Nasal Tip Surgery

Background

The foundation and support of the nasal tip is based on the shape, strength, and location of the lower lateral cartilages (LLC) as well as their association with the ligaments. In addition, the nasal tip is supported by the upper lateral nostril cartilage, septum, base, and the pyriform aperture [1].

Before surgery, an examination may shed light on nasal tip deformities, including primary and/or other imbalances. Iatrogenic injury to the nasal tip may reduce structural support [2,3]. In addition, cephalic pruning of the LLCs, resection, dorsal reduction, nasal incisions, and/or base resections may contribute to a significant loss in tip protrusion [4][5][6][7][8]. Open rhinoplasty may also result in tip diminution upon soft tissue disruption [9].

A face examination is crucial for diagnosing nasal malformations and nasal tip reconstruction planning. A surgeon uses the symmetrical structure relationship, which is backed by strategic judgment. Numerous indicators, including demographics, cartilage strength, scarring preconditioning, and skin quality, are strongly considered in the preparation stage [10].

History

Nose restoration after an injury has been cited in literature as early as 800BC in the Hindu book, Susruta Samhita.

Interestingly, John Roe, an American surgeon, documented an operation for nose reconstruction and appearance improvement in 1891. He was able to reduce a large protruded nose by exposing the core osteocartilaginous structure using an external incision. Following this, Jacques Joseph, a German surgeon, used internal incisions to restructure the nose, which eliminated any visual scarring. The closed procedure was the gold-standard late into the twentieth century [11].

Good rhinoplasty results hinge on the sound structure and the surrounding skin and soft tissues. The closed approach is often used and the external skin is lifted to modify any malformation. The closed approach is enough to achieve the desired result. However, the procedure can be difficult when using the small incisions within the nostril where conceptualization and workspace are limited [11].

Several surgeons were instrumental in developing the open approach and increasing its popularity during the 1900s [9,12,13]. During this time, the bilateral rimming incision was and the external transcolumellar incision was combined to increase visualization. The open approach allowed for better access and modification of the nasal framework, which was a disadvantage when using the closed approach. The consensus is that open approach creates a better diagnosis and accuracy of bone and cartilage excision, which facilitates a simpler reshaping and modification of the nose [11]. Ultimately, open rhinoplasty affords the opportunity to generate better architectural support and better outcomes [11].

Anatomy

The nose is composed of skin and hard and soft tissue. These anatomic layers contribute to the general nose shape; however, the bone and cartilage are the major contributors. Visually, the attractiveness of the nose is dictated by the nasal tip contour [14].

The alar cartilage delivers sustenance and shape to the tip lobule, which defines the size, shape, and position. During primary rhinoplasty, the tip cartilage is altered to give the desired result [11].

The tip is typically thicker and richer in comparison to other parts of the nose. Variability in tip thickness is common and the surgeon has no control over this variation [10].

The contours of the alar cartilage define the detail of the nasal tip. The alar cartilage is composed of three crura that have two segments that are aesthetically important. The alar cartilage has similarities to a flying bird, with the lateral crura shaped like "wings," and the medial crura forms the body and the feet [15][16][17]. The medial crus is composed of the lower footplate and the superior columellar segment. This segment is vertically oriented and makes up the narrowest part of the columella. There is an association with the nostril and the length of the superior columellar segment [10] (Fig. 97.1).

The domal segment can be found between the lobular and medial segments of the middle crus and lateral crus, respectively. The dome angle is calculated using the medial and lateral crus angle [15][16][17]. The domal segment has a notch and this associates with the soft lobule triangle. Cephalically, the domal segment is attached to its mirroring and the opposite side at the midline. The lateral crus starts at the domal junction and finishes near the sesamoid cartilage, which are positioned at the pyriform aperture ( Fig. 97.1). A previous report has [14] described two important ideas for the visual surface, which are the angle of divergence and rotation. This angle demonstrates the divide of the middle crura and is important for demonstrating tip malformation type ( Fig. 97.2).

Sheen and colleagues [14] describes four markers on the nasal tip: (1) the point of differentiation, (2) the right and (3) left dome, and (4) the columella-lobular junction. A nose that is visually pleasing defines a point of differentiation that has a subtle depression and differentiates the tip from the nasal dorsum. The point of differentiation is a result of the changes within the dome projections and the LLCs and the dorsal septal plane. The major point of the tip is the part that protrudes at the transition zone. The model axis of the tip defining point is 45° from the midline [10,14,16].

