projection, tip rotation, and alar/columellar relationship.
NASAL TIP SURGERY Shield shaped tip grafts increase tip projection by expanding the infratip lobule without changing the nasal base.3 The author avoids the use of shield grafts in patients with thin skin because of the higher incidence of visibility of the graft.12 It is unlikely that a tip graft will show in patients with thick nasal tip skin unless used inappropriately. When using tip grafts, appropriate camouflage of the leading edge of the graft is critical to avoid graft visibility after the edema resolves or scar contracture occurs. The author uses several different methods to camouflage the leading edge of a tip graft. A buttress or cap graft is a rectangular shaped graft that is sutured behind the leading edge of the tip graft and acts to stabilize the graft and provide a better transition from the lateral
aspect of the tip graft to the existing domes (Fig. 10).3,12 Buttress grafts are also used when the tip graft tends to rotate cephalically and requires support behind the leading edge of the graft. Lateral crural grafts are cartilage grafts that are sutured to the lateral margin of the tip graft and then fixated to the lateral crura (Fig. 11).3,12 The lateral crural grafts provide a smooth transition from the lateral margin of the tip graft to the existing tip structures (Fig. 12). Lateral crural grafts create a transitional support structure that extends from the lateral margin of the tip graft to the existing lateral crura. Buttress grafts support the tip graft but are not able to provide the same degree of camouflage that is provided by the lateral crural grafts. Lateral crural grafts are used primarily in cases when the tip graft extends more than 3 mm above the existing domes.
Figure 5. Note how the caudal extension graft overlaps the existing caudal septum. The caudal margin of the extension graft lies in the midline.
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Figure 6. Costal cartilage extended columellar strut fixated to the periosteum around the nasal spine. A, Underprojected nasal tip with acute nasolabial angle. B, The medial crura and nasal base is advanced on the stable strut to increase tip projection and open the nasolabial angle.
When tip grafting is necessary in patients with thin skin, acellular dermis (Alloderm, LifeCell Corp., NJ) can be sutured over the leading edge of the tip graft to provide additional camouflage and soft tissue augmentation. When applying accellular dermis into the nasal tip, it should be suture fixated and applied symmetrically. The author also prefers to use a thinner sheet of acellular dermis in the nasal tip. If a thick piece of acellular dermis is used over a tip graft, it may create excessive aug-
mentation and tip fullness. Postoperatively, the nasal tip can be expected to be edematous for an extended period of time because the acellular dermis becomes incorporated with host cells. This early postoperative edema will resolve, leaving a soft contour to the nasal tip. The use of suturing maneuvers to manage the bulbous nasal tip is being increased because it is a safe and reliable method of recontouring the nasal tip. In most cases, a dome binding suture is placed through each dome to
Figure 7. Extended columellar strut set into a notch in a premaxillary graft that is fixated to the periosteum around the nasal spine.
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Figure 8. Extended columellar strut sutured between medial crura. The nasal base was advanced on the extended strut to increase tip projection and open the nasolabial angle. The strut will be trimmed once appropriate tip projection is determined.
narrow the domes and decrease the bulbosity of the nasal tip (Fig. 13).7,13 In some cases, placement of the dome binding sutures acts to pinch the lateral crura lateral to the domes, creating deformity. In some patients, there is a tendency for the lateral aspect of the lateral crura to recurve into the airway after placement of dome binding sutures (Fig. 14). Other options for treating the bulbous nasal tip may require more aggressive resection of cartilage or division of the domes. The author prefers not to divide the domes in patients with thinner nasal tip skin because of the increased potential for visibility of the cut edges of the cartilage. The lateral crural strut graft is a rectangular shaped segment of cartilage that is placed between the undersurface of the lateral crura and the vestibular skin.2 The graft is sutured to the lateral crura and acts to flatten the lateral crura, eliminating the bulbous contour of the nasal tip (Figs. 15 and 16). When placing these grafts, local anesthetic is injected into the vestibular skin on the undersurface of the lateral crura. This will hydrodissect the vestibular skin and make dissection easier. After performing cephalic trim of the lateral crura, Converse scissors are used to dissect the vestibular skin off the undersurface of the lateral crura. The rectangular shaped lateral crura strut graft then is sutured to the undersurface of the lateral crura with two 5-0 clear nylon sutures (Fig. 17). The grafts act to flatten the bulbous
lateral crura and eliminate the bulbous shape of the nasal tip without resecting cartilage (Fig. 18). After placement of the lateral crural strut grafts, the tip bulbosity is improved, and the lateral crura are stronger because of the additional layer of cartilage applied to them (Fig. 19). In some cases, there is a lack of support along the alar margin, and the favorable triangular shape to the nasal base is lost. This tends to be seen in patients with cephalic positioning of the lateral crura or after tip modifications have been made. Alar rim grafts are narrow cartilage grafts that are inserted into pockets made along the caudal margin of the marginal incision. The grafts are typically 5 mm to 8 mm in length, 2 mm to 3 mm in width, and 1 mm to 2 mm in thickness. Softer, pliable cartilage is preferred for these grafts as they are placed along the alar margin. The cartilage from a conservative cephalic trim of the lateral crura is ideal for alar rim grafts. The grafts are placed into the pockets and fixated with 6-0 PDS suture. The medial aspect of the grafts can be lightly morselized to minimize the chances of graft visualization. If alar rim grafts are too stiff or too large, they are at higher risk of becoming visible or palpable. In some cases, the alar rim grafts can be sutured to the lateral margins of a shield graft. Alar rim grafts provide a smooth transition from the tip structure to the ala, creating a triangular nasal base with good support. Alar rim grafts are
STRUCTURE APPROACH IN RHINOPLASTY
effective in stabilizing the alar margin in patients with alar collapse (external nasal valve collapse).
