The contoured auricular projection graft for nasal tip projection

In all rhinoplasty surgery, the universal need exists to increase, decrease, or preserve existing tip projection. When proper tip projection is lacking, a variety of techniques are useful for improving projection. We describe a valuable technique for tip projection, particularly useful and indicated in the Asian rhinoplasty, African American rhinoplasty, and in certain revision rhinoplasties. In the past 15 years, the senior author (M.E.T.) has used the contoured auricular projection graft in selected patients for achieving satisfactory tip projection in patients with blunted tips. The aesthetic outcomes have been predictable, pleasing, and reliable for the long term. Precision pocket preparation for auricular conchal cartilage graft placement is key to symmetry and projection of the final outcome. The results yielded a rounded nasal tip that may be more natural-appearing in Asians, African Americans, and selected patients with revision rhinoplasty. The contoured auricular projection graft provides a highly useful graft for the nasal tip.     

Male revision rhinoplasty: pearls and surgical techniques

Male revision rhinoplasty surgery is the most difficult and challenging procedure that facial plastic surgeons perform because males usually have thick nasal skin, which is more difficult to re-support and project the nasal tip, and often have high or unrealistic expectations. The primary etiology for the need for male revision rhinoplasty is a primary rhinoplasty with aggressive lower lateral cartilage reduction that causes tip ptosis and loss of projection. The goal to an aesthetically pleasing revision rhinoplasty is to re-create adequate tip projection and an intact strong tripod complex. Following tip reconstruction, the height and width of the dorsum should be set. For male revision nasal surgery, a clear and thorough knowledge of nasal anatomy, function, and surgical techniques is paramount. Having an extensive preoperative discussion including expectations, outcomes, and a detailed list of potential complications with the patient can prevent physician-patient mis-communication. Prior to surgery, review the examination, previous operative summary, photographs, nasal analysis sheet, problem list, and plan and then proceed with the surgical treatment.     

The extended columellar strut-tip graft

The extended columellar strut-tip graft is a structural unit used in endonasal rhinoplasty that combines the attributes of the columellar strut and the tip graft. It is used to provide projection and contour to the nasal tip. Our goal with this study was to evaluate a 15-year experience with 155 patients who underwent rhinoplasty with the extended columellar strut-tip graft. Of these, 110 underwent secondary rhinoplasty, and 45 underwent primary rhinoplasty. There were 6 patients in the secondary rhinoplasty group who experienced complications: in 3, the graft became visible postoperatively, and 3 patients had graft placement asymmetry. These 6 patients underwent surgery in the initial years of graft development. One patient with graft edge visibility and 1 patient with graft asymmetry underwent revision surgery with satisfactory results. The extended columella strut-tip graft is a reliable method to provide nasal tip projection and contour. The successful use of the graft requires precise diagnosis and surgical technique.     

Four suture tip rhinoplasty: a powerful tool for controlling tip dynamics.

OBJECTIVE: To evaluate the short-term effectiveness of using a 4-suture technique to control nasal tip dynamics. The 4 sutures include a medial crural suture, bilateral intradomal sutures, and an interdomal suture. STUDY DESIGN AND SETTING: Retrospective photograph analysis of preoperative and postoperative photographs of 77 patients with respect to 7 dynamic variables: supratip break, projection, rotation, tip shape, tip definition, tip symmetry, and the presence of a double columellar break. RESULTS: Seventy-four patients underwent primary rhinoplasty and had an overall average score of 5.2 on a -7 to +7 scale, with a mean follow-up period of 3.8 months. The 3 patients undergoing revision rhinoplasty had an overall average score of 5.0 and a mean follow-up of 8.7 months. CONCLUSION: The 4-suture technique worked best with respect to projection and tip symmetry, although the technique proved to be an effective tool overall in controlling all 7 variables mentioned above. EBM rating: C-4.     

Correction of the cleft-lip nasal deformity

Correction of the cleft-lip nasal deformity is a difficult task that requires a clear understanding of the associated complex anatomic abnormalities. These deformities tend to accentuate as nasal growth continues. Primary tip rhinoplasty in the unilateral deformity improves nasal tip symmetry and decreases the need for intermediate surgery. Intermediate rhinoplasty in the bilateral deformity is performed when nasal tip projection is markedly diminished. In both the unilateral and bilateral deformity, definitive rhinoplasty utilizing the open-structure rhinoplasty approach allows maximum exposure for placement of structural grafts to improve tip projection, definition, support, and function. In this article, the pathologic anatomy of the unilateral and bilateral cleft nasal deformity is described. The philosophy and timing of repair are discussed. Finally, the techniques used by the authors to address both the aesthetic and functional problems are outlined.     

