Dome truncation for management of the overprojected nasal tip

A New Technique for Use Instead of Lateral Crural Overlay for Reduction of Nasal Tip Projection in Revision Rhinoplasty

Objective

Correction of nasal tip projection (NTP) deformities involve techniques for the lower lateral cartilage of the nose. Previously, it would have been surgically difficult to perform the lateral crural overlay (LCO) technique for the second time in revision rhinoplasty in patients who already had undergone rhinoplasty with the LCO technique because of the length of the NTP. In this study, we evaluated the lateral crural segmental excision (LCSE) technique in patients with overprojected nasal tip in revision rhinoplasty.

Methods

We retrospectively studied the cases of 19 patients who had initially undergone rhinoplasty with the LCO technique for overprojected nasal tip, and later underwent revision rhinoplasty with the LCSE technique after insufficient NTP was observed on facial analysis between 2018 and 2022.

Results

Of the patients, 12 (63%) were male, with an average age of 29.6 years, and 7 (17%) patients were female, with an average age of 25.3 years. Using Goode's formula, NTP indexes of patients measured 79.4±1.8 preoperatively and 56.0±1.3 postoperatively. Stastically significant difference was observed between preoperative and postoperative values. None of the patients had malnutrition at the incision margins, and all patients recovered on time and without any problems. Granulation tissue was detected in the mucosa in only one patient.

Conclusion

The LCSE technique, with a short surgical time, recovery period without complications, and satisfactory nasal respiratory function, is preferred over a second LCO application in cases of NTP.

Cosmetic Rhinoplasty

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Perform a systematic nasofacial analysis. 2. Identify the underlying anatomical cause of specific external nasal findings. 3. Recognize the interrelated effects of operative maneuvers. 4. Develop an appropriate operative plan to address patient concerns.

SUMMARY

The rhinoplasty operation is one of the most challenging procedures in plastic surgery, and requires a combination of surgical judgment, knowledge of anatomy, technical skill, and lifelong study. A foundation must be built on clearly defined patient goals and an accurate diagnosis, based on known ideals and their anatomical correlation. It is important to recognize the definitive impact of each operative maneuver to achieve predictable outcomes. This article provides a problem-based approach to common cosmetic nasal deformities.

Composite Tissue Columella Wedge Excision for Nasal Tip Overprojection

BACKGROUND

The overprojected nasal tip is a challenge in facial surgery. Although several techniques are available, none has been proven to be superior. The aim of this study was to introduce a novel approach to overcome nasal tip overprojection and to evaluate its safety and efficacy.

METHODS

All patients with protruding nasal tip who underwent correction by means of a novel columella wedge technique were included in this study. In addition to detailed description of the novel surgical approach, its efficacy was analyzed by comparison of preoperative and postoperative nose dimensions. In addition, patients were examined during follow-up, and complication and revision rates were determined.

RESULTS

Forty-two patients were included in this study. Columella wedge technique involved resection of a 2- to 5-mm section of the middle part of the columella. Postoperatively, nose projection and length decreased by 9 and 12 percent, respectively. The relation between projection and length of the nose changed from 0.68 preoperatively to 0.61 postoperatively. This difference was statistically significant (p = 0.002). After a mean follow-up of 28 months (range, 6 to 144 months), revision operations were necessary in seven patients (16.6 percent). No instabilities, impairment of breathing, or other complications occurred.

CONCLUSION

The introduced columella wedge technique is efficient and safe for correction of the overprojected nasal tip.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

The Pillars of the Nose-Crura Shortening for Over Projected Nose

BACKGROUND

The over projected nose, commonly referred to as the "Pinocchio" nose is a significant challenge to the rhinoplasty surgeon. Firstly, we speak about a very large nose, and secondly, we speak about the correction of nasal cartilages (alar and triangular). Surgical correction of the over projected nose is the most difficult and least predictable component of rhinoplasty surgery.

AIM

By performing rhinoseptoplasty we aimed to achieve an ideal landmarks position according to concepts of nasal projection as well as by making preoperative analyses to determine the ideal position for the nasal tip after having understood and defined the ideal position for the nasion.

