Rhinoplasty is a procedure that is crucial in providing aesthetic and harmony to the face. One of the main goals of rhinoplasty is to achieve an aesthetically pleasing nasal tip contour. Modification of the definition, projection, stability, and symmetry of the tip are the primary goals in tip rhinoplasty. The tip should be located in front of the dorsal plane with ideal tip projection being approximately 0.67 times the length of the nose.1 Tip problems are among the most common reasons for reoperation in secondary rhinoplasty cases.2
There are many reports that describe tip grafts and modifications for obtaining nasal tip projection.3,4 The most important aspects to be considered before performing these modifications are their longevity and effectiveness.5 Asymmetry in the middle crura, insufficient support, and loss of projection and definition are issues that are particularly problematic for the tip contour. Malposition, deformity, and extreme concavity of the lateral crura can also cause problems in the tip region.
Malposition or malformation of lateral crura can cause deformities that are a frustrating challenge for the rhinoplasty surgeon. The lateral segment of the lower lateral cartilage (LLC) can show signs of decreased resistance, cephalic malposition, or vertical plane angulations due to congenital or acquired developmental deformities.
Nostril lobule disproportion and deformation can also become complex problems that can impair the harmony of the tip. This problem can usually be solved by increasing the tip definition in patients with nostrils that are not too large.
Trimming of the lateral crura can help fix the deformities in the LLCs. The folding of this surplus cartilage can increase tip definition and projection at the level of the middle crura. This can help fix nostril lobule incompatibility issues particularly in a narrow tip with insufficient projection.
The aim of this study was to report the results of a new technique that involves folding the cephalic portion of the lateral crura into the subdomal area in combination with tip sutures in patients with insufficient stabilization and definition in the middle crura.
MATERIALS AND METHODS
A retrospective chart review was performed in this study. Informed consents were obtained from all the patients, and the study was conducted in accordance with the tenets of the Helsinki Declaration. Twenty-nine patients with insufficient definition and projection of the tip particularly in the middle crura who underwent reconstruction with tip reinforcement flaps between January 1, 2016 and February 28, 2018, were included in this study. The first author performed all the surgical procedures in this study. Preoperative and postoperative nasal tip length, nasal tip rotation, and nasal tip angle were calculated from standardized preoperative and postoperative photographs from selected patients with ImageJ software.6 Nasal tip length was calculated from the anterior-most portion of the nostril to the most projected part of the tip in the lateral view. Nasal tip rotation was determined by the measure of the nasolabial angle between parallel lines from columellar and the upper lip. Nasal tip projection was measured as the ratio between alar root–nasal tip and nasion–nasal tip distance.7
t Test comparison was performed using GraphPad Prism version 7.00 for Mac OS (GraphPad Software, La Jolla, CA).
Open rhinoplasty was performed with a transcolumellar inverted V-shaped incision connected to the bilateral marginal rim incisions. All the nasal components of the tip (deformed LLCs, caudal septum, and Pitanguy ligament) were exposed and examined intraoperatively. Tip reinforcement flap technique was performed in cases of insufficient tip definition, stabilization, and projection.
The lateral crura of the LLC were incised to form a 3- to 5-mm-wide flap depending on the requirement based on the width of the middle crura. The base of the flap was kept between the middle crura and the dome, and the mucosa underlying the cartilage was kept intact (Fig. 1). The remaining width of the lateral crura of the LLC was kept between 5 and 7 mm. The flap was trimmed as required then folded and adapted under the dome and over the mucosa. The flap was folded and adapted to its place with 5.0 polydioxanone sutures along the distal, anterior, and posterior edges (Fig. 2; Supplementary video, http://links.lww.com/SAP/A331). A carefully harvested septal cartilage graft was adapted into the flap in patients needing extra tip support. Tip plasty was performed using interdomal, transdomal, and tip-defining sutures and other tip sutures (Fig. 3). The dorsal hump was removed when necessary. Percutaneous, medial, and lateral osteotomies were performed. Finally, a strut graft was prepared from the septum and fixed to the medial crura with 5.0 polydioxanone sutures, and adjustments were made for tip rotation and projection.
