Techniques for Controlling Tip Rotation in Closed Rhinoplasty and Rhinoplasty Anesthesia
Barış Çakır
Mustafa Özgön
DEFINITION
A droopy nasal tip is one of the most frequently encountered indications for rhinoplasty.
ANATOMY
The following anatomical features impact nasal tip rotation:
Maxilla
Columella
Lateral crus
Caudal septum
Upper lateral caudal
Pitanguy, scroll and interdomal ligaments
All these anatomical structures have to be of the right dimension in order to ensure the desired nasal tip position (FIG 1).
PATHOGENESIS
The most frequent problem causing a droopy nasal tip is the “tension nasal.” Septum that extends too far caudally shapes the domes by bending the nasal tip cartilages from the middle crura.
Septum pushes the footplates forward.
Because the depressor and orbicularis muscles are under tension, an excessively droopy nasal occurs when laughing.
Because the domes emerge from the middle crura, we encounter a long, wide and generally convex cartilage.
Also, trauma or a resection of the caudal septum creates projection and loss of rotation.
 FIG 1 • Anatomy. |
NATURAL HISTORY
The nasal tip has an elastic rotation and projection.
The nasal tip contributes to minimal facial expressions. A nasal tip that remains stiff when speaking is one of the last remaining stigmata of rhinoplasty.
It is important for the nasal tip to be mobile, so that the patient is able to comfortably lie face down and to kiss.
Techniques such as septal extension graft and tongue in groove are proven solutions for rotation and projection; however, the nasal tip loses its softness.
The nasal ligaments, and most importantly the Pitanguy ligament, ensure an elastic rotation and projection (FIG 2).
PATIENT HISTORY AND PHYSICAL FINDINGS
The patient complains about a “droopy nasal tip.”
The nasolabial angle is narrow.
The patient’s skin type is of significance. Patients with thick skin and a nasal tip that droops excessively when laughing are more likely to experience loss of rotation.
IMAGING
Front, base, top, lateral, and oblique photographs are standard. A lateral smiling photograph gives clues about the dynamics of the nasal tip. Taking a photograph of a beautiful nose, rotating it by 90 degrees, and looking at it in this way will facilitate the decision-making process concerning rotation during the surgery.
NONOPERATIVE MANAGEMENT
Filler and Botox can be applied to the nasal base. This cannot substitute for rhinoplasty, however.
SURGICAL MANAGEMENT
Suggested treatments for rotation control consist of different ways of attaching the medial crura to the septum.
FIG 2 • Pitanguy and scroll anatomy.
The medial crura can be sutured to the septum named tongue-in-groove technique
Permanent sutures can be applied from the medial crura to the septum named rotation control suture.
The rotation can be stabilized with a septal extension graft.
However, these techniques may lead to a stiff nasal tip.
When deprojection is performed, the footplates, which are connected to the depressor muscles, change place posteriorly. This procedure decreases the muscle’s excursion and weakens its function. For deprojection, it is generally sufficient to dissect the caudal septum in the subperichondrial plane.
For proper rotation, it is necessary to shorten the lateral crural cartilage, the upper lateral cartilage and caudal septum.
Shortening the lateral crus by means of the lateral crus steal technique increases lobule projection.
Without performing deprojection, a steal does not guarantee projection. The steal procedure re-establishes the projection lost due to deprojection.1
The basic effect of the lateral crus steal technique is an increase in rotation.
A strut graft is important to strengthen the support of the columella. In patients with weak columella support, 2 to 3 struts can be placed. Loss of projection causes loss of rotation.
In patients with an insufficient maxilla support, it is difficult to obtain rotation and projection. In these patients, the front of the maxilla should be filled with cartilage and bone (FIG 3).
In thick-skinned patients, it is necessary to select a strong and long cartilage as a strut graft and to use septocolumellar suture with 5-0 Prolene passing through the medial crus or the strut graft.
Positioning
The patient is positioned in the Trendelenburg position and lumbar flexion, with the neck in an extension of 20 to 30 degrees and parallel to the floor. In this position, intracranial blood pressure and surgical bleeding decrease. Keeping the head always parallel to the floor makes it less likely for errors to occur in rotation.
The patient is positioned on the back, with a pillow under the head, the arms on belly, and supported by a silicone cushion placed under their legs in such a way that their heels do not touch the operating table. The arms are secured by wrapping them with a sheet so that the chest is left either exposed or covered.
In the operating room, the anesthesia device is placed at a 45-degree angle next to the patient’s head, to their right side. Thus, the surgeon can access the patient’s head and check for symmetry (FIG 4). If the surgeon is right handed, the anesthesia device is placed to the left side.Related posts:
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