A New Twist in Nasal Tip Surgery
An Alternative to the Goldman Tip for
the Wide or Bulbous Lobule
E. Gaylon McCollough, M.D., Jim l.
English, M.D.
When the cartilaginous framework in the
tip of the nose fails to provide adequate support and definition, the
rhinoplastic surgeon must create strength and refinement. To achieve
these results, we advocate a new twist of an old concept that can be
used to create a stronger, more triangular lobule in the wide, bulbous,
or bifid tip. Morselizing, incising, and suturing alar cartilages have
long been recognized as adjunctive procedures in tip rhinoplasty;
however, the specific method described herein can provide results
comparable to the classic Goldman tip while guarding against the
possibility of cartilage displacement and mucous membrane entrapment.
(Arch Otolaryngol 1985; 111:524-529)
Surgical correction of the nasal tip is
often considered to be the most difficult component of rhinoplasty.1
The wide, boxy, bifid, or bulbous tip poses a special problem in that
total reconstruction of the alar domes is often necessary. Achieving the
desired appearance while maintaining functional support can often be
difficult and requires careful preoperative analysis and design. Due to
the artistic nature of rhinoplastic surgery, the surgeon must be able to
conceptualize the aesthetic character of an "ideal nasal tip"
and as part of the surgical armamentarium be prepared to use one of
several techniques to obtain the desired cosmetic result.2
The "ideal" aesthetic dimensions have been carefully
documented in the literature and should represent the basic analytical
considerations in choosing the most appropriate surgical design.3
The principles of trimming, incising,
morselizing, and suturing alar cartilages are not new; therefore, no
claim of uniqueness is made for that concept. To our knowledge, the
specific technique described herein and how these principles are used to
reconstruct the alar domes have not previously been published. The
surgical creation of the "double-dome unit" we describe herein
could replace some of the more "classic" procedures that have
been previously used in an attempt to obtain maximum tip projection and
definition. It will be useful for the surgeon who wishes to defer
complete vertical interruption of the alar cartilages or to omit the use
of cartilaginous grafts, battons, or struts sometimes needed to help
maintain tip support.
The technique that follows not only
achieves and maintains tip support but also provides increased
projection and lobule refinement. It has been performed numerous times
by one of us (E.G.M.) and has proved to be effective in providing
predictable postoperative results. This method employs sound surgical
principles and is an excellent addition to any surgeon's armamentarium.
The best results have been obtained in the wide, boxy, bifid, or bulbous
tip in which conventional or more conservative maneuvers fail to provide
the desired improvement (Fig 1). On the other hand, if the tip has a
nice triangular appearance preoperatively, the most conservative
surgical techniques should be employed. The philosophy "If it ain't
broke, don't fix it" also applies in plastic surgery. It is wise
not to disturb the aesthetically pleasing features and to concentrate
the reconstructive techniques on the features that fall out of the realm
of normalcy.
When the cartilaginous framework of a
tip fails to provide adequate support and definition, the rhinoplastic
surgeon must create strength and refinement. Goldman4
accomplished this with bilateral vertical division of the domes, and
interruption of the vestibular skin, suturing the two vertically divided
medial crural components to each other and securing them to the caudal
end of the septum, generally discarding the effect of the lateral crura
on tip support. Brown5 and others advocated excision of the
existing cartilaginous dome and creation of a new one at the point where
the newly transected ends of the medial and lateral crura came into
apposition, but without suture fixation.
Although we occasionally perform these
aforementioned operative techniques, in most cases we choose to defer
complete transection of the dome until after the double-dome unit
procedure has been attempted. If unsatisfactory, it may be necessary to
proceed with complete vertical interruption of the dome of the alar
cartilage, creating a more acute angle. The medial and lateral crural
components are sutured together; the two domes are then sutured to each
other.
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Technique
Through a cartilage delivery (or an external approach), an intact or
complete strip maneuver is performed by a horizontal division and
excision of the cephalic portion of the lateral crural component of each
lower lateral cartilage. The exposure from either of these techniques is
excellent and allows careful assessment and accurate identification of
the domes, which is essential in performing the technique we advocate
(Fig 2). Once the lateral crural alterations are made, the alar
cartilages are replaced to their previous intranasal, nondelivered
position. Then nasal tip symmetry, definition, and projection are
reassessed. If the results are satisfactory, the incisions are closed;
if not, as is usually the case in the wide or bulbous tip, the
cartilages are redelivered and a decision is made regarding additional
modifications. If tip asymmetry exists, trimming the excessive portions
may sometimes suffice. If either excessive tip fullness or insufficient
support exists, then additional dome refinement measures are usually
indicated. Although the more conservative approach to tip refinement is
advocated as the initial step, in the bulbous tip, additional measures
are usually necessary. The surgeon may then proceed to alternative domal
reconstructive techniques, with or without fixation sutures.
Should a new dome contour be desired,
this can be accomplished by reducing cartilage "memory" with
gentle morselization of the medial and lateral components of the dome of
the alar cartilages and suturing them together to form a new double dome
unit. The specific technique of morselization is all important; if
performed incorrectly, further widening of the domes and a loss of tip
support and projection occurs, resulting in additional postoperative
widening of the lower one third of the nose.
