Essentials of Septorhinoplasty

Behrbohm/Tardy:  Essentials of Septorhinoplasty

CHAPTER 8: ENDONASAL TIP APPROACHES AND TECHNIQUES

Stephen W. Perkins, M.D.

Mark M. Hamilton, M.D.

Introduction

Often, the most challenging part of rhinoplasty is modifying and refining the nasal tip. Endonasal delivery flap techniques have an extensive and successful history. This chapter will focus on the beauty, versatility and the simplicity of endonasal tip surgery.

Achieving tip definition has evolved since Joseph introduced cosmetic rhinoplasty in the late 1800s. This evolution is well described by Tebbetts1. Initially, nasal tip shaping techniques were destructive, consisting mostly of incising and resecting cartilage. Often the tip was approached in either a retrograde or a cartilage splitting fashion. The limited visibility of these approaches lowered the threshold for possible asymmetry or other deformity. These early destructive techniques resulted in consistent loss of tip support and increased the risk of secondary deformities.

Then came the era of open structure rhinoplasty with the routine use of tip grafts. This increased the number of variables in the surgical maneuvers and long term healing results where modifying and sculpting the normal anatomic structures could produce the same or better results. We now have evolved into an era of nondestructive tip-shaping techniques. These methods allow achievement of the desired aesthetic appearance while maintaining or recreating projection and functional tip support. This assures excellent results not just at one year, but also at 5 years, 10 years and more.

Our approach is based on the creation of the double-dome unit as described by McCollough and English2. In addition, individual treatment of each dome to create the correct contour is further described. Long-term success using these techniques has been well described3 . We will first describe our basic surgical technique, followed by specific nasal tip deformities and steps utilized to correct these.

Preoperative Analysis and Patient Selection

It is critical to determine the exact tip deformities before creating a surgical plan. What is the aesthetic problem of the tip and what is one attempting to achieve? This begins with a detailed examination during the consultation period. Standardized forms are helpful for assuring a complete examination as well as simplifying documentation (Figure 1) The tip shape should be described, such as bulbous, twisted or infantile. Both the degree of rotation and the extent of projection should be evaluated. Skin thickness is critical to assess and this issue alone may dictate approach and/or procedure to be performed. Palpation is helpful in determining the nature, volume, strength, and resiliency of the lobular cartilages as well as in evaluating tip support. Finally, it is important to note columellar abnormalities and their relation to the alar cartilages.

The ideal patient for these techniques has been described by Tardy et al4. The ideal patient has a slightly bifid or broad tip with dual dome highlights. Thin skin and sparse subcutaneous tissue allow for more refined results from these endonasal techniques. The alar cartilages themselves must be firm and strong. Finally, the alar sidewalls should be thin and delicate, yet resist collapse and recurvature. Most patients do not have these ideal features. Yet by using the endonasal approach and a progressive method with each tip, excellent aesthetic results can still be achieved.

There are certain conditions in our experience that favor the use of the external columellar approach. It is often difficult to deliver, in a safe and adequate manner, alar cartilages in a patient with scar tissue in the lobule from previous surgery or trauma. Middle nasal vault deformities, in our experience, are more easily corrected through the external columellar approach. Patients with marked asymmetry in the nasal tip, with thin skin and bossa, may require camouflage tip grafting sutured in place. Also, marked twisting of the columella with significant discrepancies between the two medial crura may necessitate the external approach. Other indications for the external columellar approach are extremely soft alar cartilages with no inherent support as well as marked over projection, over rotation, under projection and under rotation of the lobule.

All patients are initially seen in consultation with their selected surgeon. The consult room is designed to put the patient at ease while still maintaining a professional environment. The nasal analysis begins with the patient on a comfortable bar stool in front of a three-way mirror with the physician directly behind him or her. Together they analyze the nose with the physician gently guiding the discussion. The three way mirror offers a more three dimensional conversation.

