13.1 Analysis

The first prerequisite for a successful operation is an analysis of the problem:

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  Symmetry of the dorsal aesthetic lines

  
  
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  Projection and protection of the nose

  
  
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  Nasolabial angle and nasofrontal angle

  
  
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  Width of the nasal tip

  
  
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  Shape and texture of the lower lateral cartilage. Thin, soft lower lateral cartilages cannot tolerate major structural sacrifice. They lose their stability very easily. In this case, stable long-term results can be achieved only by using additional grafts, struts, and appropriate suture techniques.

  
  
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  Length of the nose in relation to facial proportions

  
  
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  Relationship of chin and forehead projection to nasal tip projection in the lateral view

  
  
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  Facial asymmetry (should be considered in planning the nasal axis)

  
  
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  Length and width of the columella

  
  
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  Assessment of the depressor septi muscle

  
  
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  Quality and thickness of the skin

  
  
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  The septum. Unrecognized deviation or kinking of the septum will affect the aesthetic outcome of the nasal tip and may lead to functional problems. Note also the length of the nasal septum, which may affect tip rotation and the configuration of the columella.

  
  
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  Size and position of the anterior nasal spine

  
  
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  Assessment of the nasal base, including the shape of the nostrils

  
  
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  Any external and internal nasal valve dysfunction, which must be detected before surgery ¹

13.2 Approach

Especially in secondary rhinoplasties, the open approach is preferred for tip corrections because it gives excellent visualization of the cartilaginous framework of the nose. Often this is necessary for an accurate assessment of cartilage status after previous surgery.

With asymmetries of the nasal tip, especially after a previous closed rhinoplasty, we often find that the cartilages were not worked in the same way on both sides (iatrogenic asymmetry). In some cases we also see an overreduction or complete resection of the caudal cartilage. Secondarily, there are congenital malformations of the caudal cartilage, especially at the medial and intermediate crus, which were not recognized during the previous operation and therefore were not corrected (residual asymmetries).

Previously placed grafts can also be clearly visualized through an external approach. An inverted-V incision is recommended for the open approach. When placed in the narrowest part of the columella, this incision leaves a very inconspicuous scar. However, especially in secondary rhinoplasties, the preexisting scar may not be in an optimum position. In most cases we use the old scar to avoid compromising the blood supply to the columella by incisions at different levels. We also have the opportunity to perform a scar revision at that time ( Fig. 13.1 ).

Extensive scarring of the nasal tip is very common after prior surgery, so the dissection must be done in a way that does not injure the skin or delicate cartilage structures. Another drawback of scarring is that it often increases diffuse bleeding during the dissection.

13.3 Intra-, Inter-, and Transdomal Sutures

Intradomal and dome-defining sutures can narrow the single dome precisely ( Fig. 13.2). Interdomal sutures approximate the domes at the desired distance ( Fig. 13.3 ). Sometimes a preexisting underprojection of the nasal tip might not have been adequately corrected during the previous surgery. To reinforce the projection, the domes can be redefined and sutured together by transdomal suturing. Transdomal sutures can simultaneously narrow the domes and move them closer together ( Fig. 13.4 ). Thereby overcorrection should be avoided. Otherwise this limits the function because of reducing the angle between columella and nostrils. Even properly placed sutures often cause some degree of pinching in very soft lateral cartilages. In these cases the lateral alar cartilage can be reinforced with thin cartilage grafts such as batten grafts, underbatten grafts, or lateral crural strut grafts. ²

13.4 Domal Equalization Suture

The domal equalization suture is placed through the cephalic domal segments and moves them closer together ( Fig. 13.5 ). The suture ensures tip symmetry and lowers the cephalic portion of the rim below the tip-defining points. ³

13.5 Spanning Suture

Lateral convexity or “flaring” of the alar cartilages can be effectively corrected with a spanning suture placed through the lateral crura ( Fig. 13.6 ), using 5–0 material.

13.6 Tip Suspension Suture

Ptosis of the reconstructed nasal tip is prevented by passing a thread beneath a tip suspension suture fixed through the dorsal septal border ( Fig. 13.6 ). This technique will prevent drooping of the tip. Nasal tip rotation and position are optimized and secured with a tip suspension suture. A modification is the suspension suture with an anterior sling for shortening the nose. ⁴ With the aid of a cannula, the suture ends are brought anteriorly to the medial crura and tied together ( Fig. 13.7 ).