Patients were discharged on the first postoperative day. The internal and external nasal splints, as well as the sutures, were removed on the seventh day. After the external splint was removed, the nasal area was taped with omnistrip (Paul Hartmann AG) for 1 week. Once all the sutures and splints had been removed, the patients were followed up at 4 weeks, 8 weeks, and 3 months postoperatively and afterward at 3-month intervals for 1 year. After 1 year, patients were followed up annually.
There were 29 patients (17 women, 12 men) aged 18 to 44 years (mean age, 31 years). The mean procedure time was 110 minutes (range, 54–140 minutes). All cases were primary rhinoplasty cases. Indication for use of the tip reinforcement flap was insufficient definition and stabilization of middle crura and tip. Tip graft was not used in any of the cases. All cases involved poor tip definition and stabilization. Tip reinforcement flaps were used in all cases. Five patients (17.2%) required extra stabilization and definition, so a thin septal graft was harvested and inserted into the folded flap.
All patients were followed up for a mean duration of 21 months (range, 3–25 months). All patients except one achieved a significant improvement in tip definition, stabilization, and nasal tip contour (Figs. 4–6). Preoperative and postoperative average of nasal tip length was 10.84 (±1.07) mm and 14.32 (±2.34) mm, respectively (P = 0.0214). Preoperative and postoperative average of nasolabial angle was 97.42° (±9.84°) and 107.99° (±12.16°), respectively (P = 0.0344). Preoperative and postoperative average of nasal projection ratio was 0.53 (±0.04) and 0.57 (±0.03), respectively (P = 0.4347) (Table 1). The narrow interdomal distance was corrected in selected patients. We did not encounter infection, hematoma, recurrence of deformities, or asymmetry of the tip. Minimal to moderate columellar hanging was noted in 1 patient, and this was corrected in the postoperative first year with additional caudal septal excision in addition to the tongue-in-groove technique. This patient did not experience any complications in the 12 months following the revision. None of the patients had stiff tip, flap visibility, or tip asymmetry problems. All patients were satisfied with their results (Figs. 4–8).
The most important factors determining final tip projection are the definition and projection of the middle crura and the position of the lateral crura. Achieving an ideal tip projection is one of the hardest goals in any primary rhinoplasty operation particularly in patients with weak and malformed cartilages. Various techniques have been developed to increase tip projection and definition including tip grafts,3,4 flaps,8,9 tip sutures,10,11 and synthetic materials.12,13
Tip grafts have various complications such as visibility, asymmetry, graft resorption, projection, and loss of definition.8 Possessing similar characteristics, conchal cartilage graft can maintain form and structure and provide projection and support for the tip area. Despite these advantages, harvesting the cartilage prolongs the operation and creates donor site morbidity. In addition, there are various other problems associated with the use of cartilage grafts such as asymmetry, malposition, palpability, resorption, and infratip lobule deformity.14,15 In this study, a cartilage flap raised from the cephalic portion of the LLC was folded inside the submucosal region of the dome area. None of the complications associated with cartilage grafts were seen in our cases.
