Abstract
Background
With some frequency, in mestizo rhinoplasty, we focus much of our attention on the nasal tip. This work also highlights the importance of obtaining a proper balance of the columella, achieving a pleasing visual effect of the vector lines that make up the nasal profile (columella and nasal tip vectors).
Methods
We performed a complete medical history in all patients and developed a surgical plan after nasal anatomy analysis. Pre- and postoperative photographs were obtained for medium and long term control.
Results
We treated 112 patients with this surgical technique, 77 with an open approach and 35 with a closed approach. The results were documented in the short and long term with a range of 6 months to 5 years.
Conclusions
We feel that the use of an angulated extended columellar graft is highly polyfunctional, providing length, definition and support to nasal tip grafts. Because of the graft design, it is possible to predetermine the new columella length/tip, thus visualizing the columella and nasal tip vectors of the nasal profile. The angulated extension prevents cephalic–lateral–caudal displacements of the tip graft, and to some degree it is possible to increase or decrease nasal length depending on the angularity of the extension.
1
Background
The anatomical characteristics of the Mestizo patient’s nose usually include an apparently large nose, a convex dorsum with a deep radix, and a wide nasal base. The length of the nasal columella and tip is decreased because the alar cartilages are short and also weak and thin, providing insufficient structural support, poor definition and nasal tip projection. Skin thickness also contributes to the poor overall definition of the nose, especially of the tip . Patients often have alveolar protrusion that projects the lips forward. This effect makes the reduced nasolabial angle more apparent.
The normal anatomy of the nose in a profile view describes two vectors: the columellar vector and the nasal tip vector, each with an origin, length, direction and an end ( Fig. 1 ). The vector describing the columella starts in the sub-nasal point and ends at the columella–lobe junction (cephalic rotation point). The vector of the nasal tip begins precisely at the point of cephalic rotation and ends at the dome, which is the maximum point of projection of the nose. Both vectors from their beginning move in an anterior and cephalic direction, the intersection of these vectors at the columella–lobe junction forms an average angle of rotation of 50° ( Fig. 1 A) . The longitudinal relationship of these vectors is approximately 2/3 and 1/3, respectively ( Fig. 1 B).
The mestizo nose usually has a short columella, which is more or less retracted and hidden because of its alar borders ( Fig. 2 ). The shortness and lack of deflection of the internal domal angle of the segments of the middle crura (lobule and dome segment) give the tip a convex aspect ( Fig. 2 A). This obtuse angle prevents the formation of a point of maximum projection of the nose tip. The vectors representing the columella and tip are short and their crosslink generates an obtuse angle of cephalic rotation (greater than 50°) ( Fig. 2 A). These variables establish a poorly defined short convex nasal tip, which is often below the level of the dorsum ( Fig. 2 B).
Surgical modeling of the nasal tip in a Caucasian rhinoplasty involves, according to its anatomical features, strategic modeling of the lower lateral cartilages with sutures. The use of a columellar support depends on these variables, and less frequently on a tip graft. However, contrary to these standards, in mestizo patients, the use of a columellar support and a cartilage graft for the nasal tip is practically the rule.
The columellar graft provides support, projection and length; in turn the tip graft provides tip projection and definition ; however, with a certain frequency, due to the weak support of the cartilaginous tripod, particularly the central pillar, and also the thickness and weight of the soft tissues on these grafts, and possibly also due to the fixation technique and the retraction effect of the scar, these grafts may undergo basal, cephalic, and/or lateral displacement with the loss of a good result ( Fig. 3 ).
In this work, we have focused our attention not only on obtaining a good result, strictly of the nasal tip, but also on achieving an appropriate balance of the columella, with this being reflected externally with the visualization of the lines (vectors) originating from the columella and the nasal tip. Based on this, we propose the use of an angulated extended columellar graft (AECG) as a single unit that allows us to establish a clear definition of these vectors with the breaking point that defines them (cephalic rotation point) ( Fig. 4 ). Thus with the AECG, whose design predetermines these vector lines, it is possible to reach a high standard of beauty, which is difficult to attain, for the mestizo nose.
