7 Lobular Surgery

Approaches to the Lobule

The Four Main Approaches: Advantages, Disadvantages, and Indications

None of these approaches is by definition the best. The choice of method to be used in a given case is based on the type and the degree of the pathology, on the one hand, and the surgeon’s skill and experience on the other(Table 7.1).

1 Retrograde (or Inversion) Technique

2 Luxation (or Delivery) Technique

The luxation (or delivery) technique is a more traumatic method which allows extensive modification of the lateral crus, dome, and upper part of the medial crus under direct view. The ventral (anterior) side of the lobular cartilage is supraperichondrially mobilized using an intercartilaginous and an infracartilaginous incision. The medial two-thirds of the lateral crus, the dome, and the upper third of the medial crus are then delivered (luxated) outside the nostril. This is always performed on both sides to avoid postoperative asymmetries. In special cases, the lateral crus is completely dissected out and modified (redraped, rotated upward, or resected and reconstructed (see p. 255, 256 and p. 260ff).

The luxation method is much more traumatic than the retrograde technique and requires meticulous care in dissecting, modifying, and repositioning the cartilages as well as in closing the incisions.

Specific risks are loss of tip support, a drooping tip, and a “polly beak” nose. The technique is the classic way to address the more pronounced abnormalities and asymmetries of the lobule. In the last decades, it has been partially replaced by the external approach.

Undermining the lobular skin and exposing the lobular cartilages is done supraperichondrially as close to the perichondrium as possible to avoid damage to the dermis, musculature, and the vascular and nervous supply.

3 External (or Open) Approach

Fig. 7.1 The lobular cartilages are outlined on the skin. The domes are marked.

4 Cartilage-Splitting (or Transcartilaginous) Technique

The cartilage-splitting (or transcartilaginous) technique is an endonasal nondelivery method which allows resections from the cranial part of the lateral crus and dome. The vestibular skin and the lateral crus is incised at a distance of about 4–5 mm from the lower margin of the cartilage. The skin overlying the cartilaginous dorsum and lobule is then undermined, and resections can be carried out as necessary. The method does not entail high risk. Too much resection, however, may cause weakness of the lateral nasal wall and inspiratory collapse.

Fig. 7.2 The IC incision is continued around the valve angle.

Techniques

1 Retrograde (or Inversion) Technique

• The domes and the margins of the lateral and medial crura are marked on the skin (Fig. 7.1).
  
• Intercartilaginous incisions are made bilaterally and continued around the valve angle (Fig. 7.2).
  
• The skin over the cartilaginous and the lower half of the bony dorsum is undermined with slightly curved, blunt scissors.
  
• The skin of the lobule over the lateral crura and domes is undermined in a retrograde direction with fully curved, blunt scissors (Fig. 7.3). We do not undermine far laterally to avoid cutting the fibers of the dilator muscle which insert at the lateral end of the lateral crus. Cutting these fibers would increase the inspiratory collapsibility of the ala as the dilator muscle contracts during inspiration.
  
• The connective tissue between the domes and the upper part of the medial crura is slightly loosened (Fig. 7.3). This should be done in a conservative way to avoid postoperative drooping of the tip.
  
• The ala is lifted with a blunt four-pronged retractor and inverted by pressure of the middle finger. The cranial margin of the dome is then grabbed with a sharp, round hook using the marks on the skin as points of reference. The hook is poked through the cartilage and the vestibular skin (Fig. 7.4). The dome can then be pulled downward and inverted.
  
• The vestibular skin is subperichondrially dissected from the cranial margin of the cartilage with pointed scissors or a Beaver knife (Fig. 7.5).
  
• The cranial margin of the lateral crus and the dome is now exposed and may be modified by small resections as required to narrow and/or upwardly rotate the tip (see p. 250ff).

Fig. 7.3 The skin over the lateral crura, domes, and interdomal area is undermined in a retrograde direction with a fully curved, blunt scissors.

