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.

Surgeon’s Review of Dr. Dean Toriumi’s Surgical Techniques: 2

Testimonial on Dr. Toriumi's Surgical Techniques 
 -Mauricio Buitrago, MD.   

Dean M. Toriumi MD. came to San Jose Costa Rica on a probono mission trip to help patients with complex nasal deformities from April 22 to April 28 2013. Dr. Toriumi used complex surgical techniques that are not commonly used in Costa Rica. He harvested rib cartilage and performed complex cartilage grafting on a young man with a bilateral cleft lip nasal deformity . This patient underwent several previous surgeries and had severely deficient nasal tip projection and a very wide nasal tip with nasal obstruction. Dr. Toriumi performed a very successful operation and the patient has done very well since surgery and is very happy with his outcome both from an appearance point of view and from a functional standpoint. Dr. Toriumi also operated on a patient with a severely deviated nose with nasal obstruction who underwent a couple of previous surgeries. He performed rib cartilage harvest and cartilage grafting to correct the patients breathing problems. Dr. Toriumi performed the surgeries at the Clinica Biblica Hospital and the public children's hospital in San Jose. Other patients had severe functional problems and complex nasal deformities.

In addition to performing the surgeries on the patients Dr. Toriumi also taught Costa Rican surgeons in the operating room. He provided a very concise didactic experience explaining all of the maneuvers so the observing surgeons could understand the surgeries . He also gave an 80 minute presentation to the Costa Rican surgeons to augment the teaching points made in surgery.

This was a very special mission trip donated by Dr. Torium i and we are very grateful for his generosity and donated time and expense.

Mauricio Buitrago, MD.
Otolaryngology Department Hospital Clinica Biblica
Costa Rica

Dean Toriumi Gives You Balanced Features

Dr. Toriumi Gives You Balanced Features

This patient presented with an under-projected chin.

To help balance her nose with her other facial features, Dr. Toriumi augmented her chin and increased the projection of her her nasal tip.

The photographs represent a two year postoperative outcome.

Pre-Operative Photos	Post-Operative Photos

Dean Toriumi: In News

Dr. Toriumi Coordinates Global Meeting on Rhinoplasty

CHICAGO (December, 2012):  Dean M. Toriumi, M.D., Professor of Otolaryngology – Head and Neck Surgery and Head of the Division of Facial Plastic & Reconstructive Surgery at the University of Illinois at Chicago, served as co-organizer of the “Cutting Edge 2012 Aesthetic Surgery Symposium Advanced Sculpting of the Nose” meeting in New York City, November 29 to December 1 in New York City.

Along with colleagues Dr. Sherrell Aston and Dan Baker, Dr. Toriumi organized the interdisciplinary symposium, which drew more than 600 surgeons from 55 countries, including some of the most highly regarded international experts in rhinoplasty.   Major topics addressed in panels included new and more established rhinoplasty techniques in areas such as nasal tip surgery, osteotomies, dorsal augmentation, nasal function, the deviated nose, revision rhinoplasty, ethnic rhinoplasty, and others.

“The meeting was a smashing success, given its overwhelming attendance,” Dr. Toriumi said.  “Many of the attendees said it was the best rhinoplasty meeting that they had ever attended, telling us that the focused presentations, panels of top rhinoplasty surgeons from all over the world, and use of video made the symposium highly educational and useful.”

M. Eugene Tardy, M.D., former Chair of the Department, gave a keynote presentation, as did Dr. Toriumi, who spoke on his new methods of managing nasal tip contour and tip position.

Dean Toriumi: Replacing the Nasal Septum

Does Dr. Toriumi take out and replace the nasal septum, and, if so, under what circumstances ? 

Dean Toriumi:

Rarely do I remove the nasal septum and replace it. The vast majority of patients will undergo a conventional septoplasty to straighten their septal deviation. In the conventional septoplasty operation, deviated portions of the septal cartilage are removed leaving an intact L-shaped septal strut (see figures 1 and 2). It is important to preserve this L-shaped septal strut to avoid loss of support and possible collapse of the nose. 

Perhaps some of the confusion arises from the name of a graft that I commonly use, called a caudal septal extension graft. In many cases I will place a caudal septal extension graft, which is a cartilage graft that is positioned end to end or may overlap the existing caudal nasal septum (see figure 3). 

A caudal septal extension graft is similar to a columellar strut except it is more stable, as it is connected to the existing caudal septum. This graft provides excellent support to the nasal tip without changing the existing septum. The caudal septal extension graft prevents postoperative loss of tip projection and sets nasal length as well as other parameters. I find this graft very helpful to avoid common rhinoplasty complications, such as postoperative loss of tip projection (resulting in a polybeak deformity), short nose deformity, overrotated nose ("turned up nose"), etc. However, use of this graft is clearly not equivalent to replacing the nasal septum, as it is a cartilage graft that is added to the existing nasal septum to provide support. 