METHODS

We performed a retrospective study of patients who were admitted to ENT University Clinic, University Campus "St. Mother Theresa" Skopje, the Republic of Macedonia in the period 2011-2019. A total of 70 patients were enrolled in the study; 46 women (33%) and 24 men (33%). Operative technique rhinoseptoplasty was realised in 70 patients. All of the 70 (100%) patients underwent preoperative and postoperative evaluation during this period regularly to record the effects of various approaches on nasal projection, rotation, need for revision, and patient satisfaction.

RESULTS

All patients used one or more of the preferred methods to treat over projection. Patients who had undergone 2 previous rhino/septoplasty procedures were excluded from the study, and hence, a total of 70 patients were evaluated. Full-transfixion incisions were made in all patients. From 2011 to 2019, in 72 cases, 1 or more of the preferred methods were used to treat over projection.

CONCLUSION

The crural anatomy of the nasal tip relates to the size and shape of the lower lateral cartilages (LLC) and their relationship with the caudal septum and upper lateral cartilages (ULC). Modification of nasal tip rotation and projection should attempt to preserve or reconstruct major tip mechanisms.

Cutting the Holy Dome: The Evolution of Vertical Alar Resection

INTRODUCTION

Dome division or vertical dome division (VDD) is a tip plasty technique that is effective when applied appropriately to suitable patients. For 15 years, we have used VDD and made modifications as needed. In classical VDD, the dome area is cut and left to heal, but experience shows that additional components are needed to complement dome division, such as sutures or grafts. In this study, we retrospectively analysed our rhinoplasty patients in whom we used vertical alar resection (VAR) to assess the advantages and disadvantages of this technique. To our knowledge, this is one of the most exhaustive studies of VDD, including over 3000 patients.

MATERIALS AND METHODS

This retrospective case series reviewed the charts of 3965 patients who underwent VAR between 2000 and 2015. All patients were operated on by the senior surgeon. Dome division was used for various reasons, including a deformed tip area in revision rhinoplasties, droopy nose, wide tip, pinched nose, tip asymmetry, and overprojected nasal tip. Patients were excluded if they had septal deviation that enabled tip rotation, or a dorsum problem that caused tip asymmetry.

RESULTS

The study included 3965 patients (3172 women and 793 men) who underwent open rhinoplasty from 2000 to 2015. The mean patient age was 28.3 years (range 18-50 years). The mean clinical follow-up duration was 11.2 years.

CONCLUSION

In conclusion, this technique is capable of modifying all parameters of the nasal tip (projection, rotation, and volume), as required, at the same time, addressing many tip problems.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Projection and Deprojection Techniques in Rhinoplasty

Projection of the nasal tip is among the most important aspects of the nose. In this article, a wide spectrum of techniques are presented that allow the rhinoplasty surgeon to decrease, maintain, or increase nasal tip projection. Rhinoplasty surgeons must be adept with suture techniques, lower lateral cartilage overlay techniques, and structural grafting to be able to achieve excellent long-term results.

Decreasing nasal tip projection in rhinoplasty

BACKGROUND

Decreasing nasal tip projection is occasionally required in rhinoplasty and requires a working knowledge of nasal support and function. Equally important is an understanding of the evolution to a more conservative and incremental approach when decreasing nasal tip projection. Such a conservative approach reserves the most aggressive and precarious maneuvers to be used only when absolutely required.

METHODS

The authors review the history and evolution of techniques regarding decrease in nasal tip projection. Anatomy of the nasal tip with focus on tip support structures is reviewed. Distinguishing between pseudo-overprojection and true overprojection of the nasal tip is discussed. Methods of diagnosing nasal tip projection are reviewed and a suggested surgical approach is presented.

RESULTS

Reduction of nasal tip projection requires a thorough knowledge of relevant anatomy and tissue interplay. Although a variety of techniques and algorithms exist in addition to those recommended in this article, the goal should be an incremental approach with constant reassessment. Tip truncation is rarely if ever indicated and is often associated with eventual contour deformity.

CONCLUSION

The described approach in this article has been proven reliable for the vast majority of patients undergoing rhinoplasty with the overprojected nose.