MIDDLE NASAL VAULT The middle nasal vault is composed of the upper lateral cartilages and nasal septum. When dorsal hump reduction is performed in a patient with short nasal bones and long upper lateral cartilages, there is a higher risk of inferomedial collapse of the upper lateral cartilages.4,5,9 In these patients, dorsal hump removal excises the horizontal component of the upper lateral cartilages where it meets the dorsal margin of the nasal septum. Loss of the horizontal component of the middle nasal vault may result in narrowing of the middle nasal vault and possible inferomedial collapse of the upper lateral cartilages. These changes may occur many years after surgery. Middle vault collapse can be prevented by placing spreader grafts between the upper lateral cartilages and dorsal margin of the septum (Fig. 20).4 The spreader grafts should be slightly thicker as the spreader grafts meet the nasal bones to preserve the normal contour of the middle nasal vault. In patients with middle nasal vault collapse, spreader grafts can be applied into precise tunnels made under the junction between the upper lateral cartilages and dorsal septum.4,5,9 An incision is made high on the nasal septal mucosa, and a subperichondrial tunnel is dissected just under the upper lateral cartilage. The pocket should be as narrow as possible so the graft fits tightly into the tunnel. Then a rectangular shaped cartilage spreader graft measuring 6 mm to 18 mm in length, 3 mm to 5 mm in height, and 2 mm to 4 mm in thickness is placed into the tunnel to lateralize the upper lateral cartilage. The change in position of the upper lateral cartilage as the graft is placed should be noted. Spreader grafts applied into tunnels under an intact attachment between the upper lateral cartilage and dorsal septum provide a cantilever effect on the upper lateral cartilages and open the airway (Fig. 21). If the graft does not fit tightly into the tunnel, the graft will not change the position of the upper lateral cartilage or the patency of the
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airway. In most cases, the upper lateral cartilages will need to be freed from the dorsal septum, placing rectangular shaped spreader grafts between the upper lateral cartilages and dorsal septum. Spreader grafts typically extend from the junction with the nasal bones to the anterior septal angle. Special care must be taken to create symmetry of the middle nasal vault. If there is a concavity on one side of the middle nasal vault, a thicker spreader graft can be placed on that side of the septum. This allows for improvement of symmetry of the middle nasal vault. The upper lateral cartilages are then sutured to the dorsal septum with 5-0 PDS sutures to complete reconstruction of the middle nasal vault. Once the spreader grafts are sutured into position, they can be trimmed along the dorsal margin of the septum to ensure a smooth dorsal profile. If the patient has pronounced supra-alar pinching and lateral wall weakness, spreader grafts alone will not correct alar collapse. In these cases, the patient will need to undergo placement of lateral wall grafts such as alar batten grafts.14 These grafts can be placed into precise pockets along the lateral wall of the nose at the point of maximal supra-alar pinching with the convex surface oriented laterally (Fig. 22). Conchal cartilage is ideal for alar batten grafts because of its curvilinear contour. This graft will stabilize the lateral wall of the nose, correct alar and lateral wall collapse, and lessen the supra-alar pinching.
BALANCING THE THICK-SKINNED NOSE When dealing with patients with thick nasal tip skin, it is imperative to balance the contour of the lower third of the nose with the upper third of the nose. Many patients who have thick skin and supratip fullness lack nasal tip projection. Increasing tip projection allows for better draping of the nasal tip skin and provides improved tip contour.10 If the patient has a low radix (nasal starting point) or low dorsum, the surgeon can augment the radix or dorsum and elevate the nasal starting point.11 Ideally, the nasal starting point should be at the level of the superior palpebral fold with the patient in forward gaze. If the radix is deep
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Figure 9. Patient with an underprojected nasal tip and acute nasolabial angle. Preoperative (A, C, E, G) and postoperative (B, D, F, H) lateral, frontal, oblique, and basal views. Note the favorable change in the nasolabial angle.
or low, a radix graft can be placed into a precise pocket and used to create a higher nasal starting point. This allows the surgeon to project the tip without creating a discrepancy between tip projection and dorsal height. Increasing dorsal height helps redistribute the thicker nasal skin and create a more balanced nasal contour (Fig. 23). Making the nose larger is not acceptable to many patients. Therefore, computer imaging is critical to educate patients on how balance is useful in creating better overall nasal aesthetics.