2
Material and Methods
The technique was used in 112 rhinoplasty patients with a mestizo nose (89 women and 23 men) ranging from 16 to 55 years of age. A complete medical evaluation was performed with preoperative and postoperative photographs to aid in the evaluation of intermediate and long-term results. The majority of the patients underwent surgery with local anesthesia and sedation. There were 85 primary cases and 27 secondary cases, with 77 cases being done with an open approach and 35 with a closed approach. We obtained the informed consent from all patients, who were also informed fully regarding the aim of the study. The clinical study was approved by the appropriate institutional review boards from the “Dr. José E. González” University Hospital.
The day before surgery, oral cephalexin (500 mg tid) and oral arnica (as a preventive anti-inflammatory drug) were prescribed. Postoperatively, cephalexin was continued for four days and arnica was continued for 10 days.
Local anesthesia consisted of 1% lidocaine with epinephrine (ratio of 1:100,000). Cotton applicators soaked with this solution were introduced to create a vasoconstrictive effect on the mucopericondrium of the septum and turbinates. The infraorbital nerves and the areas to be dissected were infiltrated. The mucopericondrium of the nasal septum was infiltrated, directing the bevel of the needle towards the wall of the septum in order to perform hydrodissection, thereby facilitating elevation of the mucoperichondrial flap.
In most patients, we performed an external approach through a stepwise transcolumellar incision connected to a marginal incision through the lower edge of the alar cartilage . Then we symmetrically exposed the cartilaginous framework and dissection continued upward to the bony dorsum. When it was necessary to remove a large hump, subperichondrial tunnels were created along the anterior edge of the septum up to the level of the nasal bones, allowing for extramucous resection .
We preferred to harvest the septal cartilage and then work on the dorsum, continuing with necessary modifications of the tip. This provided us with a fixed point of reference from which to establish a dynamic balance between the dorsum and the tip. The grafts were obtained from the septum for the columella, tip, and dorsum and carved to the size and shape determined by preoperative planning . If there is insufficient septal cartilage for the graft, ear cartilage provided a good alternative. Rib cartilage can also be used when a greater amount of cartilage is needed or when other donor areas have been used previously.
2.1
Design of the angulated extended columellar graft
Graft design conforms to the nasal profile with its two vectors and in contrast with the usual columellar support. The AECG is formed by two parts: a long portion for columellar support (the columellar vector) and a short angled portion termed the angulated extension (the nasal tip vector) ( Fig. 4 ).
2.2
Columellar support (Columellar vector)
The mestizo patient usually has a short columella; therefore, we define a new length of the columella in the design of the graft. Initially, we identify the lobule–collumella junction of the crura to estimate the length that the columellar support must have ( Fig. 5 A ). We dissect an intercollumelar pocket through which the AECG is introduced and tested in different positions to establish a suitable height for the columella. The columella is usually hidden by the alar borders therefore the graft must be placed anteriorly, according to the required projection. We must simultaneously predetermine the nasolabial angle (commonly reduced), so that the graft will have a slight cephalic rotation to increase the nasolabial angle ( Fig. 5 B). It is important to remember that the depressor septi nasi muscle and the ligament of Pitanguy intrinsically paticipate in nasal dynamics, so manipulation must be controlled (action-effect) . The adequate length and projection of the columellar graft support ensure satisfactory visualization of the columellar vector. Finally, the graft is secured at the previously determined site with two or three 5-0 horizontal mattress sutures .
2.3
Triangular extension of the Columellar support
Some patients have a long upper lip, so we add a triangular extension to the base of the columella support of the graft. This technique helps the nasolabial junction seem lower and the upper lip seem shorter ( Fig. 6 ).
2.4
Angulated extension (Nasal tip vector)
As previously mentioned, the nasal tip is short and convex without definition and with an obtuse angle of cephalic rotation. The angulated extension functions as a bed on which the tip graft directly lies. This prevents cephalic–caudal displacement. We also place rectangular mini-grafts on both sides of the extension to prevent lateral displacement thus increasing the contact surface (rectangular mini-grafts for lateral stability) ( Fig. 7 ). These two maneuvers provide greater stability to the nasal tip graft. We establish the angularity of the extension; however, in almost all cases a reduction of the angle of cephalic rotation is necessary. At the same time we determine the length of this portion of the graft. We usually place the vertex of the angled extension above the level of the nasal dorsum ( Fig. 5 A). This will be our reference point to estimate projection of the tip graft ( Fig. 7 ). The height and projection of the columellar portion, the angularity of the point of cephalic rotation, and the length of the angled extension are determined before the procedure and confirmed during surgery.