Common tip-narrowing procedures such as dome-binding sutures can create iatrogenic nasal obstruction due to subtle malformations of the lateral crura and can cause pinched-tip appearance particularly in cases where the sutures are tightened with high tension.16 Tip modifications performed with suture techniques in primary rhinoplasty patients with thin nasal skin can create undesired results such as bifid tip and domal cartilage angularity.17
The use of synthetic materials has several advantages including the elimination of donor area morbidity, ease of use, and shortening the operating time. However, they can also cause unwanted effects such as infection, extrusion, tip ulceration, and deformation of the mobile tip unit.13,18,19
García-Velasco et al8 defined a technique in which lateral crural flaps were adapted directly over the dome to increase tip projection. The problem with this approach is that the top point of the flaps does not adapt well to the horizontal position of the domes. Also, there is the increased risk of supratip fibrosis and swelling.9
Guyuron et al12 reported a technique involving the placement of a strip of septal cartilage graft under the domal cartilage. They demonstrated that using this technique interdomal distance can be increased and dome asymmetry can be corrected in patients with narrow interdomal distance. The disadvantage of this approach is that if the cartilage strip is not narrow enough the domal arch can widen, the supratip definition can be lost, and the lateral crura of the LLC can rotate in the cephalic direction. We too have used this technique in patients who were not suitable for tip reinforcement flap having no cephalic excess in the lateral crura. These patients were not included in this study. In our technique, a lateral crural flap was used instead of a septal graft to provide similar support to the tip. Both of these technique provides an internal support to the dome area. This way the support cartilage can be hidden behind the domal cartilages as opposed to a tip graft, which provides an external support and has the potential to become visible under the skin.
The angle of rotation as defined by Sheen and Sheen is the angle between the middle and the medial crura in the lateral view.20 This angle defines the inferior border of the lobule and the transition between the lobule and the columella. Tip re-enforcement flap can help maintain this angle and can fix the prominence in the inferior part of the lobule and tip definition. Tip sutures can provide only 1 to 2 mm of projection to the tip.21 Tip definition and projection can also be achieved effectively with a columellar graft. But columellar grafts are often insufficient in terms of increasing the length of the middle crura or its projection and definition especially in patients with strong and stiff LLCs.
Existing literature on treating nostril lobule disproportion is limited, and previous techniques are far from giving specific answers or clear data.20,22 Daniel23 reported that in patients with large nostrils and small tips ideal nostril tip proportion should be slightly in favor of the tip. We increased the tip projection and definition and performed nostril sill/alar base excision to achieve this ratio. Middle crura length and strength are 2 important factors determining tip projection and lobule length.24 Nostril lobule disproportion can also be addressed by lengthening the middle crura. In our study, most of the patients had nostril lobule disproportion, not only wide nostrils in which nostril- and alar-based excision can fix the problem. Tip reinforcement flap can fix this problem by increasing the definition of the middle crura. This approach can provide projection to the middle crura and a more defined, stabilized, and projected tip appearance by utilizing the cephalic part of the LLC, which would otherwise have been resected, as a flap.
The tip reinforcement flap does not have any particular blood supply, so it could be considered as a graft rather than a flap. This flap would depend mostly on diffusion for survival like any other cartilage graft. Despite this, it was described as a flap because the incised cartilage is not completely separated from its origin in the LLC. Despite its benefits, the tip reinforcement flap technique can be time consuming. Using this technique can present challenges in the secondary and tertiary patients, who may lack sufficient cephalic excess in the lateral crura. We believe that this procedure should be reserved for select patients with a cephalic excess of LLCs, deficiency of middle crura, and inadequate projection of tip.
One of the primary goals of a rhinoplasty is to achieve adequate tip definition and projection while addressing tip asymmetry and instability. A smooth tip-nostril transition should be aimed for by providing a natural relation and ratio between tip lobule and the nostril.
Tip reinforcement flap is a simple technique that, when applied with proper accuracy, can provide an effective and permanent definition, stability, and projection to the tip while fixing nasal tip asymmetry particularly in patients with insufficient middle crura strength, projection, and definition. This technique can also improve nostril lobule ratio.
In this technique, the flap from the cephalic part of the lateral crura is inserted under the dome and is not visible or palpable. Because it is designed as a flap, its resorption will be minimal if at all. The results of this study support the claim that tip reinforcement flap can adjust tip symmetry and achieve support at the level of the middle crura to provide tip projection and definition.
Informed consent was received for publication of the figures in this article.
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