Additionally, an area of highlight is created along the rim of the nostril near the base of the nose similar to the artist’s rendition of the ideal nasal tip. It may be difficult to understand that increased width or bulk is good in some areas of the nasal tip but this is exactly what we see in the favorable nasal tip. We see areas of shadow in the supratip and lateral supratip with areas of highlight along the margin of the ala. This area of highlight along the margin of the ala is represented by a uninterrupted triangular shape of the base of the nose. (Figure 5)
In the pinched nasal tip there tends to be a shadow just lateral to the tip which acts to isolate the tip making it appear less desirable and in some cases more bulbous.(Figure 6) Examination of the base view of such a nasal tip will usually show an interruption in the desired triangular shape to the base view. (Figure 6)
In the pinched tip the shadows extend into areas that are not favorable and these shadows are due to concavities or depressions just lateral to the tip. Many commonly used nasal tip techniques tend to narrow the nasal tip cartilage without considering that good support should be preserved along the caudal margin of the lateral crura and to preserve or create a triangular shape to the nasal base. Again it is counterintuitive that one should believe that areas of the lower lateral cartilages should be left prominent as most would think that all around smaller would be better. Unfortunately, that is not the case. In order to create proper shape the skin envelope must be controlled creating shadows and highlights, preferably favorably positioned shadows and highlights. Therefore, creation of an aesthetically normal looking nasal tip is not necessarily narrow and a narrow nasal tip is not necessarily aesthetically normal. Nasal tip surgery is complex and far more complicated than simply an exercise in suturing the tip cartilages or placing a tip graft.
Patients that have cephalically positioned lateral crura
will also tend to have weakness in the lateral wall of their nose. This
weakness can contribute to collapse of the lateral wall of the nose. This type
of collapse can be easily seen on base view as the patient breathes in through
their nose (Figure 7).
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Figure 7 |
If one side collapses and the other does not it is likely
due to a significant septal deviation in addition to the lateral wall weakness.
This is because most of the nasal airflow is passing through the side opposite
the septal deviation. This airflow overwhelms the lateral nasal sidewall on the
side opposite the deviation and the flow of air collapses the nostril on that
side. In order to correct collapse of the nasal sidewall the first step is to
correct the septal deviation to create more symmetric airflow through both
nostrils. Airflow through both nostrils is rarely symmetric but the key is to
eliminate significant differences in airflow.
Correction may also require some
conservative work on the inferior turbinate which can be enlarged on the side
opposite the septal deviation. Once the internal nasal airway problems are
corrected weakness of the lateral wall of the nose should be addressed. If not
corrected the patient may be left with a compromised nasal airway. Correction of lateral weakness can be accomplished using
several different methods. One of the more common methods is to insert an alar
batten. These grafts are placed into the sidewall of the nose
and provide extra support to help prevent lateral wall collapse. These grafts can
work well but typically do not improve nasal tip shape. In order to improve
nasal tip shape I frequently “reposition” or move the lateral crura into a more
caudal orientation. In this technique the cephalically positioned lateral crura
are dissected from the underlying vestibular skin and then moved into a more
favorable orientation or more obtuse angulation off of midline (greater than 35
degrees in most cases). This technique is not new and is used by other surgeons
as well. Since increasing the use of
lower lateral cartilage repositioning I have found two major benefits to the
patients. First of all, these patients have their lateral crura moved to a more
caudal orientation which acts to support the lateral wall of the nose, minimize
lateral wall collapse and improve nasal airflow. The reason for this
improvement in nasal function is that the cartilage is moved to an area where
the lateral wall has a propensity to collapse and provides support that helps
to prevent collapse. (Figure 8 A,B and C)
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The other major benefit is that the tip cartilages are moved
into a position that improves nasal tip shape by moving bulk from the area of
the supratip (area above nasal tip) to the area of the inferior tip. In the
ideal nasal tip there should be a gentle widening of the nose as the lateral
wall approaches the inferior nostril margin.
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Postop frontal view |
This favorable shape creates the normal nasal contour seen
in the artists composite from our study of aesthetically pleasing nasal tips.
If the nasal tip is pinched and the normal flare toward the nostril rim is not
present the nose may look unnatural (Preoperative view).