An in depth nasal history is taken during the consult. Inquiries include any previous nasal trauma or surgery, difficulties breathing through the nose, any history of sinus disease or allergies and present nasal medications. The physician reviews a more extensive overall history form, completed by the patient prior to consultation, at this time. Intranasal exam is also performed at this time to detect deformities of the septum, enlargement of the turbinates, or other intranasal pathology. A preprinted nose form helps to ensure a complete evaluation.

The procedure should be thoroughly discussed at this time and goals summarized with the patient. The physician reviews with the patient what to expect on the day of surgery, including the length of surgery, anesthesia, recovery and discharge. Initial postoperative care and activity restrictions are also discussed. Finally, the limitations of the surgery as well as possible complications are given as part of obtaining informed consent.

The consultation is then continued in the photography suite, where computer imaging is utilized to illustrate the physician’s goals for surgery. This allows for confirmation that both the patient and the surgeon agree on the desired goals to be achieved. Following this a full set of nasal images are taken for preoperative documentation.

The last phase of the consultation is spent with the scheduling nurse, where questions can be answered in what often is a more comfortable setting for the patient. Fees are reviewed with the patient and signed copies of the procedures and fees are given to the patient. Any necessary lab work is arranged at this time.

Prior to surgery, all patients receive folders with detailed instructions for surgery, prescriptions, and a booklet reviewing postoperative healing and expectations. All patients start an oral antibiotic the day prior to surgery, most often either oral Keflex or Zithromax, and continue this for five days.

Surgical Technique

One-and-one-half hours prior to surgery, patients are given oral Valium, phenergan, reglan and decadron as well as Afrin nasal spray. In the operating room, deep sedation, typically utilizing i.v. propofol, is utilized prior to beginning local anesthesia. First pledgets soaked in 10% cocaine are placed intranasally. After adequate time for decongestion, infiltration is started with 2% Xylocaine with 1:50,000 epinephrine. No more than 7-8cc is injected with minimal volume distortion.

The delivery approach is begun by making either a complete transfixion or high septal transfixion incision depending on tip projection (Figure 2). Curved sharp scissors are then used to dissect up over the anterior superior angle and expose the upper lateral cartilages. Next, intercartilaginous and marginal incisions are made in a standard fashion (Figure 3). Thin Metzenbaum scissors are then used to separate the overlying skin from the underlying lower lateral cartilages, nasal domes, and infratip lobule (intermediate crura). Finally, the alar cartilages are delivered with a single hook and supported with Metzenbaum scissors (Figure 4). In this fashion each dome is assessed and recontoured individually.

The first step in achieving improved tip definition is the removal of fibrofatty tissue between the domes. This allows greater approximation of the two alar domes. An intact or complete strip can be performed next by excising the cephalic portion of the lateral crura. (Figure 5) This achieves both volume reduction as well as improved supratip definition. It is essential to preserve at least a 7-9mm width of cartilage. In a few select cases, this may be all that is required and the cartilages may be replaced in situ. In most cases, however, other techniques are required to achieve satisfactory tip definition and symmetry.

The ideal alar configuration has been described as being when the domal segment is convex, the adjacent lateral crura is slightly concave, and the overlying soft tissue is thin.5 Occasionally, careful “pinching” of the individual dome cartilages can mold the cartilage into the ideal shape. Most often, however, individual dome treatment with suture is required. Prior to placing the single dome suture, the vestibular skin is separated from the undersurface of the domal cartilage ( Figure 6). A 5-0 absorbable synthetic polyglycolic acid (Dexon) mattress suture is placed at the junction of the lateral and medial crura. The knot is tightened to the point where the proper amount of domal definition is achieved (Figure 7).

If the individual domes remain asymmetric or improved supratip definition is desired, individual dome trimming can be performed. This involves “beveling” the cephalic portion of the single dome unit.(Figure 8).

With achievement of symmetrical, aesthetically pleasing individual domes, the entire tip is re-evaluated. Utilization of the endonasal approach allows this continual critiquing. A double-dome or transdomal mattress suture is next used to bring the individually defined domes together and

stabilize these into one unit. (Key point;) Stabilization is the key to maintenance of long-term results. The suture is placed horizontally through the lateral and medial crura of both domes. We typically utilize a 5-0 clear polypropylene (Prolene) suture. The desired amount of lobular narrowing can be achieved by altering the tension of the stitch. With the domes replaced, the amount of narrowing can be seen as one tightens the knot (Figure 9). It is important to avoid cinching down the suture and creating a unitip appearance.