高密度多孔聚乙烯植入体在鼻整形中的应用

目的 探讨高密度多孔聚乙烯在鼻整形中的应用.方法 2008年1月至2010年12月,分别将单片鼻小柱支架、双片鼻小柱支架和蝶形支架应用于33例鼻整形术患者.术后以6个指标评价手术效果,即鼻高度/鼻长度比例、ATC角、ACP角、鼻唇角、鼻额角和鼻尖角.结果 所有患者均获得满意疗效,除1例因鼻尖红肿而取出材料.女性患者中,术后鼻高度、鼻长度比例、ATC角度、鼻尖角、鼻唇角和鼻额角等指标有显著改善;男性患者显著改善的指标涉及鼻高度/鼻长度比例、ATC角度、鼻尖角和鼻额角等.结论 高密度多孔聚乙烯可提供足够的支撑力,是鼻整形的理想材料.     

Labiocolumellar Graft Combined with Tip Graft in the Management of Inadequate Tip Projection

The short distance of the nasal tip from the alar crease indicates inadequate projection. Tip grafts are commonly used for the management of this problem. In addition to tip grafts, labiocolumellar augmentation by cartilage grafts also provides further elevation of the tip complex for patients with poor tip definition, excessive alar base width, inadequate tip projection, or plunging nasal tip. In addition to standard rhinoplasty procedure and tip grafting for nasal tip augmentation, a linear cartilage graft was inserted centrally just behind the labiocolumellar angle for further tip elevation. The graft was placed in the subdermal plane just anterior to the orbicularis oris muscle to prevent graft displacement and clicking during muscle motion. This procedure was performed for 45 rhinoplasty patients, only three of whom underwent tip plasty procedures alone. During 1 year, 43 patients were followed up. Most of the patients (75%) were satisfied with the results of the procedure. Tip graft combined with labiocolumellar graft is an effective technique for obtaining satisfactory tip projection and correcting the acute labiocolumellar angle. Presented at The XVI. Congress of ISAPS, 26–29 May 2002, Istanbul, Turkey, and should be attributed to Department of Plastic and Reconstructive Surgery, Cerrahpasa School of Medicine, Istanbul University, and Haseki Hospital, Department of Otolaryngology Istanbul, Turkey.     

Nasal tip refinement in primary rhinoplasty: The cephalic trim cap graft

Background: Commonly used techniques for achieving nasal tip projection and refinement are adequate for most primary rhinoplasty patients, but they may result in undesirable tip bifidity and visible lower lateral cartilage angularity, especially in patients with thin skin. Objective: We report the use of “like” local tissues, cephalic trim cartilage remnants of the lower lateral cartilages, as invisible tip grafts to soften any angular cartilage edges or tip bifidity. Methods: The cartilaginous framework was exposed by using the open rhinoplasty approach. Lower lateral cartilages were separated from upper lateral cartilages, the caudal septum at the anterior septal angle, and from each other. A cephalic trim was performed as necessary, with the cartilaginous segments preserved for use as a cap graft. Interdomal sutures and transdermal sutures were used either alone or in combination to set the desired tip projection. If tip bifidity was visible through thin nasal tip skin, a cephalic trim cap graft was placed. Results: The procedure can achieve a well-unified nasal tip with no evidence of bifidity, angularity, or cartilage graft visibility. Conclusion: Use of this technique to improve nasal tip projection can avoid undesirable tip bifidity and visible lower lateral cartilage angularity in patients with thin nasal skin. (Aesthetic Surg J 2002;22:39-45.)     

A Technical Refinement to Prevent Supratip Deformity in Aesthetic Rhinoplasty: “The Trapezoid Peak”

Background The relationship between appropriate caudal dorsum resection and supratip deformity or inadequate tip projection currently is clear. Correct quadrangular cartilage management seems to have a basic role in the final tip aspect after aesthetic rhinoplasty. Methods Primary aesthetic rhinoplasty was performed for 38 Caucasian patients. A septal refinement was used for patients requiring extra tip support and not requiring grafts. Results The minimum follow-up period was 1 year. No supratip deformity was noted after surgery. The tip and midvault had adequate projection. Conclusions The described maneuver sustains the alar cartilage without sutures, preventing supratip deformity, sustaining soft tissues, and avoiding loss of tip projection. Presented at the 51st National Italian Congress of Plastic Surgery, SICPRE, Verona, Italy, 19–21 September 2002, and at the 9th International Congress of Italian and American Plastic Surgeons; New Orleans, 20 September 2004     