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Preoperative view |
This “pinched” look gives the nose an operated look and can
be associated with poor nasal function. The one drawback is that this maneuver
creates increased stiffness to the lateral wall of the nose and nasal tip. It
is this increased stiffness that improves nasal function. In most patients this
is an acceptable trade off. If there is little support in the lateral wall of
the nose collapse is likely to occur at some point in time. All too often
patients have little concern about their nasal function when they undergo
rhinoplasty and just want their nose to look good. Unfortunately, if the nose
is weakened and there is inadequate lateral wall support nasal function may
become compromised over time. This will likely catch up with most patients
later in life. A more sensible approach is to provide good lateral wall support
and enhance aesthetics with the tradeoff of some increased stiffness in the
sidewall to provide good long term breathing. (Figure 11)
In order to reposition the nasal tip cartilage a cartilage
graft (lateral crural strut graft) is sutured onto the undersurface of the
lateral crus and then the cartilage is placed into a newly created pocket in
the sidewall of the nose. It is this additional layer of cartilage that creates
the increased strength and stiffness but also provides the improved support.
Placing lateral crural strut grafts requires two relatively large pieces of
cartilage. Usually these cartilage grafts are harvested from the nasal septum.
I also use spreader grafts in most patients which are rectangular shaped grafts that act to reconstruct the middle portion of the nose below the nasal bones. These cartilage grafts act to prevent middle nasal vault collapse or the “inverted-V deformity.” (Figure 12)
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Figure 12 |
The inverted-V deformity indicates that the cartilages in
the middle portion of the nose have collapsed and also can compromise nasal
breathing and create deformity. Spreader grafts are typically used after dorsal
hump reduction to recreate a stable “roof” to the middle segment of the
nose.(Figure 13)
The other common cartilage graft that I use is the caudal
septal extension graft. This is a cartilage graft that is typically placed as an
extension off of the inferior part of the septum. This graft preserves nasal
tip projection and helps to prevent the “polybeak deformity” by preventing
postoperative loss of nasal tip projection . The caudal extension graft is
similar to a columellar strut but is fixated to the patients existing nasal
septum to provide additional support.(Figure 14)
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Figure 14 |
This additional support stabilizes the base of the nose to
increase and support nasal tip projection.(Figure 15)
The caudal septal extension graft also adds some stiffness
to the nasal tip. This is a reasonable trade off to provide a stable nasal tip
that will not lose projection postoperatively.
The techniques described require a significant amount of
septal cartilage and in the past I have gone to the ear or rib to have enough
cartilage to execute these grafting maneuvers. Another new addition to my
technique is the use of a resorbable (dissolvable) implant made from a suture
material that can be used to stabilize caudal septal extension grafts. In the
past I would need to make spreader grafts long enough to support the septal
extension grafts. With the use of the resorbable “PDS” plates I can stabilize
the extension grafts without using extra cartilage for that purpose. (Figure 16)
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The PDS plates a completely gone from the patient in about 6 months. |
I am also able to occasionally join two pieces of cartilage
together to make a single longer graft that can be used for a lateral crural
strut graft or spreader graft. The incorporation of the PDS plate has
significantly decreased the need to harvest cartilage from the ear or rib. In
fact, I rarely harvest cartilage from the ear or rib in primary rhinoplasty
patients. The primary rhinoplasty patients that require rib cartilage are
typically undergoing complex reconstruction or major augmentation such as saddle
nose deformity, major dorsal nasal augmentation in Asian patients, severe
crooked nose deformities or congenital nasal deformities. These are complex
cases requiring a large amount of grafting material to correct their
deformities and rib cartilage is abundant and strong for a stable
reconstruction.
If I harvest rib cartilage I use a very small 1.0 cm to 1.1
cm incision placed just below the right breast. (Figure 17)
This incision usually gets stretched to 1.3 cm. This small
incision looks like a small stab incision once it is healed. In the past I
would make a larger incision that was more prominent and was noticeable to
patients. This small incision is rarely an issue with patients as it usually
barely visible once the redness fades. (Figure 18).
This small incision is important to most patients as the
presence of a large chest scar on a patient’s body will be a prominent visible
reminder of their surgery.