The instrument must be held in a
horizontal position so that the dome cartilage can be
"tented-up" between the two grids (Fig 3). It is not necessary
to use the guard, because the vestibular skin is "sandwiched"
between cartilage, which affords adequate protection. The cartilage is
crushed, or morselized, only enough to ensure adequate "loss of
memory" and to provide a more acute angle between the medial and
lateral crura, thereby creating a new physiologic dome. Finesse is
essential in this step to avoid "breaking" the cartilage at
the point of the new dome with the morselizer, or destroying the
integrity and strength of the cartilage with overzealous morselization.
The more acute angulation of two newly sculptured domes and their
relationship to each other can be maintained with through-and-through
mattress sutures (5-0 Dexon or Vicryl) (Fig 4). If necessary, complete
vertical interruption followed by mattress sutures can produce even more
tip definition. Accurate placement of the sutures is essential to
prevent asymmetries. Rather than simply securing one dome to the other
with sutures placed through the medial crural component, this suture
must be passed in a horizontal mattress fashion through both medial and
lateral crura just below the dome to provide additional narrowing and
support. By incorporating the lateral crura into the "unit,"
the more acute angulation of each dome is ensured, resulting in a more
triangular and projected lobule while lending more strength to the tip.
This technique therefore converts the medial and lateral crura
components of both alar cartilages to a single double-dome unit when
sutured together.
The amount of tension on the intradomal
suture can be altered depending on the amount of lobule narrowing
desired (Figs 5 and 6). The act of morselization or total division and
the subsequent development of the fibrous adhesions that form between
the domes as a result of the cartilage delivery technique will also help
to maintain the position of the newly constructed domes after the
sutures have dissolved, usually within six weeks. The surgical principle
of passing sutures through alar domes in various fashions has been used
for many years by us and others. The specific technique of suture
placement described herein, however, has provided increased narrowing,
projection, and support, which was previously offered only by the
classic Goldman technique while eliminating some of its potential
problems, particularly in the patient with thin skin who has a bifid
tip.
Once the suture is tied, both alar
cartilages are carefully positioned in the midline, now as a single
unit, beneath the skin of the nasal tip. If additional correction of the
lobule is desired after morselization, further surgical measures may be
appropriate, i.e., total interruption, excision of portions of one or
both domes superior to the sutures, or placement of additional sutures.
The technique used in producing the new double-dome unit is summarized
by the drawings in Fig. 7.
For the wide, bulbous, or bifid tip
this more conservative approach employing the progressive surgical
intervention allows the surgeon to stop short of total vertical
transection of the alar cartilages if that maneuver is not absolutely
necessary to achieve the desired result. Providing the surgeon has the
skills and experience, when cartilage interruption is necessary (as is
often the case in the grossly asymmetrical tip), he or she should not
hesitate to do whatever is needed to accomplish the optimum result;
however, knowing when to stop is as important as knowing what to do and
how to do it. Once the desired appearance of the nasal tip is achieved
(Fig 5, right), attention is directed to the septum, then to the hump
removal, and finally to narrowing the bony pyramid with osteotomies.
Care should be taken not to unduly distort the nasal tip during
retraction for exposure of other areas, lest the dome sutures be
disturbed. After all sutures are placed, a final assessment is made. If
necessary, additional adjunctive procedures can be performed (alar sil
resections, plumping, or filler cartilaginous grafts, and so on). If
creation of the double-dome unit has produced too much projection of the
tip, extending a complete bilateral transfixion incision inferiorly
toward the nasal spine and freeing the intervening soft-tissue will
allow the tip tripod to drop, or retrodisplace back closer to the face,
resulting in a reduction in projection.1 Proper application
of the nasal dressing is a crucial step in obtaining the maximum
aesthetic result. Finesse and caution are especially important for the
tip to avoid displacement, pinching, or improper alignment of the newly
sculptured tissues. As a part of the internal nasal dressings, a small
rolled piece of oxidized regenerated cellulose (Surgicel) is carefully
placed inside the nose within the vestibule of each newly constructed
dome to add stability during the initial healing phase. Finally, the tip
is taped in its desired position and a metal splint placed over the
nasal dorsum. These dressings remain in place for one week. Figures 8
and 9 demonstrate the practical application of this surgical technique.
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Comment
The procedure described herein is an effort to provide another useful
surgical technique in correction of the bulbous, wide, or bifid nasal
tip. The surgical principles are sound, and when combined with an
approach of progressive surgical intervention, the results can be
rewarding. If the surgeon cannot obtain the desired result with simple
horizontal excision of cephalic portions of the lateral alar cartilages,
then appropriate gentle morselization and/or vertical division with
suturing of the newly reconstructed alar domes to each other, creating
the double-dome unit, may provide the desired tip sculpturing.
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References
1. McCollough E.G., Devinder M.: Systematic approach to correction of
the nasal tip in rhinoplasty. Arch Otolaryngol 1981;107:12-16.
2. McCurdy J.A., Jr.: Surgery of the nasal tip: Current concepts. Ear
Nose Throat J 1977;56:10-29.
3. Denecke H.J., Meyer R.: Plastic Surgery of the Head and Neck:
Corrective and Reconstructive Rhinoplasty. New York, Springer-Verlag
Inc, 1967.
4. Goldman I.B.: Surgical tips on the nasal tip. Ear Nose Throat J
1954;33:583.
5. Brown J.B., McDowell F.: Plastic Surgery of the Nose. St. Louis, CV
Mosby Co, 1951.
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