2 Luxation (or Delivery) Technique

The luxation or delivery technique is the classic way to deal with abnormalities of the lobule, in particular of the tip and alae. The technique was developed in the 1940s and further refined in the 1950s. The lateral crura, domes, and the upper part of the medial crura are dissected on both sides and delivered outside the nostril. To this end, intercartilaginous and infracartilaginous incisions are made bilaterally (Figs. 7.2, 7.6). The cartilages are exposed on a flat instrument (back end of a chisel or a Neivert retractor). The vestibular skin remains attached to cartilage. The lateral crura, domes, and the upper part of the medial crura can now be modified under direct view, as required. One risk specific to the luxation technique is loss of tip support. When wide exposure is required, a columellar strut may be inserted at the end of the operation to preserve support.

Fig. 7.4 The dome and lateral crus are pulled caudally and inverted with a round hook that is poked through the cartilage and skin at the cranial margin of the dome.

Steps

• The lobular cartilages are outlined on the skin; the domes are marked (see Fig. 7.1).
  
• IC incisions are made bilaterally and continued around the valve angle (see Fig. 7.2).
  
• If wide exposure is required, the two IC incisions are continued downward in front of the caudal septum about half way across the membranous septum (socalled transfixion; see Fig. 7.23).
  
• The skin over the cartilaginous and lower part of the bony dorsum is undermined. The skin over the lateral crura, domes, and medial crura is elevated in a retrograde direction with fully curved, blunt scissors (see Fig. 7.3).
  
• Infracartilaginous incisions are made on both sides with a No.15 blade. The ala is inverted, for example with a two-pronged sharp–dull (right side) or a dull–sharp hook (left side), while counterpressure is given by the middle finger of the left hand (Fig. 7.6).
  
• The lower margin of the lateral crus is identified. The incision is started laterally and follows precisely the caudal margin of the cartilage (for details see Chapter 4, p. 128ff).
  
• The incision is opened with slightly curved, pointed scissors. The skin over the lateral crus and dome is then supraperichondrially undermined with slightly curved, blunt scissors (Fig. 7.7).
  
• A curved hook is poked through the skin and cartilage at the caudal margin of the dome. The cartilage is pulled downward and luxated out of the nostril (Fig. 7.8).
  
• A flat instrument (the back end of a chisel or a Neivert retractor) is introduced through the IC incision to expose the cartilage (Fig. 7.9). Care is taken to avoid overstretching or tearing the cartilage and the vestibular skin.
  
• The procedure is carried out again on the other side.
  
• Both cartilages can now be inspected and compared. They are modified as required by the pathology and the desired changes (for techniques see p. 251ff).

Fig. 7.5 The inverted lateral crus is cut over a distance of 2–4 mm with straight, pointed scissors just lateral to the hook. The vestibular skin and the perichondrium are dissected from the inside of the inverted cartilage.

Fig. 7.6 Intercartilaginous and infracartilaginous incisions are made to allow dissection and delivery of the lateral crus, dome, and upper part of the medial crus of the lobular cartilage.

Fig. 7.7 The skin over the lateral crura, domes, and upper part of the medial crura is undermined through the infracartilaginous incision.

Fig. 7.8 The lateral crus and dome are pulled out with a hook poked through the cartilage and skin at the inferior margin of the dome.

Fig. 7.9 The lateral crus and dome are exposed with the vestibular skin over a Neivert retractor or the flat back end of a Cottle chisel. They can now be modified under direct view.

3 External Approach

• The incision is outlined.
  
• A transverse inverted-V incision is made in the columella at one-third from its base using a No. 15 blade (Fig. 7.10). Care is taken to avoid cutting into the medial crura.
  
• The medial leg of the infracartilaginous incision is made bilaterally (Fig. 7.10). This part of the incision is made over the middle of the cartilage instead of at its caudal margin, to avoid postoperative retraction of the columella (see Chapter 4, p. 130).
  
• The columellar skin is gently dissected from the medial crura by pointed, slightly curved scissors through the lower end of the infracartilaginous incision (Fig. 7.11a).
  