Patient A.S. underwent a primary rhinoplasty after suffering trauma to her nose leaving her with a deviated nose, nasal obstruction and nasal deformity. She requested that her nose be straightened, her nasal tip shape be improved, and her airway corrected. She also requested to keep her nose on the shorter side. Her surgery required straightening the nasal septum, and a caudal septal extension graft was used to stabilize and straighten her nasal tip. Her caudal septum was not replaced, but, rather, the extension graft was added to provide tip support and move her tip back to the midline. This is the method used in the majority of primary cases. Rarely do I remove and replace the septum. Postoperatively, her nose is noted to be straight, and her airway is dramatically improved. 

Patient J.F. underwent a primary rhinoplasty to correct an overprojected nose and large dorsal hump. In her operation her nasal septum was straightened. Only the deviated portion of the nasal septum was removed, leaving an L-shaped septal strut behind. This is typical and does not require replacing the nasal septum. Postoperatively, her nose is noted to be straighter, and her dorsal hump was reduced. 

This patient underwent a fairly typical primary rhinoplasty using the open rhinoplasty approach, dorsal hump reduction, placement of spreader grafts, and tip work to reshape her tip. She had plenty of her own septal cartilage to perform the necessary grafts and provide her with excellent structure to better insure a long term outcome.

On rare occasions I do replace the caudal portion of the septum. The primary indications include the severely deviated caudal septum, unstable caudal septum, or a previously over-resected caudal septum. In the case of the severely deviated nasal septum, removal and replacement of the deviation is the best method in my hands to create a straight nose with a good airway. Many surgeons will leave the deviated septum or try to manipulate it, which can be successful but also has a high incidence of failure or partial correction. Failure to straighten the septum may leave the patient with a deviated nasal septum and nasal obstruction. Many surgeons try to resect the deviated portions of the deviated caudal septum without replacing it, leaving the patient with a potential loss of tip support. These patients will frequently be left with a residual septal deviation, inadequate tip projection, turned up short nose, retraction of the columella, etc. To prevent these deformities I prefer to replace the deviated septal cartilage that is removed in order to reestablish appropriate tip support and prevent complications.

Patient S.L. had a crooked nose deformity and severely deviated caudal septum that was blocking her airway on the right side. Correction required removal of the existing caudal septum and replacing it with another piece of her own cartilage to recreate a stable nasal septal structure. Using this technique her nose could be reconstructed around this new midline caudal septum. The postoperative result shows correction of the deviation of her nose, excellent symmetry to the base of the nose with an open nasal airway. 

This patient is very happy with her outcome and has excellent nasal function with no consequences of replacing her deviated caudal septum.The patients who undergo this type of operation do well, and what is accomplished is the reconstruction of the caudal septum to a state that would be considered normal instead of deviated. In my opinion it is better to reconstruct a new straight caudal septum that will support the tip and create an excellent airway instead of doing a less stable operation potentially leaving deviation and obstruction. Over the past 20 years, I have had great success with this approach to correct severe septal deviations. I published this technique in 1994 in an article entitled, "Subtotal septal reconstruction of the nasal septum," (Toriumi DM, Laryngoscope Vol. 104, 7, July 2004). Since then many other surgeons have adopted this technique for correction of the deviated caudal septum, overresection of the septum, lengthening the nose, etc.

One of the most common steps in a typical reductive rhinoplasty is to trim the existing caudal septum to shorten the nose or rotate the nasal tip. This frequently leaves patients with a severely deficient caudal septum. When these patients come to me for revision, I often find that the caudal septum is essentially gone or severely damaged. I prefer to place a new caudal septum in these cases to replace the normal anatomy and regain tip support. Patient C.F. underwent a previous rhinoplasty in which an excessive amount of caudal septum was resected in a previous operation. This resulted in a severe loss of tip support, loss of tip projection, and drooping of the nasal tip. Replacement of the deficient caudal septum allowed replacement of support and improved tip contour 

This is the type of patient that requires structural grafting to insure a good outcome. To overview, surgical management of the nasal base involves either placement of a columellar strut, caudal extension graft, or rarely replacement of the caudal septum. Patients undergo placement of a caudal septal extension graft that does not involve replacement of the caudal septum. The caudal septal extension graft actually involves placement of a graft that acts as an extension off of the existing caudal septum. This is a very powerful graft, enables stabilization of the base of the nose, and helps prevent postoperative loss of tip projection, drooping of the tip and shortening of the nose. The caudal septal extension graft or caudal septal replacement can result in stiffness of the nasal tip or change in upper lip feel and position.. We discuss these potential sequellae with patients if such grafting maneuvers may be used. Over the past 20 years, I have noted that the vast majority of patients have no negative consequences from such grafts and do well with a good, long-lasting outcome.