Lateral crural techniques for repositioning the nasal tip

Effect of lateral crural cut overlay and medial crural cut and overlay in creating and maintaining tip projection and rotation: a randomised single-blind trial

Lateral crural cut and overlay (LCC) or medial crural cut and overlay (MCC) are two of the many techniques applied to ensure an adequate nasal tip projection and rotation, but little evidence supports their long-term efficacy. Fifty-four rhinoplasty candidates were studied prospectively in this randomised clinical trial. The subjects were randomly divided into two groups according to the use of LCC or MCC. The outcome measures were gaining and maintaining tip projection and rotation in the long term. Standardised photographs taken before and at three and 12 months after surgery were used to compare nasolabial angle and projection between groups. Patients' satisfaction with the cosmetic results and nasal obstruction were evaluated using the Standardised Cosmesis and Health Nasal Outcomes Survey (SCHNOS). LCC and MCC were each used in 26 cases. Preoperatively, the nasolabial angle, tip projection, and other characteristics were not significantly different between the groups. There was no significant difference in tip rotation stability (p = 0.624) and projection (p = 0.329) between the groups postoperatively, but patients' satisfaction with the cosmetic results was significantly higher in the MCC group (p = 0.046). It seems that both LCC and MCC are effective techniques in rhinoplasty. Compared with LCC, the use of MCC in qualified hands may increase the patients' satisfaction with the cosmetic results.

The Effect of Anchoring the Columellar Strut Graft to the Lateral Crural Steal Suture in Patients With a Low Nasal Tip: A New Technique

OBJECTIVE

The achievement of consistently superior results in rhinoplasty is difficult. This study aimed to evaluate the effect of anchoring the columellar strut graft to the thread of the lateral crural steal for nasal tip projection and rotation.

STUDY DESIGN

A retrospective, case-control study.

METHODS

Two groups were created which consisted of patients who had a history of low nasal tip deformity according to the type of nasal tip surgery in rhinoplasty. In group 1, the lateral crural steal technique with the strut graft was used, whereas in group 2, a new technique, in which the strut graft was anchored to the thread of the lateral crural steal, was used. Patients with low nasal tip deformity due to intrinsic factors such as long lateral crura were included. The effects of the 2 different surgical approaches on facial parameters (the nasolabial angle, nasofacial angle, and Goode ratio) were statistically compared using the Mann-Whitney U test and Student t test, as applicable.

RESULTS

Sixty patients were enrolled: half of them were included in group 1 and the other half in group 2. Average postoperative increases of the nasolabial angle score were 10.9 ± 4.72° and 18.76 ± 6.30° in groups 1 and 2, respectively (P < 0.001). Average improvements of the nasofacial angle were 2.33 ± 2.12° and 3.50 ± 2.44° in groups 1 and 2, respectively (P = 0.053). Average postoperative increases of the Goode ratio were 0.02 ± 0.02 in group 1 and 0.04 ± 0.03 in group 2 (P = 0.028).

CONCLUSION

The new technique provided a prominent nasal cephalic rotation with a strong effect on the nasolabial angle and a partial effect on nasal projection.

Effects of the Tongue-in-Groove Maneuver on Nasal Tip Rotation

BACKGROUND

A change in nasal tip rotation is a very common maneuver performed during rhinoplasty. Among the many techniques used to achieve this goal is the tongue-in-groove (TIG).

OBJECTIVES

This study addresses the long-term effect of the TIG on the nasal tip rotation 1 year after rhinoplasty.

METHODS

The authors prospectively identified patients who were submitted to a rhinoplasty with a TIG maneuver over a period of 1 year. The angle of rotation was measured along the nostril axis angle. The data were analyzed using the t test and a linear regression model.

RESULTS

Seventeen patients were included. The average preoperative tip rotation was 93.95° (SD, 3.12°). Immediate postoperative tip rotation averaged 114.47° (SD, 3.79°). At the 1-year follow-up appointment, the tip rotation averaged 106.55° (SD, 3.54°). There was a significant loss of rotation at the 1-year postoperative visit (P < 0.0001), with an average loss of 7.9° (SD, 3.25°), which amounted to 6.8%. The preoperative rotation didn't affect the amount of loss of rotation (P = 0.04). It can be estimated that, for every degree of rotation that is changed at surgery, the tip can be expected to lose 0.35 degrees over the first year.

CONCLUSIONS

TIG is a more dependable technique than the ones that rely on healing and contraction to obtain rotation. Our data demonstrated a significant loss of rotation during the first year. This suggests that the surgeon needs to slightly overcorrect the tip rotation to account for this loss.