SUMMARY
Many postoperative sequellae of rhinoplasty can be prevented by minimizing resection of the supporting tissues of the nose and by using structural grafting to increase tip support. Stabilizing the nasal base is a critical step in providing a good long-term outcome with preservation of nasal tip projection. The surgeon must also anticipate the effects of scar contracture, which can aid in creating a favor-
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Figure 10. A buttress graft or cap graft is fixated behind the leading edge of the tip graft to stabilize the graft and create a smooth transition from tip graft to existing domes.
Figure 11. Lateral crural grafts placed over the existing lateral crura and sutured to the lateral border of the tip graft. The lateral crural graft provides a smooth transition from the tip graft to the lateral crura. The lateral crural grafts create a natural appearing triangular shape to the nasal base, which may not be achieved with the buttress graft.
Figure 12. Lateral crural strut grafts create a triangular nasal base and camouflage of the tip graft.
STRUCTURE APPROACH IN RHINOPLASTY
Figure 13. A, Dome binding sutures of 5-0 clear nylon are placed through each dome. Symmetrical placement of the sutures is important to preserve tip symmetry. B, Tightening of the sutures narrows the domes and creates a narrower nasal tip.
Figure 14. In some cases, dome binding sutures compromise the airway by causing internal recurvature of the lateral aspect of the lateral crura into the airway.
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Figure 15. Lateral crural grafts are rectangular shaped cartilage grafts placed between the undersurface of the lateral crura and the vestibular skin. Suture fixation with 5-0 clear nylon sutures flatten the lateral crura and decrease nasal tip bulbosity.
Figure 16. Bulbous nasal tip cartilages.
STRUCTURE APPROACH IN RHINOPLASTY
Figure 17. Placement of lateral crural strut grafts under the lateral crura.
Figure 18. Flattening of the lateral crura as a result of placement of the lateral crural strut grafts.
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STRUCTURE APPROACH IN RHINOPLASTY
Figure 19. Patient with a bulbous nasal tip. Preoperative (A, C, E, G) and postoperative (B, D, F, H) frontal, lateral, oblique, and basal views of patient after placement of lateral crural strut grafts. Note the decrease in bulbosity of the nasal tip.
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Figure 20. Spreader grafts used to reconstruct the middle nasal vault.
Figure 21. Spreader grafts applied under an intact connection between the upper lateral cartilages and dorsal septum. The bulk of the spreader graft asserts a cantilever effect on the upper lateral cartilage opening the nasal airway.
STRUCTURE APPROACH IN RHINOPLASTY
Figure 22. Conchal cartilage alar batten graft is applied at the point of maximal lateral wall collapse and most pronounced supra-alar pinching. The convex surface of the graft is oriented laterally.
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Figure 23. Patient with thick nasal tip skin and low dorsum. Augmentation of the dorsum helped balance the nose and improve the nasal contour. Preoperative (A) and postoperative (B) lateral views demonstrate increased dorsal height. Preoperative (C) and postoperative (D) frontal views showing decreased tip bulbosity. Preoperative (E and G) and postoperative (F and H) oblique and basal views.
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able tip contour over time and avoid complications.
References 1. Anderson JR: The dynamics of rhinoplasty. In Proceedings of the Ninth International Congress of Otolaryngology. Exerpta Medica International Congress Series, No. 206. Amsterdam, Exerpta Medica, 1969, pp 708–710 2. Gunter JP, Friedman RM: Lateral crural strut graft: Technique and clinical applications in rhinoplasty. Plast Reconstr Surg 99:943–955, 1997 3. Johnson CM, Toriumi DM: Open Structure Rhinoplasty. W.B. Saunders, Philadelphia, 1989 4. Sheen JH: Spreader graft: A method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg 73:230–237, 1984 5. Sheen JH, Sheen AP: Aesthetic Rhinoplasty. St. Louis, CV Mosby, 1987 6. Tardy ME: Rhinoplasty: The Art and Science. Philadelphia, W.B. Saunders, 1997
7. Tebbetts JB: Shaping and positioning the nasal tip without structural disruption. Plastic Reconstr Surg 94:61–77, 1994 8. Toriumi DM: Caudal extension graft for correction of the retracted columella. Op Tech Otolaryngol Head Neck Surg 6:311–318, 1995 9. Toriumi DM: Management of the middle nasal vault. Op Tech Plast Reconst Surg 2:16–30, 1995 10. Toriumi DM, Becker DG: Rhinoplasty Dissection Manual. Philadelphia, Lippincott, 1999 11. Toriumi DM, Hecht DA: Skeletal modifications in rhinoplasty. Facial Plastic Surgery Clinics of North America 8:413–431, 2000 12. Toriumi DM, Johnson CM: Open structure rhinoplasty: Featured technical points and long-term followup. Facial Plastic Surgery Clinics of North America 1:1–22, 1993 13. Toriumi DM, Tardy ME: Cartilage suturing techniques for correction of nasal tip deformities. Op Tech Otolaryngol Head Neck Surg 6:265–273, 1995 14. Toriumi DM, Josen J, Weinberger MS, et al: Use of alar batten grafts for correction of nasal valve collapse. Arch Otolaryngol Head Neck Surg 123:802–808, 1997