• The columellar skin is separated from the medial crura in an upward direction, while the skin is gently lifted up with a delicate nontraumatic forceps or a small, sharp, two-pronged retractor (Fig. 7.11b). Damage to the skin and the soft tissues is avoided as much as possible to prevent postoperative scarring and retraction. Bleeding vessels (the columellar artery and its branches) are, for that reason, coagulated bipolarly with utmost precision.
  
• The skin over the domes is elevated supraperichondrially, while the infracartilaginous incision is continued in a lateral direction, following the caudal margin of the dome and lateral crus (Fig. 4.12).
  
• The columellar flap is inverted and retracted with a blunt, angulated retractor (Fig. 7.13).
  
• The lateral crura are exposed by continuing the dissection in a lateral direction, using slightly curved, blunt scissors or angulated scissors.
  
• The lobular cartilages are almost completely exposed. They may be modified while in position. They can also be dissected from the underlying vestibular skin and then either modified and fixed into another position or resected and reconstructed.
  
• The incisions are carefully closed with a monofilament 5–0 or 6–0 suture, avoiding traction and ischemia. The transverse columellar incision is closed first.
  
• An internal dressing with ointment is applied in the vestibule. The lobule is externally taped to support the tissues in their new position and to prevent swelling and hematoma.

Fig. 7.10 External approach. A transcolumellar inverted-V incision and bilateral infracartilaginous incisions are made using a No. 15 blade.

Fig. 7.11a The columellar skin is carefully dissected from the caudal margin of the medial crura using pointed, slightly curved scissors.

Fig. 7.11b Upward dissection of the columellar skin from the medial crura using small, slightly curved scissors or angulated scissors and a delicate, sharp, two-pronged retractor.

Fig. 7.12 The lobular cartilages and the cartilaginous dorsum are exposed supraperichondrially with pointed, slightly curved scissors or angulated scissors.

Fig. 7.13 The columellar flap is inverted and retracted with a blunt hook.

Fig. 7.14 Cartilage-splitting technique. A transcartilaginous incision is made 4–5 mm cranial to the caudal margin of the lateral crus using a No. 15 blade.

Historical development of the external approach

1929, 1933: Aurel Réthi (Budapest) introduces a high horizontal columellar incision for surgery of the lobular cartilages, the cartilaginous and bony dorsum, and for inserting a dorsal implant.

1938: EC Padget, very likely unaware of the publications in German by Réthi, describes “cross-cutting the columella and undermining the skin covering the tip and dorsum,” and speaks of an “external exposure.”

1951: H May publishes on “Réthi’s incision.”

1958, 1962: Ante Šerčer (Zagreb) uses a midcolumellar horizontal incision in combination with bilateral endonasal incisions and elevates the skin up to the nasion to correct the nasal pyramid and lobule. He speaks of “decortication of the nose.”

1960, 1966, 1972: Ivo Padovan (pupil and successor of Sercer at Zagreb) and his pupil Jugo (New York), continue using this technique and introduce a V-shaped incision at the columellar base. In 1970 Padovan reports on this approach at the AAFPRS in New York.

1970s: North-American surgeons, especially Anderson (New Orleans), Goodman (Toronto) and Adamson (Toronto), further explore the potentials of the method.

1980s: Although controversial in the beginning, the “external approach” gradually gains worldwide recognition as one of the standard approaches in nasal surgery, also named “open (structure) rhinoplasty.”

Fig. 7.15 Intercartilaginous, transcartilaginous, and infracartilaginous incision.

4 Cartilage-Splitting (or Transcartilaginous) Technique

In the cartilage-splitting or transcartilaginous technique, the lobule is approached through a bilateral incision of the vestibular skin and the lateral crus (Figs. 7.14, 7.15). This incision is usuallymade at a distance of 4–5 mm from the caudal margin of the lateral crus. A so-called continuous strip of (lateral) cartilage is kept intact. This approach allows resection of a strip from the cranial margin of the lateral crus and dome to narrow a bulbous lobule and tip. At the same time, the tip may be rotated upward. The technique is relatively atraumatic. The level of the incision is of utmost importance. If it is too low, toomuch of the lateral crus will be resected leaving a weak and depressed area which might cause inspiratory obstruction and a pinchednose appearance.