The tip is then reevaluated. At this point the decision is made whether or not more aggressive steps will be required to achieve the desired tip aesthetics. This could include steps such as lateral crural flap, dome division or the Lipsett maneuver. Marked disparity in length between the two medial crura is best corrected with the Lipsett procedure. With this technique the lengthier medial crura is delivered and dissected free from its attachments. An appropriate length of crura is resected to achieve equality in length between the medial crura. The two resected ends are then reapproximated with 6-0 monocryl. (Figure 10)

Removing or replacing the double-dome mattress sutures and addressing the anterior-posterior or caudal-cephalic placement of a suture in relation to the other dome may address minor asymmetries.

Dome division is utilized for a variety of situations when the above more conservative techniques have not been successful. Dome division can allow for more tip narrowing, which is especially required in those with thick skin. Dome division can also be used to achieve upward rotation and increase or decrease tip projection. Finally, correction of tip asymmetries may be more easily addressed with dome division.

Dome division can be performed medial to the dome, lateral to the dome, or at the dome(Figure 11).

Conservative upward rotation of the tip is typically achieved by resection of an inverted triangle of caudal septum with corresponding vestibular skin and using a columellar strut to assist in “pushing” the lobule cephalically. If further rotation is required following this, the lateral crural flap technique can be employed. This can involve a full incision of the lateral crura or simply a cephalic wedge excision (Figure 12). The lateral crura can be overlapped and sutured to shorten their length and create upward rotation.

Following achievement of a symmetrical and well-defined tip, attention is then turned to the septum, the dorsum and, lastly, osteotomies. A columellar strut fashioned from septal cartilage is placed between the medial crura and anterior to the nasal spine prior to osteotomies. Intranasal incisions are closed with 5-0 catgut. In closing the marginal incisions, it is important to avoid the lateral crura when suturing. Retraction of the lateral crura could lead to possible alar collapse and nostril asymmetries.

A small rolled piece of absorbable oxidized regenerated cellulose (Surgicel) is placed inside the nose within the vestibule of each newly constructed dome to add stability and prevent hematoma. Tan surgical tape (Micropore) along with an alloy metal splint is used for the external dressing that is removed at one week.

Individual Case Examples

Broad|Wide Tip

Tips that demonstrate minimal deformity and minimally excess width can be addressed in the most conservative fashion. Single dome suture treatment is often not required in these patients if the alar dome cartilages are delicate, thin, or soft. A conservative cephalic trim followed by a double dome suture alone can often achieve the desire result (Figure 13).

Bulbous\Boxy Tip

The bulbous tip requires individual treatment of the domes. This is most often addressed with a conservative cephalic trim and an individual single dome mattress suture. Reconstitution of the double dome unit with a 5-0 clear prolene completes tip refinement (Figure 14).

Bifid Tip

The Bifid tip often requires both single dome and double dome mattress treatment of the tip complex. Occasionally, suture approximation of the tip alone will eliminate the bifidity. Most often, however, placement of either a non-sutured tip graft or a columellar filler graft is required (Figure 15).

Trapezoid Tip

The trapezoid tip deformity is due to divergent intermediate crura (Figure 16). Cartilage splitting or transcartilaginous cephalic margin resection is unwise in these patients as both can often lead to the late development of bossae. The alar cartilages have to be re-oriented more caudally, or lateral alar batten grafts or possibly even alar struts must be added. This can be necessary if the lateral alar sidewalls are weak and tend to collapse or re-curve inward when the domes are brought together. Reconstitution of the interdomal ligament- single dome and double dome suture techniques- is required for correction. Tip grafting of the infratip lobule is also often necessary. Often times even when the above aggressive techniques are employed, an aesthetic tip cannot be achieved. In these more difficult cases, dome division is indicated to narrow the tip and straighten the lateral ala.