Address reprint requests to Dean M. Toriumi, MD Division of Facial Plastic and Reconstructive Surgery Department of Otolaryngology–Head and Neck Surgery (M/C 648) University of Illinois at Chicago 1855 West Taylor Street Chicago, IL 60612
1064–7406/02 $15.00 ⫹ .00
STRUCTURE APPROACH IN RHINOPLASTY Dean M. Toriumi, MD
Over the past decade, rhinoplasty techniques have moved away from excisional methods and focused more on repositioning and restructuring existing tissues. These changes in surgical technique were made in part because of some of the untoward long-term changes noted in noses that were treated with excisional techniques. Patients who undergo aggressive resection of the lateral crura tend to develop alar retraction, supra-alar pinching, lateral wall weakness, and nasal valve collapse. Aggressive excision of the middle nasal vault without appropriate reconstruction tends to result in inferomedial collapse of the upper lateral cartilages and nasal valve collapse. Excessive excision of the caudal margin of the septum can result in foreshortening of the nose and postoperative loss of tip projection. The incidence of many of these complications is greater in patients with certain nasal anatomy. It is the responsibility of the surgeon to identify these anatomic variants and make necessary adjustments in surgical technique to avoid complications. The effect of performing cephalic trim of the lateral crura is noted over the lifetime of the patient. When these patients are followed, supra-alar pinching can begin soon after surgery and become much more pronounced 10 to 15 years later.6 At the time of surgery, a reduction
in fullness in the supra-alar region is noted after performing cephalic trim of the lateral crura. Then, after surgery, scar contracture acts on the weakened lateral crura, creating continued narrowing of the supra-alar region. If excessive cephalic trim was performed, the lateral crus can contract superiorly, creating alar retraction. Even if conservative cephalic trim is performed, scar contracture will tend to create narrowing in the supra-alar region. Patients with thin skin, narrow lateral nasal walls, and preoperative prominence of the supra-alar crease are at much higher risk for continued collapse of the supra-alar region postoperatively. In these patients, alar batten grafts or lateral crural strut grafts are placed at the time of the primary surgery to help prevent this complication. Recognition of variant nasal anatomy, alteration of techniques, and placement of grafts to avoid complications will maximize the aesthetic and functional outcomes in rhinoplasty.
CONTROLLING NASAL TIP PROJECTION Success in rhinoplasty is in part related to the surgeon’s ability to control nasal tip projection. When the surgeon has control of
From the Department of Otolaryngology–Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, University of Illinois at Chicago, Chicago, Illinois
FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA VOLUME 10 • NUMBER 1 • FEBRUARY 2002
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nasal tip projection, variables related to healing are decreased and a favorable tip/supratip relationship can be preserved. If adequate tip projection can be attained, the patient’s nasal dorsum can be left higher or raised to provide more favorable lateral wall shadowing and definition. By increasing tip projection, the surgeon can project a favorable shaped tip or dome structure into the nasal tip skin to improve tip shape. This concept is particularly important in patients with thick nasal tip skin. Increasing tip projection will act to narrow the nasal base and open the nasolabial angle. Adequate control of nasal tip projection also requires preventing postoperative loss of nasal tip projection. Postoperative loss of nasal tip projection can result in a supratip polybeak as the tip drops below the supratip. Lack of control of nasal tip projection forces the surgeon to anticipate where the tip will settle. This leads to potential deformities such as a residual dorsal hump, polybeak deformity, or a pronounced tip/supratip relationship. Control of nasal tip projection provides the surgeon with the ability to confidently set intraoperative nasal tip projection and feel confident that the
tip/supratip relationship noted at the time of surgery will be preserved.
STABILIZING THE NASAL BASE Tip projection can be controlled by stabilizing the nasal base before modifying the nasal tip lobule. Anderson1 simplified nasal tip surgery by likening the lower lateral cartilages to a tripod-like structure with the conjoined medial crura making up one leg of the tripod and the lateral crura making up the other two (Fig. 1). The position and stability of the conjoined medial crura greatly influence the position of the nasal tip. Patients who have a poorly supported nasal base are more likely to have an underprojected or dependent nasal tip and acute nasolabial angle. Stabilizing the nasal base in these patients can act to increase nasal tip projection, rotate the nasal tip, and open the nasolabial angle. Maneuvers used to stabilize the nasal base include setting back the medial crura on a midline caudal septum, sutured in place columellar strut, caudal extension graft, or extended columellar strut.