Steps

• The lobular cartilages are outlined on the lobular skin (Fig. 7.14).
  
• The endonasal incisions to be made in the vestibular skin are marked. They are usually made at a distance of about 4–5 mm from the lower margin of the lateral crus.
  
• The lateral wall of the vestibulum is subcutaneously injected with lidocaine–adrenaline to facilitate the next steps.
  
• The incisions are made in the skin only.
  
• The skin is dissected from the inside of the lateral crus in a cranial direction.
  
• The lateral crus and dome are incised endonasally under direct view and simultaneous outside control
  
• The vertical dimension of the lateral crura and the domes is shortened under direct view as required. Care is taken to leave a strip of cartilage of at least 4–5 mm in width.
  
• A small wedge at the domes may be resected additionally to (further) narrow the tip when indicated.

Tip Surgery

Characteristics of the Tip

Definition

The nasal tip is defined by the two domes. Ideally they should not be visible as separate structures. On palpation they are usually well distinguishable, however, and they produce a double light reflex (Figs. 7.16a,b).

Projection

• the lobular baseline (Fig. 7.17);
  
• the nasal baseline (NBL) (Fig. 7.18);
  
• the prominence of the bony and cartilaginous pyramid (Fig. 7.18); and
  
• nasal length (distance nasion–tip) (Fig. 1.12).

According to today’s “beauty standard” for the Caucasian population, tip projection should be less than 0.6 of nasal length.

Position

Mechanics of the Tip

Others like to compare the tip-supporting structures with a double tripod. In this concept, the medial crus is its short, medial, and almost horizontal leg. The lateral crus forms its lateral and slightly upwardly tilted leg, while its third medial and upward leg is formed by the septum and cartilaginous vault (Fig. 7.19).

The medial crura and their neighboring soft tissues are essential in keeping up the tip. The main factors determining the supporting capacity are the rigidity and length of the paracrural connective-tissue fibers, the connective-tissue fibers of the septocrural area, the membranous septum, and the depressor septi muscle.

The support provided by the second leg is dependent upon the length and rigidity of the lateral crura and on the connection between the lateral crus and the triangular cartilage. The rigidity and elasticity of the caudal part of the cartilaginous septumis the third factor determining the strength of the tip-supporting tripod.

Fig. 7.16a Double light reflex of the tip.

Fig. 7.16b Double light reflex of the tip.

Fig. 7.17 Projection (prominence, salience) of the tip in relation to the lobular base line.

Fig. 7.18 Projection of the nasal tip (t) and prominence of the cartilaginous (c) and bony (b) pyramid in relation to the NBL.

Note

In contrast to general belief, a recent study has shown that there are no intercrural-running and septocruralrunning fibers or ligaments (Zhai et al. 1995, 1996).

Fig. 7.19 Double tripod configuration of tip support.

Deformities, Abnormalities, and Variations of the Tip and Their Surgical Correction

The most common variations and deformities of the nasal tip have already been described and illustrated in Chapter 2 (p. 80ff). In this section we briefly discuss the most common deformities and abnormalities in relation to the most important tip-modifying procedures.

Many of the deformities, abnormalities, and variations occur in combination. An amorphous tip is often underprojected at the same time, while an upwardly rotated tip is frequently overprojected. It must be stressed that several variations are race-specific.

Broad, Bulbous (Amorphous), Square, and Ball Tip

The tip is not well-defined. This group includes the broad (wide) tip, the bulbous (amorphous) tip, the square tip, and the ball tip. In the broad tip, the domes are far apart. In the bulbous or amorphous tip, they are wide and massive. In the square tip, they are not archshaped but rectangular. In the ball tip, the domes are rounded. It should be stressed that these variations and abnormalities are not solely due to the form and thickness of the cartilage. The thickness of the lobular skin and the subcutaneous soft-tissue layers is another important factor (see Figs. 2.57, 2.58, 2.59).

In all these cases, the tip might be given more definition by a narrowing procedure, as required. Function should not be compromised. The continuity of the domes is therefore either respected or reconstructed.