13.7 Horizontal Mattress Suture Technique (Gruber)

Nonabsorbable mattress sutures placed in the lateral crus can balance both concave and convex bulbous deformities, depending on the direction of suture placement. ⁵ The vestibular skin on the undersurface of the cartilage is carefully undermined in the area of the deformity. Bulbous alar cartilages are corrected by placing the first stitch perpendicular to the length of the alar cartilage, then placing a second stitch perpendicular to the first and 6–8 mm from it. The knot is tied posterior to the lateral crus. A concavity is corrected with basically the same mattress suture placed on the undersurface of the lateral crus. In a modification described by Gruber, which also allows corrections of concave deformities, the cartilage is held in the desired shape with a forceps and the knot is tied posterior to the lateral crus, applying a carefully controlled amount of tension ( Fig. 13.8 ). ¹

13.8 Lateral Crural Reversal Technique, Upside-Down Technique

Concavity of the lower lateral cartilages not only may be aesthetically objectionable but may also cause functional problems by pushing the convex undersurface into the vestibule. The deformed portion of the lower lateral cartilage is removed and turned 180° after separation of the vestibular skin from the cartilage. It is then sutured back into place ( Fig. 13.9 ). Aiach recommended leaving a thin cartilage strip at the edge of the crus so that the lateral crus could be fixed more easily and securely after the reversal maneuver. ¹

13.9 Lateral Crural Overlay Technique

This technique also corrects concave deformities of the lower lateral cartilages. The cephalic edges of the lateral crura are separated from the vestibular skin ( Fig. 13.10a ) and are incised but not excised ( Fig. 13.10b ). The cephalic edges are then folded over the remaining portion of the lateral crura ( Fig. 13.10c ) and secured at the edges with fine sutures. The formerly concave cartilage is now convex and functionally stable.

13.10 Lateral Crural Underlay Technique

This technique provides another option for correcting concave deformity of the lateral crus. First the underlying vestibular skin is elevated from the cartilage. Then the cephalic portion is incised but left attached to the inferior perichondrium and passed beneath the remaining lateral crus. Fine sutures fix the position ( Fig. 13.11 ). A modification is turn-in folding, in which the underlying vestibular skin remains and the cephalic edges of the lateral crura are simply incised and folded downward and reinforced with a spanning suture. Because of the caudal folding, however, the patient may complain of an unusual palpable finding within the nose, especially when the cartilage is of adequate width and thickness. ¹

13.11 Cephalic Trim

A sparing cephalic resection of the lower lateral cartilages will narrow the supratip area while also producing some cephalic tip rotation. The resection should not be parallel to the cartilage edge over the entire length of the cartilage, and the lateral third should be left wider than the medial third ( Fig. 13.12 ). The cartilage should be left at least a minimum of 4–5 mm wide to preserve the necessary functional stability of the caudal cartilage framework. Trimming too much cartilage from the lateral third may lead to pinching and collapse of the lower lateral cartilage with subsequent nasal airway constriction. This may even become accentuated over time.

The nose can be precisely analyzed and corrected through an open approach. An asymmetrical cephalic trim of the lower lateral cartilages can be corrected if necessary by resecting additional cartilage from a too-wide lateral crus or by reconstructing an overresected cartilage with batten grafts.

13.12 Dome Division Technique

The dome division technique is most suitable in thick-skinned patients. ⁶ – ⁹ The concept of dome division was first described by Goldmann ^{10 , 11} as a universal tip correction technique. Dome division affects both the projection and configuration of the nasal tip. Originally the technique involved incising not just the cartilages but also the vestibular skin at the dome, but today this is obsolete.

Although Goldmann illustrated his technique as a vertical cartilage-splitting incision at the angle of the lobular dome, the term “vertical dome division” was not used at that time and did not appear in the literature until the 1980s. ^{9 , 12}

The dome is divided by a vertical incision and reapproximate the cartilage edges with sutures, thereby increasing the tip projection ( Fig. 13.13 ). Resecting a vertical cartilage strip causes deprojection. The exact amount of tip deprojection and derotation cannot be accurately predicted, however. Consequently, we recommend this technique only in very thick seborrheic skin and only if increased projection is desired. Dome division in thin-skinned patients may produce a sharp, narrowed tip with potential collapse of the alar sidewalls. ¹