Changes Made to My Technique Over the Past Six Years

Over the past 6 years several changes have been made to improve our techniques. These changes were made in an effort to improve our outcomes and improve patient satisfaction.

One of the biggest changes is the way I am managing the nasal tip cartilages. Over the past six years I have moved to repositioning the lower lateral cartilages into a more favorable position. This concept is complex and may be difficult to understand however I will try to explain it. Many patients that have a bulbous nasal tip exhibit cartilage anatomy that creates the roundness seen on frontal view. (Figure 1)

Figure 1

This bulbous shape is frequently created by the patient’s cartilages being large and round bulging outward to create the poorly defined shape. Another contributing factor is the angulation of the lower lateral cartilages as they move cephalically or upward.

In the ideal nasal tip there is less bulk in the supratip area of the nose (area just above the nasal tip as shown in this illustration that was developed from a composite of many ideal nasal tips and merged into a single “ideal” nasal tip. (Figure 2)

Figure 2

This is not universal but has many of the favorable characteristics of an aesthetically pleasing nasal tip. In our review of patients with aesthetically pleasing nasal tips we also found that they possessed either flat lateral crura (tip cartilages) or have lateral crura that move in a caudal orientation. Caudally oriented lateral crura move laterally at a larger angle (greater than 30 degrees of off midline). Most bulbous tips will have lateral crura that move at a more acute angle off of midline (less than 30 degrees). This cartilage orientation is referred to as “cephalically positioned lateral crura.” These angles are averages and not absolute. There are some patients that have an angle less than 30 degrees and still have nice nasal tips but most of these patients will also have relatively flat cartilages. Most patients with an angle less than 30 degrees and convex cartilages will have a bulbous nasal tip contour.

To better understand this concept one can think of the nasal tip as a series of shadows and highlights. Shadows are created by concavities and highlights are created by convexities. If we look at the actual nasal tip cartilage anatomy in a patient with a bulbous cephalically positioned lateral crura the tip cartilages pass directly through the area where the shadow of the supratip should be located.(Figure 3)

Figure 3

If the tip cartilages are moved to a more caudal orientation (angle greater than 35 degrees) the area of the supratip is cleared of the convex cartilage and a shadow is created.(Figure 4)

Figure 4

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)

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)

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).

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)

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.

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).

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)

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)

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)

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)

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). 

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. 

Another change that I have made is that when I bank cartilage I only place smaller softer pieces in a small incision behind the hairline. These cartilage grafts are ideal for filling small defects in the nose or providing a subtle contour change. The banked cartilage is very helpful in cases where a revision is needed as the ear or rib is rarely needed. In patients that are more likely to need a significant revision I prefer to bank the larger pieces of cartilage that may be bothersome to the patient but can be removed at a later date.