Dealing with the overprojecting pinched tip

OBJECTIVE

When reshaping the pinched and/or pointed nasal tip, the use of cartilage grafting and internal sutures has been proven to be an excellent tool when the skin is not too thin. A new technique in tip aesthetics is presented. Its surgical applications are discussed.

STUDY DESIGN

A tip reshaping without cartilage grafting or internal stitching was performed on 355 patients with thin skin; 317 were female and 38 were male. The follow-up period ranged from 6 months to several years, with an average of 16 months.

METHODS

The closed approach was used. Parallel incisions on the alar cartilage have been made and alternate spicules of cartilage have been then excised to reduce the length of the arc of the cartilage and to reshape the tip.

RESULTS

The technique was effective in achieving aesthetic norms.

CONCLUSIONS

When dealing with a very thin skin, the pinched or pointed tip may sometimes need a different approach. The use of cartilage crafting or internal stitching for the reshaping of the tip, in those cases, is not obligatory.

'Universal retraction suture' for the overprojecting nasal tip

Achieving a proper nasal tip projection is a crucial element of a successful rhinoplasty. A large number of correction methods and manoeuvres have been proposed in the medical literature as solutions for the prominent nasal tip, thus complicating the surgeon's strife to choose the ideal plan of action. In the present article, a single straight-forward technique, christened the 'universal retraction suture', is suggested to tackle the overprojecting tip in a simplified, controlled and efficient fashion.

Intermediate crural overlay in rhinoplasty: a deprojection technique that shortens the medial leg of the tripod without lengthening the nose

OBJECTIVE

To review the indications for, surgical techniques of, and results of intermediate crural overlay of the alar cartilages in rhinoplasty.

DESIGN

Prospective study of patients undergoing intermediate crural overlay of the lower lateral cartilages. The setting was a facial plastic surgery private practice. Patients included 10 primary rhinoplasty patients and 1 revision rhinoplasty patient who underwent intermediate crural overlay of the lower lateral cartilages. The main outcome measures were postoperative photographs and patient records, which were reviewed for tip projection and rotation, preservation of the double break, bossae, and knuckling.

RESULTS

Intermediate crural overlay decreased projection in all 11 patients and increased the nasolabial angle in 7 patients. One patient had no change in the nasolabial angle, and 3 patients had counterrotation of 1 degrees , 3 degrees , and 4 degrees . A postoperative physical examination revealed that no patient had developed bossae, tip asymmetries, or knuckling. In addition, the double break was maintained in all the study patients.

CONCLUSIONS

Intermedial crural overlay is a reliable technique for achieving tip deprojection. Overall, the nasolabial angle is maintained (although in 3 patients, clinically insignificant counterrotation did occur). In addition, the length of the intermediate crura is reduced, but the double break is preserved. In the group of patients with thin skin and tip overprojection secondary to overdevelopment of the lower lateral cartilages, intermediate crural overlay achieves tip deprojection while controlling the nasolabial angle and preserving the natural curvature of the dome.

Nasal tip overprojection: algorithm of surgical deprojection techniques and introduction of medial crural overlay

OBJECTIVES

To discuss the evaluation of the overprojected nasal tip, present an algorithm of various treatments for deprojection of the nasal tip, and introduce our experience of greater than 10 years with medial crural overlay.

DESIGN

Retrospective review of a large sequential series of patients undergoing rhinoplasty who were treated with various deprojection techniques by the senior author (R.W.H.K.) from January 1, 1991, through December 31, 2002. Patients underwent preoperative and postoperative evaluation during this period on a regular basis to record the effects of various approaches on nasal projection, rotation, need for revision, and patient satisfaction. Medical records and photographic documentation were reviewed. The occurrence of postoperative complications and secondary revision procedures were noted. We used the information obtained to evaluate and expound on an algorithmic paradigm for treatment of nasal tip overprojection.

RESULTS

From 1991 to 2002, 130 cases used 1 or more of the senior author's preferred methods for deprojection. Ten patients were excluded owing to the primarily reconstructive nature of their surgery. Of the remaining 120 patients, 3 (2.5%) underwent minor revision of dorsal irregularities and another 5 (4.2%) underwent tip revision. Only 9 patients (7.5%) required concomitant alar base reduction. One patient had postoperative epistaxis, and there were no cases of postoperative functional complaints.