Figure 1. A, Tripod complex of lower third of the nose. The lateral crura make up two legs of the tripod and the third leg is comprised of the conjoined medial crura. Modifications in nasal tip position can be anticipated using the tripod complex of the lower third of the nose. B, Shaded area represents the intermediate crura that diverge to meet the domes.
STRUCTURE APPROACH IN RHINOPLASTY
These maneuvers act to increase projection of the medial crural component of the tripod complex. Patients who have an overly long midline caudal septum are good candidates for setting back the medial crura on the caudal septum. This technique is typically used in patients who would otherwise require trimming of the caudal margin of the nasal septum. In this case, the excessively long caudal septum is suture fixated between the medial crura in a tongue-in-groove fashion and the redundant caudal septum is used to support the nasal tip. After dissecting between the medial crura, the caudal septum is identified. Then bilateral mucoperichondrial flaps are elevated, and redundant septal mucosa is moved cephalically, eliminating the need to trim septal mucosa after repositioning the nasal tip (Fig. 2A). The medial crura are repositioned on the caudal septum and then sutured to the septal cartilage with a 5-0 chromic mattress suture (Fig. 2B). If the tip position, rotation, and alar/ columellar relationship is appropriate, a 5-0 PDS suture is placed from the inner surface of both medial crura to the caudal septum. After the tip position is set and all septal work is completed, a running 5-0 plain gut suture on a straight septal needle is used to quilt the septal mucosa and redistribute the septal mucosa along the nasal septum. If not performed properly, the septal mucosa may bunch intranasally. In most cases, this maneuver is used in patients with a tension nose deformity, overprojected nasal tip, or hanging columella (Fig. 3). There are occasions when an under-
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projected nasal tip can be advanced anteriorly on the caudal septum to increase tip projection. When using this technique, it is critical to avoid creating a retracted columella, foreshortened nose, or over-rotated nasal tip. Other potential deformities include an obtuse nasolabial angle or long upper lip. This can be avoided by only setting back the medial crura on an overly long midline caudal septum that otherwise would require reduction. A rectangular shaped columellar strut can be used to stabilize the nasal base and correct buckling of the medial and intermediate crura.3 The strut typically measures 5 mm to 12 mm in length, 3 mm to 6 mm in width, and 1 mm to 3 mm in thickness. The strut is sutured into a pocket between the medial crura and should not extend to the nasal spine. This type of strut typically does not increase tip projection, but it does support the medial crural component of the tripod complex. The caudal extension graft is a cartilage graft that overlaps the caudal margin of the nasal septum and is sutured between the medial crura to stabilize the nasal base and set tip projection and appropriate alar/columellar relationship (Fig. 4).8 A minimum of two sutures should be applied to fixate the caudal extension graft to the septum. The caudal margin of the extension graft should lie in the midline (Fig. 5). The position of the caudal extension graft will determine the position of the nasal tip and the nasolabial angle. If the caudal extension graft is longer posteriorly, it will act to open the nasolabial angle. If the caudal
Figure 2. A, Setting back the medial crura on an overly long midline caudal septum. Dissection between the medial crura to expose the caudal septum. Note that bilateral mucoperichondrial flaps have been elevated. B, Medial crura set-back and fixated on midline caudal septum with a 5-0 plain gut suture on a straight septal needle. A 5-0 PDS suture will be added to provide additional support.
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Figure 3. Patient with a hanging columella and excessively long caudal septum. Preoperative (A, C, E, G) and postoperative (B, D, F, H) lateral, frontal, oblique, and basal views.
extension graft is longer along the anterior margin, it will tend to counter-rotate the nasal tip. The caudal extension graft is also ideal for correction of the retracted columella. The extended columellar strut is different from a conventional columellar strut because it is used to increase nasal tip projection in those patients who have a major deficiency in tip support. Many of these patients have a dependent nasal tip and an acute nasolabial angle. The extended columellar strut is usually carved from costal cartilage and is fixed to the periosteum about the nasal spine (Fig. 6). In some cases, a notch is carved into the base of
the strut to fit over the nasal spine and ensure that the strut remains in the midline. In other cases, the strut can be integrated with a premaxillary graft that is fixated to the nasal spine or premaxilla (Fig. 7). The medial crura are then advanced anteriorly on the costal cartilage strut to increase nasal tip projection and open an acute nasolabial angle (Fig. 8). In some cases, soft tissue over the premaxilla must be dissected to allow the medial crura to be advanced anteriorly. The extended costal cartilage columellar strut increases tip projection by advancing the medial crura anteriorly without expanding the nasal tip lobule (Fig. 9).
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Figure 4. Caudal extension graft sutured to caudal margin of nasal septum and extended between medial crura to set tip projection, tip rotation, and alar/columellar relationship.
