TITLE: Rhinoplasty and the Nasal Tip
SOURCE: Grand Rounds Presentation, UTMB, Dept. of Otolaryngology
DATE: March 31, 2009
RESIDENT PHYSICIAN: Jean Paul Font, MD
FACULTY PHYSICIAN:
SERIES EDITORS: Francis B. Quinn, Jr., MD
ARCHIVIST: Melinda Stoner Qui=
nn,
MS(ICS)
"This
material was prepared by resident physicians in partial fulfillment of
educational requirements established for the Postgraduate Training Program =
of
the UTMB Department of Otolaryngology/Head and Neck Surgery and was not int=
ended
for clinical use in its present form. It was prepared for the purpose of
stimulating group discussion in a conference setting. No warranties, either
express or implied, are made with respect to its accuracy, completeness, or
timeliness. The material does not necessarily reflect the current or past
opinions of members of the UTMB faculty and should not be used for purposes=
of
diagnosis or treatment without consulting appropriate literature sources and
informed professional opinion."
History of Rhinoplasty
R=
hinoplasty
was first developed by Sushruta, an important physician who lived in ancient=
India
circa 500 BC<=
/span>,
which he first described in his text Sushruta Samhita. He and his later students=
and
disciples used rhinoplasty to reconstruct noses that were amputated as a
punishment for crimes. The first intranasal rhinoplasty in the West was
performed by John Orlando Roe in 1887. It was later used for cosmetic purp=
oses
by Jacques=
Joseph
in 1898 to help a patient who felt that the shape or size of his nose caused
embarrassment and social discomfort. Joseph's first rhinoplasty patient was=
a
young man whose large nose caused him such embarrassment that he felt unabl=
e to
appear in public. He also employed the first nasal tip suture which was name
the orthopedic suture as Jacques Joseph was an Orthopedic surgeon who devel=
op a
particular interest in the field of facial plastics. Dr Joseph is considered
the father of modern facial plastic surgeon.
Introduction
Many consider rhinoplasty to be the most difficu= lt facial plastic operation. It requires a precise assessment of the deformity, nasal support mechanisms and soft tissue skin envelope. Airway function is dependent on multiple factors= modulated with every surgical maneuver. Postoperative scar contracture and healing may later modify the nasal structure over the lifetime of the patient. Not surprisingly the estimated rate of revision rhinoplasty is 8% to 15%.
Surgica=
lly
manipulating the nasal tip to achieve predictable results is the
most difficult feature of rhinoplasty. One who can control the nasal tip is
said to be able to master rhinoplasty. Attain=
ing a
well-defined, accurately rotated and properly projected nasal tip is a vital
component for success in tip shaping and is predicated on a fundamental
understanding of the anatomical components that provide nasal tip support a=
nd
their influences on tip projection and shape.
Preoperative Assessment and Planning
Preoperative and postoperative photographic documentation is essential. Full-face frontal, oblique, lateral images, and close-= up base views should be standard. Images should be obtained with dual flash sources angled 45 degrees toward the patient. An additional frontal view ta= ken with a single flash placed in front of and above the patient allows for shadowing and highlighting of the dorsal line. Close-up views should be tak= en to document any irregularities or damage to the skin. Whereas analysis of t= he patient is done in the office setting, high-quality preoperative photographs allow for more detailed study at a later time. The base view provides information about the shape and size of the columella, alar base, nostrils,= and lobule. On the lateral view, the dorsum is assessed for smoothness, vertical position of the nasal starting point, convexity or concavity, and presence = of a supratip break.
On frontal view, nasal width, symmetry, and pres= ence of dorsal deviation are noted. Ideally the width between each alar groove is equal to the intercant= hal distance, or is equal to 70% of the distance from the nasion to the tip-defining point. Wider int= eralar distance is present in oriental and black patients.
On profile view, the nasal properties to evaluate
should include the bony dorsum, the projection and rotation of the nasal ti=
p,
and the nasal length. Dorsal =
nasal
humps should be noted. Tip
projection is evaluated by determining the protrusion of the nasal tip defi=
ning
point from the anterior facial plane.
The Goode method drops a vertical from the nasion to the alar groove,
then an intersecting horizontal from the alar groove to the tip defining po=
int
to create a right triangle with the hypotenuse representing the nasal length
(nasion to the tip-defining point).
The ratio of the tip projection (horizontal) to the nasal length
(hypotenuse) ideally equals .55 to .6 to 1. Tip rotation is evaluated by deter=
mining
the nasolabial angle. The
nasolabial angle is defined by measuring the angle between a line tangent to
the columellar line and a line from the subnasale to upper lip’s
vermilion border. The angle s=
hould
be 90 to 105 degrees in men and 100 to 120 degrees in women, though ethnic
differences may influence this, with
The caudal view of the nose should show an equil= ateral triangle, with the columella in the center. The columella to lobule ratio shou= ld be about 2:1, and the nostrils should flare mildly laterally.
The skin and subcutaneous tissues should be asse= ssed during facial analysis. Thick= nasal tip skin has a tendency for more postoperative edema and scarring, predispo= sing the patient to postoperative pollybeak deformity. Thin skin is preferred because it = heals more predictably, though with extremely thin skin, even minor deformities a= fter surgery will be easily visible and palpable.