Open rhinoplasty

Open rhinoplasty provides visualization, which for many is essential for the best sculpturing. The indications for its use include every primary and secondary rhinoplasty candidate unless tip grafts are going to be under tension or if the deformity is minor. The technique of opening the nose has been described. Emphasis is placed on (1) suturing the medial crura together, (2) suturing the medial crura to the septum, (3) resecting a portion of the lateral crus, and (4) leaving as much cartilage in the supratip and cephalic parts of the lateral crus as possible. The result is (1) greater tip projection with fewer tip grafts, (2) improved correction of tip convexity, (3) fewer supratip deformities, and (4) fewer Weir excisions. The columella scar is usually inconspicuous and has not been a significant problem in any case.     

Tip grafts in revision rhinoplasty

In the patient who undergoes revision rhinoplasty, tip grafts are used often when overresection has resulted in structural deficit of deformity. As a result, the last 20 years have witnessed a progressive movement toward more conservative handling of the nasal tip. Still, as some surgeons have not adopted that philosophy and because many more surgeons have not adopted that philosophy and because many more surgeons now take on difficult primary tip problems because of the advent of the external approach, major tip problems continue to plague the final result. Despite these potential variables, when used correctly, the tip graft is critical in achieving the successful reconstruction of the nasal tip region. This article reviews the indications and techniques for tip grafts in revision rhinoplasty and explores how these indications and techniques for tip grafts in revision rhinoplasty and explores how these indications could be prevented in the primary setting.     

Rhinometry: An Important Clinical Index for Evaluation of the Nose Before and After Rhinoplasty

Background Preoperative planning and postoperative outcome assessment in rhinoplasty are important. For preoperative planning, some standard relationships are defined and evaluated primarily with standard photographs, but photographs do not necessarily reflect reality. Outcome assessment, on the other hand, is mostly subjective, and again, even photographic analyses may not address real changes after rhinoplasty. Methods “Rhinometry” is introduced as a clinical method for preoperative evaluations and postoperative judgments, and rhinometric parameters are defined. Measurements of these parameters were performed for 300 patients before rhinoplasty and in the follow-up visits 3 months postoperatively. Results Preoperatively, the nasal length and tip projection for most patients were more than ideal. There was moderate reduction in nasal length (mean, 9.21 mm) and a decrease in tip projection (mean, 3.34 mm) for the majority of the patients after rhinoplasty. Reductions in nasal length, tip projection, bony base width, alar base width, and alar base width during a smile were statistically significant. Patients who underwent surgery using the closed approach had significantly more reduction in nasal length and less reduction in tip projection. All the patients were satisfied with these pre- and postoperative data. Rhinometry changed the ideas of the authors about some changes that their operative approaches produce. Conclusions Rhinometry can change the ideas of plastic surgeons about the changes their operative approaches accomplish and can be a very useful guide for patients. It is recommended as a part of the pre- and postoperative physical examination of patients undergoing rhinoplasty.     

Caudal Septal Advancement for Nasal Tip Projection and Support in Rhinoplasty

Background Management of nasal tip projection and support for positioning of the tip represent an important part of rhinoplasty operations that must be handled properly for a final satisfying result. Manipulation of the nasal tip is complex and variable. Plastic surgeons use many techniques to achieve this goal. Methods The authors propose that the caudal septal advancement technique be used to manipulate the positioning of the nasal tip, especially in cases of an underprojected tip and those requiring tip support. The authors prepare a rectangular septal cartilage, which after advancement carries the nasal tip to the desired position. Results This technique is easy to use, and the results are dependable. All the patients who underwent surgery with this technique were satisfied with the result. Conclusion The caudal septal advancement technique presents another good and reliable alternative for managing nasal tip projection and support. Presented at the 10th Congress of European Society of Plastic Reconstructive and Aesthetic Surgery 2005, 30 August to 3 September 2005, Vienna, Austria     

Nasal tip projection: nuances in understanding, assessment, and modification

Nasal tip projection refers to the anteroposterior extent to which the nasal tip is separated from the facial surface at the level of the alar-facial groove. Although its relevance in rhinoplasty is obvious, it is important to understand that changes to the projection of the nasal tip affect nasal tip rotation, dorsal height, and nasofacial aesthetic harmony. The following article discusses the subjective and objective assessment of nasal tip projection, the relevant anatomy, and tools to plan ways of modifying aspects of tip projection. Several different techniques will then be described in detail, along with relevant clinical illustrations.     