CONCLUSIONS

Deprojection of the overprojected nasal tip can be accomplished successfully with a handful of properly used techniques. Once proper analysis has been accomplished, an algorithm can be used to help simplify the approach to deprojection. These techniques offer sound functional approaches to effect deprojection while controlling the level of rotation. The beneficial effects observed using this algorithm are attested to by the minimal number of complications, the relatively low number of patients requiring revision, and the overall long-term patient satisfaction with their results.

The quantification of surgical changes in nasal tip support

OBJECTIVES

To quantify the changes in the strength of nasal tip support associated with various surgical modifications and to identify the procedures that best maintain or augment tip support.

DESIGN

Case study in 2 phases. Phase 1 included 10 patients undergoing primary rhinoplasty, 5 undergoing secondary rhinoplasty, and 5 control patients. Fresh cadavers were used in phase 2. A purpose-built instrument (Beaty Tensegrometer; G. M. Tooling, Chamblee, Ga) was used to measure nasal tip support before and after surgical modifications.

RESULTS

In the patients who underwent primary rhinoplasty, there was a 25% decrease in tip support when the ligamentous attachments between the lateral crura were divided. Reconstruction of these attachments increased tip support over baseline by 35%. With a columellar strut and ligament reconstruction, tip support was increased by 44%. In the secondary rhinoplasty group, reconstruction with the dynamic adjustable rotation tip-tensioning technique increased nasal tip support over baseline by 70%. In cadavers, intercartilaginous incisions and delivery of the lower lateral cartilages caused a loss of tip support, while raising the skin-soft tissue envelope with the open technique did not. Extensive resection of the lower lateral cartilages caused a loss of tip support.

CONCLUSIONS

This study demonstrates that nasal tip support can be reliably quantified in a reproducible manner. Use of the open approach, reconstruction of the attachments between the lateral crura, conservative resection of the lower lateral cartilages, and the dynamic adjustable rotation tip-tensioning technique for secondary rhinoplasty best preserve nasal tip support.

Vertical lobule division in rhinoplasty: maintaining an intact strip

OBJECTIVE

To review the indications for, surgical techniques of, and results of vertical lobule division (VLD) of the alar cartilages.

DESIGN

Prospective study of patients assigned to undergo variations of VLD of the lower lateral cartilages.

SETTING

Private facial plastic surgery practice in a major university teaching hospital.

PATIENTS

Twenty-four patients who underwent variations of VLD of the lower lateral cartilages with re-creation of an intact strip, including 4 patients undergoing revision.

MAIN OUTCOME MEASURES

Postoperative photographs were reviewed for tip projection and rotation, tip symmetry, bossae, knuckles, columellar position and length, and alar retraction. Patients were polled about their overall satisfaction with nasal aesthetics and degree of subjective nasal obstruction preoperatively and postoperatively.

RESULTS

Vertical lobule division decreased projection in 22 of 22 patients, increased rotation in 12 of 12 patients, decreased rotation in 1 of 2 patients, corrected tip asymmetry in 3 of 4 patients, and shortened a long infratip lobule in 1 patient. Postoperatively, bossae and knuckling developed in 1 patient, and 2 patients demonstrated alar retraction that did not exist preoperatively. One patient undergoing revision noted worsened nasal obstruction not related to VLD.

CONCLUSIONS

Vertical lobule division is a reliable, safe technique with predictable outcomes in tip repositioning. It allows for preservation of a strong tip complex while adding versatility to tip refinement.

Deprojecting the nasal profile

The nose is the most prominent aesthetic feature of the facial profile. Nasal length, tip rotation, and tip projection are integral aspects in analysis of the nasal profile. In most rhinoplasties the surgeon has the difficult task of increasing or maintaining tip projection of an underprojected or normally projected nasal tip. Less commonly, the rhinoplastic surgeon is presented with an overprojected nasal tip, and efforts are focused on deprojecting the nasal profile. In this article, the authors present a discussion of the overprojected tip, elucidating strategies of analysis, etiologies, and management of the nasal profile and give clinical examples.