Bifid Tip

The tip is duplicated due to an abnormally large distance between the two domes with an excessive amount of interdomal connective tissue. There is mostly a vertical groove or depression between the domes and in the columella(see Fig. 2.60). This abnormality is usually congenital and the result of incomplete fusion of the two nasal primordia, although it may also be due to previous surgery. This deformity requires dissection and repositioning of the lobular cartilages through an external approach or a delivery technique.

Asymmetrical Tip

The domes are asymmetrical. This may occur as an isolated variation or deformity in combination with bifidityoras part of an asymmetrical lobule (see Fig. 2.61).

Underprojected Tip

The projection of the tip is abnormally low compared with that of the cartilaginous and bony pyramid. The tip isnot the most prominent part of the external nasal pyramid; it is depressed and usually more flat. Tip support is mostly diminished (see Fig. 2.63). This abnormality usually requires a complete septorhinoplasty. Depending on the pathology, the anterior septum has to be exorotated or reconstructed. The projection of the domes may be increased by redraping the lobular cartilages or inserting a columellar strut, or by applying a tip or shield graft.

Overprojected Tip

The tip is abnormally prominent compared with the projection of the cartilaginous and bony dorsum. The nasolabial angle is mostly decreased (see Fig. 2.62). This condition usually requires a complete septorhinoplasty. The projection of the anterior septum may be reduced, while the projection of the domes may be diminished by redraping the lobular cartilages or by minor resections.

Upwardly Rotated Tip

The tip is more cranial than normal. An upwardly rotated tip is usually also overprojected. The nasolabial angleis abnormally large (see Fig. 2.64).

Hanging (Pendant, Drooping) Tip

The tip is more caudal than normal and underprojected at the same time. The nasolabial angle is abnormally small (see Fig. 2.65). A pendant tip is often seen in elderly individuals combined with a long nose. A pendant low tipis also a standard feature of the long, slightly humped Arabic nose.

Surgical Techniques

Narrowing the Tip and Supratip Area

1 Resecting a Strip and/or Wedge of Cartilage from the Cranial Margin of the Lateral Crus

Strips and wedges (Figs. 7.20a–c) can be resected from the cranial margin of the lateral crus and dome either by a nondelivery approach (retrograde technique or cartilage-splitting technique) or by a delivery approach (luxation technique or external approach).

The retrograde (or inversion) technique is chosen when only a small degree of narrowing is required. The cartilage-splitting technique may be used when a larger resection is planned. The luxation technique has the advantage of working under direct view. The same applies to the external approach.

Steps

• An intercartilaginous incision is made in the usual way. The skin over the dorsum and lobule is undermined. The cranial margin of the dome is hooked and pulled in a caudal direction. The cranial margin of the lateral crus is now exposed (see Figs. 7.1–7.4).
  
• A cut of 2–3 mm is made in a cranial direction, just lateral to the hook, with angulated or pointed, straight scissors (Fig. 7.21a).
  
• A triangular piece of cartilage is resected by a transverse cut with angulated scissors (Fig. 7.21b).
  
• The hook is removed and the cartilage is repositioned. The effect of the resection is judged by gentle palpation with the index finger or with the thumb and index finger (Fig. 7.22)
  
• The other side is corrected in the same (usually symmetrical) way.
  
• If more narrowing is indicated, an extra sliver of cartilage may be resected. One should never remove too much cartilage (and skin) at one time. The effect of the previous resection must first be assessed and bilaterally compared before any further tissue is removed.
  
• When upward rotation of the tip is desired, small triangular pieces of skin are also resected (in a symmetrical way!). Rotation is attained when the incisions are closed. It has to be kept in mind that the amount of skin resected must be less than the amount of cartilage removed, to avoid uncontrolled retraction.
  
• The IC incision is closed by at least two 4–0 resorbable sutures. The modified lobule is supported by an internal dressing and secured in its new form and position by a “tip-narrowing tape” and by “pressure tapes” (see Figs. 10.2c and 10.2e).

Note

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