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.     

The decision process in choosing costal cartilage for use in revision rhinoplasty

The aims of rhinoplasty reconstruction include maintaining or augmenting long-term tip projection, restoring rigid dorsal stability, and restoring optimum respiratory function. The methods set forth to obtain these objectives are inherently based on the intrinsic nasal principles at the time of the rhinoplasty. Because of the excellent and consistent results autologous costal cartilage grafts provide when faced with problems such as the traumatic saddle deformity, defects after neoplastic resection, congenital nasal deformities, severe tip weakness or underprojection, rhinoplasty in the ethnic patient, and revision rhinoplasty, they are an invaluable resource to the rhinoplasty surgeon. Once the surgeon becomes comfortable and proficient at harvesting this graft, it inevitably will become the graft of choice when substantial amounts of cartilage are required.     

Control of tip rotation

Rotating the nasal tip is an integral and challenging aspect of rhinoplasty. This article describes ways of measuring tip rotation, coming to an agreement with the patient regarding desired tip rotation and psychological implications of tip rotation. Based on the tripod theory of the nasal tip, various techniques for changing tip rotation and projection are detailed and illustrated with clinical cases. The authors review the literature and present their personal preferences.     

Nasal Tip Plasty Using Various Techniques in Rhinoplasty

Rhinoplasty is one of the most common aesthetic surgical procedures in Korea today. However, simple augmentation rhinoplasty results often failed to satisfy the high expectations of patients. As a result, many procedures have been developed to improve the appearance of the nasal tip and nasal projection. However, the characteristics of Korean nasal tips including the bulbous appearance (attributable to the thickness of the skin), flared nostrils, and restriction of the nasal tip attributable to an underdeveloped medical crus of the alar cartilage and a short columella have made such procedures difficult. Currently, most plastic surgeons perform rhinoplasty simultaneously with various nasal tip plasty techniques to improve the surgical results. An important part of an aesthetically pleasing result is to ensure an adequate nasal tip positioned slightly higher than the proper dorsum, with the two tip defining points in close proximity to each other, giving the nose a triangular shape from the caudal view. From June 2002 to November 2003, the authors performed rhinoplasty with simultaneous nasal tip plasty using various techniques according to the tip status of 55 patients (25 deviated noses, 9 broad noses, 15 low noses, and 6 secondary cleft lip and nose deformities). The surgery included realignment of alar cartilage by resection and suture, fibroareolar and subcutaneous tissue resection, tip graft, and columellar strut. The postoperative results over an average period of 10 months were entirely satisfactory. There were no patient complaints, nor complications resulting from the procedures. Good nasal tip projection, natural columellar appearance, and improvement of the nasolabial angle were achieved for most patients. In conclusion, rhinoplasty with simultaneous nasal tip plasty, achieved by a variety of techniques according to patients tip status, is an effective method for improving the appearance of the nose and satisfying the desires of the patients.     

Measurement of preoperative and postoperative nasal tip projection and rotation

OBJECTIVE: To measure the effect of columellar struts and cephalic trim on tip projection and tip rotation using digitized photographs. METHODS: Using photographs of 62 patients who underwent external rhinoplasty, we retrospectively analyzed nasal tip projection (the Goode method) and rotation (nasolabial angle) before and after surgery. A cartilaginous strut was used in 36 patients, whereas 26 patients did not receive a strut. Patients were categorized into 4 subgroups, depending on the placement of a strut (placement, strut+ vs nonplacement, strut-) and the removal of the cephalic margin (removal, cephalic+ vs nonremoval, cephalic-) of the lateral crus: strut-/cephalic-, n = 17; strut+/cephalic-, n = 23; strut-/cephalic+, n = 9; strut+/cephalic+, n = 12. RESULTS: Nasal tip projection, measured with the Goode method, increased from 0.58 to 0.60 (P = .02) in the strut+ group; in the strut- group, nasal tip projection did not change significantly. Nasolabial angle increased from 93.96 degrees to 100.92 degrees in the strut+/cephalic- group and from 88.30 degrees to 95.06 degrees in the strut+/cephalic+ group. Removal of the cephalic margin alone (strut-/cephalic+) hardly affected tip rotation (P = .05). CONCLUSIONS: The external rhinoplasty approach did not lead to a decrease in nasal tip projection. A cartilaginous strut slightly increased nasal tip projection and also increased nasal tip rotation. This effect was accentuated by the removal of the cephalic margin of the lateral crus.