Asymmetric Tip

A variety of techniques can be utilized to correct the asymmetric tip depending on the degree and the exact deformity. Minor deformities may be corrected with double dome suture techniques alone. If asymmetry is due primarily to a disparity in medial crura length, the Lipsett procedure may be employed. For marked asymmetry between the domes, dome division is utilized (Figure 17) Typically the over projecting dome is truncated and the double dome unit is reconstituted. When the entire nose is over projected, bilateral dome truncation may be performed.

Complications

Bossa Formation

Knuckling of the lower lateral cartilages with healing can occur. Typically this is due to weakening of the lateral crura secondary to either over resection or cartilage splitting techniques. Patients with thin skin, strong cartilages and nasal tip bifidity are at the highest risk for this. Bossae can be treated by resecting the deformed cartilage through a marginal incision. Further camouflage can be provided by either morselized cartilage or fascia.

Alar Retraction

Retraction of ala is usually due to either over resection of the lateral crura or excess resection of vestibular mucosa. Improper suture placement during closure of the marginal incision can also retract the alar rim. Preservation of a complete strip of8 mm or more in patients with a thin alar rim will help to prevent retraction.

Alar retraction can be corrected by taking a composite graft from the cymba concha of the ear6. A marginal incision is made in the area of retraction and a small pocket is corrected. The graft is then sutured into place in effect pushing down the alar rim.

Tip Asymmetry

Postoperative asymmetry of the tip can be due to a variety of causes. Most often this is due to uneven placement of the double dome stitch. Healing forces can alter what was symmetric initially during the postoperative period. Minor asymmetries not noted before surgery may become more obvious with a more overall symmetric nose. Pre operative identification of tip asymmetries and meticulous technique can help to prevent their occurrence.

Improper Projection

Intercartilaginous as well as transfixion incisions do lead to decreased tip support as well as decreased projection. This is usually counter balanced by the increased strength of the medial crura with creation of the double dome unit. Struts provide further strength and projection.

Most commonly, due to the inherent strength achieved with the double dome unit, over projection is the more common minor complication. Preoperative planning and continual intra operative assessment will help to avoid either over or under projection.

Summary

The advantages that open rhinoplasty offers with increased exposure come with many downsides. The external incision itself can be a source of noticeable scarring, alar notching or even trap door deformity. Patients are required to make a special visit for removal of the columellar sutures at postoperative day five. This is both an inconvenience as well as a somewhat painful experience. Finally, resolution of tip edema is significantly prolonged with the external approach. For all of these reasons, our first choice is to utilize endonasal techniques whenever possible.

Endonasal double dome techniques are based on the philosophy of utilization of the normal anatomical structures of the nasal tip (lobule). The merits of these techniques are many. Results of individual steps can continuously be reevaluated. Most of these incremental steps are reversible. Often, use of grafts can be avoided as well as the possibility of secondary deformities that come with them. The disadvantages of these techniques include the need for greater surgical finesse in delivering and suturing the alar cartilages. Also, techniques for the correction of certain deformities may be better addressed through the external columellar approach. Nevertheless, for most primary cosmetic tip rhinoplasties, the beauty and expedient nature of the endonasal delivery flap approach with double dome techniques provides consistent, long term results and few complications.

Legend for Figures

Figure 1 - Image 3 Perkins personal philosophy from Dallas (PPPD)

Figure 2 - Image 18 PPPD upper left image

Figure 3 - NEED illustration of marginal and intercartilaginous incisions

Figure 4 - Image 36 PPPD

Figure 5 - Image 37 inferior right

Figure 6 - Image 70 PPPD

Figure 7 – Figure 5 Archives article

Figure 8 - Figure 6 Archives article

Figure 9 – Fugure 7 Archives article

Figure 10 – Illustration of Lipsett maneuver

Figure 11 – Image 130

Figure 12 – Image 156 PPPD

Figure 13 – Images 82, 82 PPPD

Figure 14 – Images 99, 100

Figure 15 – Images 104, 105 PPPD

Figure 16 – Images 121, 120 PPPD

Figure 17 – Image 206 PPPD