NASAL TIP SURGERY Shield shaped tip grafts increase tip projection by expanding the infratip lobule without changing the nasal base.3 The author avoids the use of shield grafts in patients with thin skin because of the higher incidence of visibility of the graft.12 It is unlikely that a tip graft will show in patients with thick nasal tip skin unless used inappropriately. When using tip grafts, appropriate camouflage of the leading edge of the graft is critical to avoid graft visibility after the edema resolves or scar contracture occurs. The author uses several different methods to camouflage the leading edge of a tip graft. A buttress or cap graft is a rectangular shaped graft that is sutured behind the leading edge of the tip graft and acts to stabilize the graft and provide a better transition from the lateral
aspect of the tip graft to the existing domes (Fig. 10).3,12 Buttress grafts are also used when the tip graft tends to rotate cephalically and requires support behind the leading edge of the graft. Lateral crural grafts are cartilage grafts that are sutured to the lateral margin of the tip graft and then fixated to the lateral crura (Fig. 11).3,12 The lateral crural grafts provide a smooth transition from the lateral margin of the tip graft to the existing tip structures (Fig. 12). Lateral crural grafts create a transitional support structure that extends from the lateral margin of the tip graft to the existing lateral crura. Buttress grafts support the tip graft but are not able to provide the same degree of camouflage that is provided by the lateral crural grafts. Lateral crural grafts are used primarily in cases when the tip graft extends more than 3 mm above the existing domes.
Figure 5. Note how the caudal extension graft overlaps the existing caudal septum. The caudal margin of the extension graft lies in the midline.
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Figure 6. Costal cartilage extended columellar strut fixated to the periosteum around the nasal spine. A, Underprojected nasal tip with acute nasolabial angle. B, The medial crura and nasal base is advanced on the stable strut to increase tip projection and open the nasolabial angle.
When tip grafting is necessary in patients with thin skin, acellular dermis (Alloderm, LifeCell Corp., NJ) can be sutured over the leading edge of the tip graft to provide additional camouflage and soft tissue augmentation. When applying accellular dermis into the nasal tip, it should be suture fixated and applied symmetrically. The author also prefers to use a thinner sheet of acellular dermis in the nasal tip. If a thick piece of acellular dermis is used over a tip graft, it may create excessive aug-
mentation and tip fullness. Postoperatively, the nasal tip can be expected to be edematous for an extended period of time because the acellular dermis becomes incorporated with host cells. This early postoperative edema will resolve, leaving a soft contour to the nasal tip. The use of suturing maneuvers to manage the bulbous nasal tip is being increased because it is a safe and reliable method of recontouring the nasal tip. In most cases, a dome binding suture is placed through each dome to
Figure 7. Extended columellar strut set into a notch in a premaxillary graft that is fixated to the periosteum around the nasal spine.
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Figure 8. Extended columellar strut sutured between medial crura. The nasal base was advanced on the extended strut to increase tip projection and open the nasolabial angle. The strut will be trimmed once appropriate tip projection is determined.
narrow the domes and decrease the bulbosity of the nasal tip (Fig. 13).7,13 In some cases, placement of the dome binding sutures acts to pinch the lateral crura lateral to the domes, creating deformity. In some patients, there is a tendency for the lateral aspect of the lateral crura to recurve into the airway after placement of dome binding sutures (Fig. 14). Other options for treating the bulbous nasal tip may require more aggressive resection of cartilage or division of the domes. The author prefers not to divide the domes in patients with thinner nasal tip skin because of the increased potential for visibility of the cut edges of the cartilage. The lateral crural strut graft is a rectangular shaped segment of cartilage that is placed between the undersurface of the lateral crura and the vestibular skin.2 The graft is sutured to the lateral crura and acts to flatten the lateral crura, eliminating the bulbous contour of the nasal tip (Figs. 15 and 16). When placing these grafts, local anesthetic is injected into the vestibular skin on the undersurface of the lateral crura. This will hydrodissect the vestibular skin and make dissection easier. After performing cephalic trim of the lateral crura, Converse scissors are used to dissect the vestibular skin off the undersurface of the lateral crura. The rectangular shaped lateral crura strut graft then is sutured to the undersurface of the lateral crura with two 5-0 clear nylon sutures (Fig. 17). The grafts act to flatten the bulbous
lateral crura and eliminate the bulbous shape of the nasal tip without resecting cartilage (Fig. 18). After placement of the lateral crural strut grafts, the tip bulbosity is improved, and the lateral crura are stronger because of the additional layer of cartilage applied to them (Fig. 19). In some cases, there is a lack of support along the alar margin, and the favorable triangular shape to the nasal base is lost. This tends to be seen in patients with cephalic positioning of the lateral crura or after tip modifications have been made. Alar rim grafts are narrow cartilage grafts that are inserted into pockets made along the caudal margin of the marginal incision. The grafts are typically 5 mm to 8 mm in length, 2 mm to 3 mm in width, and 1 mm to 2 mm in thickness. Softer, pliable cartilage is preferred for these grafts as they are placed along the alar margin. The cartilage from a conservative cephalic trim of the lateral crura is ideal for alar rim grafts. The grafts are placed into the pockets and fixated with 6-0 PDS suture. The medial aspect of the grafts can be lightly morselized to minimize the chances of graft visualization. If alar rim grafts are too stiff or too large, they are at higher risk of becoming visible or palpable. In some cases, the alar rim grafts can be sutured to the lateral margins of a shield graft. Alar rim grafts provide a smooth transition from the tip structure to the ala, creating a triangular nasal base with good support. Alar rim grafts are
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effective in stabilizing the alar margin in patients with alar collapse (external nasal valve collapse).