Key to preoperative nasal analysis is to take in= to consideration the patient’s view of nasal cosmetic deficits. For instance, though the above measurements are considered generally ideal, the individual patient may not wish to alter characteristics that they feel define their ethnicity or fami= ly traits. Careful discussion wi= th the patient with pictures or a three way mirrors helps to hash out patient expectations and the feasibility of meeting those expectations prior to any= surgery. Computer imaging techniques will continue to play a larger role in helping a patient have realistic expectat= ions of surgical results.
Tripod Theory
The tripod concept of tip projection, support, and
rotation described by
Tip Rotation
The tripod concept of nasal tip support and the =
major
and minor tip support mechanisms must be considered in nasal tip rotation
especially ptosis. In
addition, the integrity of the medial and lateral crura, the attachment of =
the
medial crural feet to the caudal end of the quadrangular cartilage, and the
scroll-like attachment of the caudal end of the upper lateral cartilage to =
the
cephalic margins of the lateral crura are the major tip support structures =
to
consider. The minor tip suppo=
rt
mechanisms include (1) the dorsal cartilaginous septum, (2) the interdomal
ligaments, (3) the nasal spine, (4) the membranous septum, and (5) the alar
attachments to the skin. Alterations in the size, shape, and integrity of t=
he
limbs of the tripod, together with the disruption of the major and minor tip
support mechanisms, result in profound alteration in tip rotation.
A major step in any tip rotation procedure is the cephalic resection of a portion of the lower lateral cartilage. Such a resection leaves a gap betw= een the lower lateral and upper cartilages.&nb= sp; This gap is partially closed as the lower lateral cartilages scar upwards, resulting in tip rotation. Two basic types of cephalic cartilage resection include those techni= ques that preserve an intact strip of cartilage, and those that interrupt the en= tire lower lateral cartilage. Complete strip techniques resect a variable amount= of the cephalic lower lateral cartilages.&nbs= p; More cartilage is resected for a greater amount of volume reduction = and for a greater degree of cephalic tip rotation. The complete strip can be weakened in several ways to assist in cephalic rotation. These methods must, however leave = the lower lateral cartilages with sufficient strength to maintain tip support. = For patients who have significant tip depression, interrupted cartilage techniq= ues may be required to achieve sufficient tip rotation. The interruption of the lower late= ral cartilage releases the spring-like tension on the nasal tip and allows much greater cephalic rotation of the tip. However, interruption also destroys a major tip support mechanism and also leaves the nasal tip subject to less predictable scar formation and asymmetries.
Adjunctive tip rotation maneuvers are often nece=
ssary
to achieve adequate tip rotation, especially when complete strip techniques=
are
used, as discussed above. Var=
ious
degrees of excision of the caudal septum can effect tip rotation. This is because excision of the ca=
udal
septum can provide room for the infratip lobule to ascend during healing.
Other tip rotation techniques can create the appearance of tip rotation by altering the nasolabial angle. Morselized cartilage grafts into t= he columella-philtrum junction can result in increasing the nasolabial angle so that the illusion of tip rotation is created. Cephalic resection of the lower la= teral cartilages to a point beyond the tip defining points can lead to a supratip= dip that creates the illusion of tip rotation.
Tip Projection
After primary rhinoplasty there is a postoperati= ve decrease in nasal tip projection unless steps are taken to increase the len= gth and strength of the medial crural segment. Either the cartilage-delivery or cartilage-splitting approach weakens or disrupts the support mechanism of t= he nasal tip. One of the ways to preserve tip projection after nasal surgery i= s to resuture the medial crural footplates to the caudal septum when they are detached. Additionally, a cau= dal strut may be fashioned from autogenous cartilage. The caudal strut should be fashion= ed with a curve that matches the collumella and should be positioned and sutur= ed between the medial crura. A p= ocket is dissected between the medial crura and the graft is placed here. The graft should not project beyon= d the domes of the lower lateral cartilages in order to avoid a tented up appeara= nce of the nasal skin. The graft = should not rest on the nasal spine, as displacement from the spine will cause the patient to experience nasal clicking and discomfort. Often the caudal strut can be sutu= red to the caudal septum.
Medialization of the lateral crura of the lower lateral cartilages can enhance tip projection. This can be accomplished in several ways. One method that is rare= ly used is the division of the lateral domes of the lower lateral cartilages a= nd suturing of these cartilages together over the midline with permanent sutures. Although this proced= ure increases tip projection, it may also lead to a tent-pole appearance of the nasal tip. Another procedure,= often referred to as the “Lateral Crural Steal,” (2), involves rotati= on of the lateral crura medially and placing an interdomal stitch to hold the crura in place. This procedure narrows the nasal tip, increases tip projection moderately, and leads to mi= ld cephalic tip rotation.
