Cosmetic: Ideas and Innovations
The pollybeak deformity, also known as supratip deformity and defined as excessive supratip fullness, is still one of the most common deformities following rhinoplasty, with occurrence rates as high as 9 percent after primary rhinoplasty.1 A study recently published by Hussein and Foda revealed that a pollybeak deformity was even present in 720 of 1160 patients (62 percent) in a Middle Eastern patient cohort undergoing revision surgery over an 11-year period.2 Because of the stigmatizing nature of this deformity, a pollybeak deformity should be avoided carefully during any rhinoplasty surgery.
Several factors contribute to the creation of a pollybeak deformity, the most common being overprojection of the caudal dorsum and underprojection of the nasal tip, cephalically oriented or inadequately cephalically resected lower lateral cartilages, excessive supratip scarring, or a high anterior septal angle.1,2 The most important predisposing patient factor for the development of a pollybeak deformity after primary rhinoplasty is heavy thick skin, accounting for higher numbers of pollybeak deformities after rhinoplasties in Middle Eastern patients, as described by many authors.3–8 Thick skin tends to accumulate in the supratip area and is unable to contract sufficiently after reduction of the cartilaginous framework, thereby rendering thick-skin patients more prone to developing a pollybeak deformity.
Therefore, the most important aspect for prevention of a pollybeak deformity after completing reduction of the cartilaginous framework is avoidance of dead space in the supratip area, especially in thick-skin patients. In our experience, merely taping the supratip region postoperatively has been proven to be insufficient, independent of the duration of the taping. Therefore, only two ways to prevent a pollybeak deformity in patients at risk of developing the deformity remain: placement of a supratip suture,9 or supratip skin excision.10 In this article, both techniques are described in detail. In addition, a brief overview of the results of our case series of 74 patients treated with the supratip suture technique along with 21 patients treated with the supratip excision technique over a 5-year period is given.
PATIENTS AND METHODS
Initially described by Guyuron et al.,1,9 the aim of the supratip suture is to reduce dead space in the supratip area, thereby preventing excessive scarring in this area. In the modification described in this article, the exact location of the suture is determined by redraping the skin envelope before skin closure in open rhinoplasty cases and placing an injection cannula in the desired supratip breakpoint region. The skin envelope is elevated again and a 5-0 Vicryl (Ethicon, Inc., Somerville, N.J.) suture is passed horizontally through the superficial musculoaponeurotic system at the exact position of the cannula (Fig. 1). Then, a 20-gauge injection cannula is inserted through the soft tissues between the medial crus and septum on one side in a cephalad direction, and the free end of the Vicryl suture is passed through the injection cannula (Fig. 2). The cannula is now inserted on the contralateral side, again between septum and medial crus, and after cutting the needle, the other end of the Vicryl suture is passed through the cannula (Fig. 3). The knot, now lying in front of the medial crura, is tied but not fastened. Now, the skin envelope is redraped and skin closure is carried out as usual. After skin closure, the tightness of the knot and therefore the amount of pull on the skin in the supratip area can be adjusted, which is a great advantage of our modification in comparison with the technique described by Guyuron et al. (SeeVideo, Supplemental Digital Content 1, which demonstrates the supratip suture technique in a primary rhinoplasty case, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/D471.) A deformation of the medial crura by the suture, though unlikely because of an only moderate degree of tension necessary, can be prevented by a previously placed strong columellar strut or septal extension graft.
A total of 74 pollybeak cases were treated with the supratip suture technique from January of 2013 through July of 2018 by a single surgeon (W.G.); 54 were female patients and 20 were male patients. Of these, 40 were primary rhinoplasty cases, whereas 34 patients were secondary cases. The mean follow-up time was 14 months.
If a severe mismatch between the amount and thickness of skin and the size of the cartilaginous framework is encountered, in rare cases an excision of supratip skin can be considered after completion of the nasal framework reduction, as enlargement of the cartilaginous framework is contraindicated in most cases of reduction rhinoplasty.10 By minimizing dead space in the supratip area, a well-defined supratip break point is created.
The amount of skin excess is determined using a pinch test and skin markings are made. A supratip elliptical skin excision is performed in the midline just behind the tip-defining point (Fig. 4). When the amount of skin excision is judged correctly, the wound edges collapse automatically and need almost no suturing. Only a subcutaneous suture approximation with 6-0 polydioxanone (Ethicon) and supportive taping are required. (SeeVideo, Supplemental Digital Content 2, which demonstrates a supratip excision being performed toward the end of a primary rhinoplasty case, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/D472.)
From January of 2013 through July of 2018, 21 patients underwent supratip excision performed by a single surgeon (W.G.); 14 were female patients and seven were male patients. Of these, 15 patients were primary rhinoplasty cases and six were secondary cases. The mean follow-up time was 10 months.
Prevention of a pollybeak deformity is still a common challenge in any rhinoplasty surgery, as occurrence rates as high as 9 percent after primary rhinoplasty have been reported.1,2 Because of the stigmatizing nature of the deformity, precautions have to be taken during any rhinoplasty to prevent its occurrence. Having excluded the most common contributing factor leading to the deformity (i.e., a mismatch in projection of the nasal dorsum and nasal tip), the next important surgical step consists of eliminating the dead space in the supratip region, especially in thick-skin patients prone to developing a pollybeak deformity.
In this article, we present two techniques to reach this aim, one being our modification of the supratip suture initially described by Guyuron et al.,1,9 and the other being a skin excision in the supratip region as described by Gubisch.10 The outcomes of a case series of 74 patients treated with the supratip suture technique and 21 patients treated with the supratip excision technique from January of 2013 through July of 2018 were assessed.
Of the 74 patients treated with the supratip suture technique, two patients needed revision rhinoplasty because of overcorrection, resulting in a very acute supratip breakpoint, proving the potential of this technique. Seven of the patients presented with temporary supratip dimpling, which resolved in all cases within the first few months postoperatively. So far, none of the 74 cases have presented with a recurrent pollybeak deformity after healing and edema resolution.
Of the 21 patients treated with the supratip excision technique, two patients showed delayed wound healing because of early local infection. Three patients needed dermabrasion because of conspicuous scarring with irregularities, two of these being the aforementioned. Eighteen patients showed very good aesthetic results after wound healing was completed.
We showed that our modification of the supratip suture has the great advantage of enabling the surgeon to adjust the amount of skin pull after skin closure of the transcolumellar incision, thereby optimizing aesthetic results. In our opinion, however, a supratip suture should be considered only in thick-skin patients at risk of developing a pollybeak deformity.
In rare cases of massive skin excess after completion of nasal framework reduction, a direct vertical skin excision can be performed as described in this study, yielding a very good aesthetic result if meticulous skin closure is performed. However, this is a last measure and should be reserved for rare cases in which, based on surgical experience and judgment, there is no chance of achieving an acceptable aesthetic result, even with the expected skin shrinkage possibly achieved by other measures such as the supratip suture taken into consideration.
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6. Foda HM. Rhinoplasty for the multiply revised nose. Am J Otolaryngol. 2005;26:28–34.
7. Apaydin F. Rhinoplasty in the Middle Eastern nose. Facial Plast Surg Clin North Am. 2014;22:349–355.
8. Rohrich RJ, Ghavami A. Rhinoplasty for Middle Eastern noses. Plast Reconstr Surg. 2009;123:1343–1354.
9. Guyuron B, Lee M. An effective algorithm for management of noses with thick skin. Aesthetic Plast Surg. 2017;41:381–387.
10. Gubisch W. Mastering Advanced Rhinoplasty. 2017.Berlin: Springer.
Supplemental Digital Content
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