MIDDLE NASAL VAULT The middle nasal vault is composed of the upper lateral cartilages and nasal septum. When dorsal hump reduction is performed in a patient with short nasal bones and long upper lateral cartilages, there is a higher risk of inferomedial collapse of the upper lateral cartilages.4,5,9 In these patients, dorsal hump removal excises the horizontal component of the upper lateral cartilages where it meets the dorsal margin of the nasal septum. Loss of the horizontal component of the middle nasal vault may result in narrowing of the middle nasal vault and possible inferomedial collapse of the upper lateral cartilages. These changes may occur many years after surgery. Middle vault collapse can be prevented by placing spreader grafts between the upper lateral cartilages and dorsal margin of the septum (Fig. 20).4 The spreader grafts should be slightly thicker as the spreader grafts meet the nasal bones to preserve the normal contour of the middle nasal vault. In patients with middle nasal vault collapse, spreader grafts can be applied into precise tunnels made under the junction between the upper lateral cartilages and dorsal septum.4,5,9 An incision is made high on the nasal septal mucosa, and a subperichondrial tunnel is dissected just under the upper lateral cartilage. The pocket should be as narrow as possible so the graft fits tightly into the tunnel. Then a rectangular shaped cartilage spreader graft measuring 6 mm to 18 mm in length, 3 mm to 5 mm in height, and 2 mm to 4 mm in thickness is placed into the tunnel to lateralize the upper lateral cartilage. The change in position of the upper lateral cartilage as the graft is placed should be noted. Spreader grafts applied into tunnels under an intact attachment between the upper lateral cartilage and dorsal septum provide a cantilever effect on the upper lateral cartilages and open the airway (Fig. 21). If the graft does not fit tightly into the tunnel, the graft will not change the position of the upper lateral cartilage or the patency of the
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airway. In most cases, the upper lateral cartilages will need to be freed from the dorsal septum, placing rectangular shaped spreader grafts between the upper lateral cartilages and dorsal septum. Spreader grafts typically extend from the junction with the nasal bones to the anterior septal angle. Special care must be taken to create symmetry of the middle nasal vault. If there is a concavity on one side of the middle nasal vault, a thicker spreader graft can be placed on that side of the septum. This allows for improvement of symmetry of the middle nasal vault. The upper lateral cartilages are then sutured to the dorsal septum with 5-0 PDS sutures to complete reconstruction of the middle nasal vault. Once the spreader grafts are sutured into position, they can be trimmed along the dorsal margin of the septum to ensure a smooth dorsal profile. If the patient has pronounced supra-alar pinching and lateral wall weakness, spreader grafts alone will not correct alar collapse. In these cases, the patient will need to undergo placement of lateral wall grafts such as alar batten grafts.14 These grafts can be placed into precise pockets along the lateral wall of the nose at the point of maximal supra-alar pinching with the convex surface oriented laterally (Fig. 22). Conchal cartilage is ideal for alar batten grafts because of its curvilinear contour. This graft will stabilize the lateral wall of the nose, correct alar and lateral wall collapse, and lessen the supra-alar pinching.
BALANCING THE THICK-SKINNED NOSE When dealing with patients with thick nasal tip skin, it is imperative to balance the contour of the lower third of the nose with the upper third of the nose. Many patients who have thick skin and supratip fullness lack nasal tip projection. Increasing tip projection allows for better draping of the nasal tip skin and provides improved tip contour.10 If the patient has a low radix (nasal starting point) or low dorsum, the surgeon can augment the radix or dorsum and elevate the nasal starting point.11 Ideally, the nasal starting point should be at the level of the superior palpebral fold with the patient in forward gaze. If the radix is deep
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Figure 9. Patient with an underprojected nasal tip and acute nasolabial angle. Preoperative (A, C, E, G) and postoperative (B, D, F, H) lateral, frontal, oblique, and basal views. Note the favorable change in the nasolabial angle.
or low, a radix graft can be placed into a precise pocket and used to create a higher nasal starting point. This allows the surgeon to project the tip without creating a discrepancy between tip projection and dorsal height. Increasing dorsal height helps redistribute the thicker nasal skin and create a more balanced nasal contour (Fig. 23). Making the nose larger is not acceptable to many patients. Therefore, computer imaging is critical to educate patients on how balance is useful in creating better overall nasal aesthetics.
SUMMARY
Many postoperative sequellae of rhinoplasty can be prevented by minimizing resection of the supporting tissues of the nose and by using structural grafting to increase tip support. Stabilizing the nasal base is a critical step in providing a good long-term outcome with preservation of nasal tip projection. The surgeon must also anticipate the effects of scar contracture, which can aid in creating a favor-
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Figure 10. A buttress graft or cap graft is fixated behind the leading edge of the tip graft to stabilize the graft and create a smooth transition from tip graft to existing domes.