Tip grafts can achieve the effect of increased n= asal tip projection. The tip graft= s can be of varying sizes and shapes. The grafts are placed in positions that enhance bilateral tip-defining points a= nd therefore achieve maximum aesthetic results. Stabilization of the graft must be assured with sutures or creation of a snug pocket so that the graft does not become displaced. A single gr= aft that is trapezoid or shield shaped can be fashioned and placed in the midli= ne to overlap both tip defining points. Some surgeons, however, utilize rectangular or circular smaller graf= ts and suture them individually over each dome so as to more closely approxima= te the natural separation of the tip defining points.
Other methods can create the illusion of increas= ed tip projection. One such method i= s the removal of a dorsal hump, which makes the nasal tip appear more prominent.<= span style=3D'mso-spacerun:yes'> Cephalic rotation itself can creat= e the illusion of tip rotation.
Reduction of tip projection is occasionally required. Reduction of tip projection is best achieved by assessing the cause of the problem and sacrificing major and minor tip support mechanisms directly related to this= . Often this overprojection is due t= o an overdeveloped quadrangular cartilage of the septum. In such patients, the septal carti= lage may place tension on the lower lateral cartilages, leading to overprojection. This can be c= orrected by reduction of the dorsal septum. When the lower lateral cartilages are responsible for overprojection= , an interrupted strip technique with conservative resection of a rectangular we= dge of cartilage with resuturing will aid in correcting the problem. An alternative method is the later= al crural overlay technique discussed above.&= nbsp; Another tip support mechanism can be sacrificed to reduce tip projec= tion via the transfixion incision, which sacrifices the medial crural footplate’s attachment to the caudal septum. Most of the reduction of tip projection methods discussed above will lead to widening of the nasal ala.<= span style=3D'mso-spacerun:yes'> Wedge excision of the alar bases m= ay be necessary to achieve nasal harmony.
Tip Definition
One of the most common problems encounter when
addressing tip definition is the bulbous tip. In order to correct this deformity=
it is
important to recognize the underlying problem. The most common causes of
bulbous tip are the wide interdomal distance, widening of the domes, weak l=
ower
lateral cartilage and thick skin with lack of definition. Many of the alrea=
dy
describe maneuvers address the definition. The transdomal suture in particu=
lar
plays an important role in definition by narrowing the domal structure and =
by
end result the tip. Interdomal suture and medial crura suture will also imp=
rove
definition by decreasing the interdomal distance. The dome division with
binding suture significantly increase tip definition by decreasing the domal
width.
Conclusion
Understanding the importance of proper preoperat=
ive
evaluation, intraoperative assessment and the individual and additive effec=
ts
of tip-modification maneuvers is paramount to a successful outcome. Improved
long-term results occur when the supporting structures of the tip are prese=
rved
or restore. A predictable res=
ult
will be obtained if harmony between the major components of the nasal tip
refinement which are nasal tip rotation, definition and projection.
Reference
Ghavami A, Janis JE Tip shaping in primary rhinoplasty= : an algorithmic approach. <= span style=3D'color:windowtext;text-decoration:none;text-underline:none'>Plast Reconstr Surg. 2008 Oct;122(4):1229-41.
Constantian MB. The two essential elements = for planning tip surgery in primary and secondary rhinoplasty: observations bas= ed on review of 100 consecutive patients. <= span style=3D'color:windowtext;text-decoration:none;text-underline:none'>Plast Reconstr Surg. 2004 Nov;114(6):1571-81; discussion 1582-5.
Cummings. Surgical refinement of the nasal t= ip. Otolaryngology: Head & Neck Surgery, 4th ed., Chapter 46-48
Behmand R, Ghavami A., Guyuron B. Nasal Tip Sutures Part = I: The Evolution. Plastic and reconstructive surgery.Volume 112(4), 15 Septem= ber 2003, pp 1125-1129.
Guyuron B, Behmand R. Nasal Tip Sutures Part= II: The Interplays. Plastic and reconstructive surgery. Volume 112(4), 15 September 2003, pp 1130-1145
Ta=
rdy,
Foda, Hossam M. T. MD. Kridel, Russell W. H. MD. “Lateral Crural Steal and Lateral
Crural Overlay: An Objective Evaluation,” Archives of Otolaryngolo=
gy
-- Head & Neck Surgery. 125(12):1365-1370, December 1999.
Ta=
rdy,
Eugene M. et al. “Surgical Anatomy of the Nose,” Byron J. Bailey’s Head and N=
eck
Surgery – Otolaryngology Third Edition, pgs.2211-2227, Lippincott Williams and Wilkins 20=
01.
Ca=
lhoun,
Karen, “Introduction to Rhinoplasty,” Byron J. Bailey’s H=
ead
and Neck Surgery – Otolaryngology Third Edition, pgs.2229-2240, Lippincott Williams and Wilkins 20=
01.
Tardy, Eugene M. et al. “Refinement of the Nasal Tip,R=
21;
Byron J. Bailey’s Head and Neck Surgery – Otolaryngology Third
Edition, pgs. 2255-2271, Lipp=
incott
Williams and Wilkins 2001.
Kr=
idel,
RW, et al. “Advances in nasal tip surgery,” Arch
Otolaryngol Head and Neck Surg. 115:1206-1212, 1989.
Farrior, EH. “Dramatic Refinement of t=
he
Nasal Tip,” Otolaryngology Clinics of