LEVEL OF EVIDENCE 4

Split Cartilage Resection of Nasal Dome: A Solution to Ptotic Nasal Tips

OBJECTIVE

In ptotic noses, it is rather difficult to achieve the intended functional and cosmetic result without modifying the alar cartilage and creating a new nasal tip. The split cartilage resection method was intended to create a new and permanent nasal tip to protect the physiologic and cosmetic appearance of the nose in the presence of long and ptotic nasal tip.

METHOD

A total of 53 patients who had nasal tip ptosis were included in the study: 26 patients (Group 1) who underwent lateral crural overlap because of the alar cartilage problem and 27 patients (Group 2) who underwent dome split cartilage resection. After at least 1 year of follow-up, the pre- and postoperative measurements of patients indicating their rotations and projections in their computerized images were compared and acoustic rhinometry was performed to determine the nasal valve function.

RESULTS

There were no significant differences between the 2 groups with respect to the pre- and postoperative nasolabial angels, rotation angles, Goode index, and nasofacial angle. There were no significant differences between the nasal cavity volume values of the 2 groups; the volume increase in wide nasal cavity in Group 2 was higher. After the operation, the increase in minimum cross-sectional area values in Group 2 was significantly >1 in Group 1.

CONCLUSIONS

The nasal tip split resection method is a method that can be implemented and should be kept in mind as a technique, which must be considered as an alternative method for noses with ptotic and long nasal tip disorder.

Management of severe tip ptosis in closed rhinoplasty: the horizontal columellar strut

BACKGROUND

Tip ptosis is a relatively common nasal deformity, with an incidence as high as 72% in rhinoplasty patients. Different techniques were described for surgical correction of the droopy tip, such as the lateral crural steel, the lateral crural overlay, the tongue-in-groove technique and others. Most authors agreed that an external rhinoplasty approach is necessary for effectively conducting the alar cartilage-modifying techniques mentioned above.

METHODS

In this article we challenge this paradigm and introduce an efficient method for aesthetic correction of severe tip ptosis through an internal rhinoplasty approach. Twenty-three patients with severe ptosis of the nasal tip were operated on by the senior author (MH) between 2000 and 2005 using the described technique. After carrying out the necessary manoeuvres to achieve the desired tip rotation (reduction of cephalic border of alar cartilages, modification of the caudal septum, reduction of upper lateral cartilages), the desired tip position was maintained with the horizontal columellar strut, whose initial operative description appears here.

RESULTS

The desired rotation and projection were maintained in all but three patients over the first year after the surgery. In three patients we observed some loss of tip projection after 1 year. We did not witness complications directly related to the horizontal columellar strut.

CONCLUSION

The horizontal columellar strut is an efficient tool for stabilising the corrected position of a severely ptotic nasal tip. We recommend adding the horizontal columellar strut to the array of available rhinoplasty techniques.

Management of the droopy tip: a comparison of three alar cartilage-modifying techniques

The droopy tip is a common nasal deformity in which the tip is inferiorly rotated. Five hundred consecutive rhinoplasty cases were studied to assess the incidence and causes of the droopy tip deformity and to evaluate the role of three alar cartilage-modifying techniques--lateral crural steal, lateral crural overlay, and tongue in groove--in correcting such a deformity. The external rhinoplasty approach was used in all cases. Only one of the three alar cartilage-modifying techniques was used in each case, and the degree of tip rotation and projection was measured both preoperatively and postoperatively. The incidence of droopy tip was 72 percent, and the use of an alar cartilage-modifying technique was required in 85 percent of these cases to achieve the desired degree of rotation. The main causes of droopy tip included inferiorly oriented alar cartilages (85 percent), overdeveloped scrolls of upper lateral cartilages (73 percent), high anterior septal angle (65 percent), and thick skin of the nasal lobule (56 percent). The lateral crural steal technique increased nasal tip rotation and projection, the lateral crural overlay technique increased tip rotation and decreased tip projection, and the tongue-in-groove technique increased tip rotation without significantly changing the amount of projection. The lateral crural overlay technique resulted in the highest degrees of rotation, followed by the lateral crural steal and finally the tongue-in-groove technique. According to these results, the lateral crural steal technique is best indicated in cases with droopy underprojected nasal tip, the lateral crural overlay technique in cases of droopy overprojected nasal tip, and the tongue-in-groove technique in cases where the droopy nasal tip is associated with an adequate amount of projection.