Figure 11. Lateral crural grafts placed over the existing lateral crura and sutured to the lateral border of the tip graft. The lateral crural graft provides a smooth transition from the tip graft to the lateral crura. The lateral crural grafts create a natural appearing triangular shape to the nasal base, which may not be achieved with the buttress graft.
Figure 12. Lateral crural strut grafts create a triangular nasal base and camouflage of the tip graft.
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Figure 13. A, Dome binding sutures of 5-0 clear nylon are placed through each dome. Symmetrical placement of the sutures is important to preserve tip symmetry. B, Tightening of the sutures narrows the domes and creates a narrower nasal tip.
Figure 14. In some cases, dome binding sutures compromise the airway by causing internal recurvature of the lateral aspect of the lateral crura into the airway.
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Figure 15. Lateral crural grafts are rectangular shaped cartilage grafts placed between the undersurface of the lateral crura and the vestibular skin. Suture fixation with 5-0 clear nylon sutures flatten the lateral crura and decrease nasal tip bulbosity.
Figure 16. Bulbous nasal tip cartilages.
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Figure 17. Placement of lateral crural strut grafts under the lateral crura.
Figure 18. Flattening of the lateral crura as a result of placement of the lateral crural strut grafts.
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Figure 19. Patient with a bulbous nasal tip. Preoperative (A, C, E, G) and postoperative (B, D, F, H) frontal, lateral, oblique, and basal views of patient after placement of lateral crural strut grafts. Note the decrease in bulbosity of the nasal tip.
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Figure 20. Spreader grafts used to reconstruct the middle nasal vault.
Figure 21. Spreader grafts applied under an intact connection between the upper lateral cartilages and dorsal septum. The bulk of the spreader graft asserts a cantilever effect on the upper lateral cartilage opening the nasal airway.
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Figure 22. Conchal cartilage alar batten graft is applied at the point of maximal lateral wall collapse and most pronounced supra-alar pinching. The convex surface of the graft is oriented laterally.
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Figure 23. Patient with thick nasal tip skin and low dorsum. Augmentation of the dorsum helped balance the nose and improve the nasal contour. Preoperative (A) and postoperative (B) lateral views demonstrate increased dorsal height. Preoperative (C) and postoperative (D) frontal views showing decreased tip bulbosity. Preoperative (E and G) and postoperative (F and H) oblique and basal views.
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able tip contour over time and avoid complications.
References 1. Anderson JR: The dynamics of rhinoplasty. In Proceedings of the Ninth International Congress of Otolaryngology. Exerpta Medica International Congress Series, No. 206. Amsterdam, Exerpta Medica, 1969, pp 708–710 2. Gunter JP, Friedman RM: Lateral crural strut graft: Technique and clinical applications in rhinoplasty. Plast Reconstr Surg 99:943–955, 1997 3. Johnson CM, Toriumi DM: Open Structure Rhinoplasty. W.B. Saunders, Philadelphia, 1989 4. Sheen JH: Spreader graft: A method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg 73:230–237, 1984 5. Sheen JH, Sheen AP: Aesthetic Rhinoplasty. St. Louis, CV Mosby, 1987 6. Tardy ME: Rhinoplasty: The Art and Science. Philadelphia, W.B. Saunders, 1997
7. Tebbetts JB: Shaping and positioning the nasal tip without structural disruption. Plastic Reconstr Surg 94:61–77, 1994 8. Toriumi DM: Caudal extension graft for correction of the retracted columella. Op Tech Otolaryngol Head Neck Surg 6:311–318, 1995 9. Toriumi DM: Management of the middle nasal vault. Op Tech Plast Reconst Surg 2:16–30, 1995 10. Toriumi DM, Becker DG: Rhinoplasty Dissection Manual. Philadelphia, Lippincott, 1999 11. Toriumi DM, Hecht DA: Skeletal modifications in rhinoplasty. Facial Plastic Surgery Clinics of North America 8:413–431, 2000 12. Toriumi DM, Johnson CM: Open structure rhinoplasty: Featured technical points and long-term followup. Facial Plastic Surgery Clinics of North America 1:1–22, 1993 13. Toriumi DM, Tardy ME: Cartilage suturing techniques for correction of nasal tip deformities. Op Tech Otolaryngol Head Neck Surg 6:265–273, 1995 14. Toriumi DM, Josen J, Weinberger MS, et al: Use of alar batten grafts for correction of nasal valve collapse. Arch Otolaryngol Head Neck Surg 123:802–808, 1997
Address reprint requests to Dean M. Toriumi, MD Division of Facial Plastic and Reconstructive Surgery Department of Otolaryngology–Head and Neck Surgery (M/C 648) University of Illinois at Chicago 1855 West Taylor Street Chicago, IL 60612