The Clinical Problem ( Fig. 16.1 )
There is great variance within the accepted norm for nasal tip appearance. Fat bulbous noses or sharply projecting nose tips are very complex anatomic structures and require considerable surgical skill and experience when attempting tip rhinoplasty. Shaping and final positioning of the nasal tip complex is the most critical and sophisticated stage of rhinoplasty. Increased control and predictability are best achieved by preserving the anatomic structures of the nose and using suturing techniques that are reversible and incremental. Limiting the use of tip grafts reduces the incidence of visibility and incongruity that can follow onlay cartilage grafts and is also consistent with the principles of modern nondestructive rhinoplasty techniques. However, some of these well-described maneuvers can still lead to complications.
Synopsis
The ideal nasal cartilage framework associated with acceptable functional and aesthetic performance includes the following:
- 1.
Stable and symmetric medial crura
- 2.
Good angle of divergence (≈60 degrees)
- 3.
Strong, horizontally oriented, almost flat lateral crura
- 4.
Well-defined tip points ( Fig. 16.2 )
FIGURE 16.2
Current etalon appearance of the nasal tip cartilaginous framework after open approach suturing techniques on views from the anterior (A), side (B), bottom (C), and above (D).
Surgical Preparation and Technique
Surgical Approaches: Open or Closed Rhinoplasty
Principles
Cartilage, ligaments, vessels, and nerves are to be preserved. Reducing the nasal tip width usually begins with resection of the cephalic portion of each lateral crus.
The first cartilage-reshaping suture is between the medial crura; the second is between the domes (interdomal stitch [IDS]). The IDS stabilizes the two medial alar cartilages in a well-defined position, allowing for suture reshaping of the remaining lateral wings.
A transdomal-defining suture (TDS) reduces flaring of the lateral crura, creates tip-defining points, and slightly adjusts tip projection. However, the use of TDS and a dome-spanning suture can result in convexity of the lateral crura complex, pinching the tip and narrowing the nasal vestibule. This can cause breathing problems, especially in patients with thin skin. Lateral crura struts that were suggested to correct this problem are now rarely used because they require abutment with the rim of the piriform aperture and can be palpable. Lateral struts can create beautiful noses, but they are often large, immobile, and stiff.
In 2005, we introduced a second interdomal stitch (SIDS) to refine the tip further into a well-designed, stable, and functional shape based on modeling the lower lateral cartilages, and, later, on similar techniques as described by Dosanjh et al. and the figure-of-eight suture by Çakir et al.
Open Nasal Tip Approach
The open approach is via an inverted V columella and marginal incisions, with medial superficial musculoaponeurotic system (SMAS) preservation as a single unit of superficial and deep layers. These include columella vessels and the Pitanguy dermocartilaginous ligament ( Fig. 16.3A ).
Long lateral crura, asymmetric domes, and medial crura are mobilized from the medial SMAS bundle, which has the points of soft tissue fixation on the upper lip and supratip break of the nasal dorsum (see Fig. 16.3B ). Separate dorsal hump removal is carried out after elevation of the perichondral-periosteum flap. A special Pshenisnov clamp is applied on the septum as a guide for predictable reduction (see Fig. 16.3C ). The medial SMAS with the Pitanguy ligament is intact (see Fig. 16.3D ).
A double-guard osteotome is used for en bloc osteocartilaginous hump removal (see Fig. 16.3E ). The hump is removed (see Fig. 16.3F ). Lateral low-to-high percutaneous osteotomies with a 2-mm chisel are performed. Then, the septoplasty is completed. The caudal septum strip is excised, and the deviated central-posterior part of the cartilaginous septum is resected. The caudal septum is positioned medially and sutured to the upper anterior nasal spine ( Fig. 16.4 ).
The dorsal septum is straightened (see Fig. 16.3G and H ), and the bony dorsum is rasped. A slight nasal radix area depression is camouflaged with diced cartilage.
The upper lateral cartilages are used as spreader flaps with temporary needle approximation, followed by 5-0 PDS mattress suture fixation (see Fig. 16.3I ). The perichondrial-periosteum flap is sutured back over the reconstructed dorsum (see Fig. 16.3J ).
The cephalic margins of the lower lateral cartilage (LLC) are not trimmed but folded with duplication to strengthen the lateral crus (see Fig. 16.3K ). The moistened cartilage graft over the depression of the distal part of the upper lateral cartilage (ULC) is shown on the right of the figure. The columellar strut between the medial crura and modified IDS is tightened with an intact medial SMAS, shown with forceps in Fig. 16.3L .
For tip creation and definition, nasal tip tripod modifications are carried out with an everted and straightened lateral crus on the side view (see Fig. 16.3M ). The columella–lobular junction contour is improved by shaving with a no. 15 blade.
Tip positioning uses projection and rotation control sutures of the medial crus, with a columellar strut to the caudal septum; However, it would be better to include the caudal septum in the basal complex via a transfixion incision (see Fig. 16.4 ).
Closed Rhinoplasty Tip Technique
This involves the following:
- 1.
Marginal incision with rim flap
- 2.
Intercartilaginous and transfixion incisions with caudal septum flap
- 3.
Subperichondrial dissection
- 4.
Subtotal lower lateral cartilage mobilization, with minimal cephalic resection
- 5.
Medial SMAS with Pitanguy dermocartilagenous ligament (DCL) mobilization
- 6.
Grafts for tip support and modified intertransdomal suture (MITDS; Figs. 16.5 and 16.6 )
FIGURE 16.5
Modified intertransdomal suture (MITDS) application technique. (A) MITDS as two hemitransdomal sutures using one stitch. (B) Cartilaginous framework modification after stitch tightening.