Preoperative Evaluation

Cautious examination of the nasal tip is one of the most important presurgery consultations for tip rhinoplasty [10].

Projection

The tip projection is evaluated on a lateral view radiograph by assessing what part of the tip lies anterior to the upper lip. It has been documented that 50-60% of the tip should be anterior, and the exact tip protrusion can be measured as twothirds of the ideal nasal length [18]. In Goode's [19] method to evaluate the tip projection, a 90° triangle is generated by connecting lines from the nasion to the alar-facial groove (Fig. 97.3). Using this calculation, an ideal tip projection ratio to nasal length is 0.55-0.60: 1.0 [10].

Position

The tip position is the location along the dorsal line (N-T). It is important for reducing a long nasal tip ( Fig. 97.4).

Alterations can vividly change the dorsal line, and generate an illusion of an altered tip position [20,21].

Rotation

The tip rotation is an upward/downward movement and composed of a centered radius at the alar crease. The tip rotation is commonly evaluated by the tip angle due to the fact that the nasolabial angle is often altered by adjacent structures [21]. The tip angle is wide and is defined by the vertical line traversing over the alar crease. According to a lateral-view radiograph, a model tip angle is 105 and 100° in females and males, respectively [21].

Tripod Concept

Anderson's tripod concept is an important topic to explain the dynamics and the effects of numerous surgical techniques nasal tip [22]. The fundamental limb of the tripod is formed by the medial crura. The two other limbs are shaped by the lateral crura (Fig. 97.4). An enhancement or reduction in the "tripod leg" length will alter the desired tip [15,[22][23][24][25].

Important Topics for Nasal Tip Surgery [1]

1. Adequate tip projection is 50-60% to the most anterior part of the upper lip.

External rhinoplasty affords the surgeon to have a direct

and precise examination and execution. 3. The skin and soft tissue should be dissected proximal to the cartilage, and tip debulking should be avoided. 4. To give adequate tip definition/projection, modifications to the cartilage should be more aggressive in patients with thick, sebaceous skin. 5. Tip projection may be reduced intraoperatively upon detaching the tip structures. This can be combatted by correctly applying invisible methods. 6. Care should be taken to preserve the character and shape of the tip-supporting structures. 7. Over-reduction of the nasal dorsum is a misguided approach. This method can result in nasal malformation worsening, which requires a more rigorous corrective method. 8. Columellar strut grafts provide a stable and strong nasal base. 9. Suturing methods must be incremental and begin with the medial crural suture, which will secure and stabilize the columellar strut. 10. The skin must be re-draped following each suture positioning to gauge any further modification that may be required to have a successful procedure. 11. Nostril-to-tip imbalances must be evaluated during a preoperative consultation and can be re-evaluated during the procedure. 12. More visible cartilage grafts can be used if the anticipated tip enhancement does not achieve the desire looked according to the surgeon examination.

Operation

Incisions

Precise nasal incisions are essential to a successful rhinoplasty procedure. An inter-cartilaginous incision (IeCI) should be positioned between the ULCs and the LLCs. Presently, this incision has been position approximately 1 mm from the caudal valve on the lateral crura side. The IeCI has a tendency to weaken the major tip support positioned at ULCs and LLCs. The intra-cartilaginous (IaCI) incision traverses the vestibular skin and the lateral crus and is beneficial to enhance the tip rotation while executing the resection of the LLCs. The IaCIs and the IeCIs can be used in combination with a full transfixion incision to visualize and gain access to the anterior septal angle. An infra-cartilaginous incision runs parallel with the caudal border of the LLCs [23,26].

Approaches

The approach is important to surgically expose the skeletal structures. Open or closed surgical methods are useful for tip rhinoplasty. The selection is strategic and is based on the difficulty and the surgeon's expertise.

The Non-delivery Approaches

The non-delivery approaches are achieved via the IeCI incisions. This affords the surgeon to trim the cephal of the lateral crura [10,20,23]. The IeCI incision is completed by cutting proximal to the caudal margin at the lateral middle crura. This conserves a strip to bolster the alar rim. The vestibular skin is dissected away from the cartilage for adequate exposure. With the eversion approach, the vestibular cut is generated at the proximal edge of the LLC without going through the cartilage [27]. The non-delivery approaches allow for a more traditional reduction in volume and minimal tip rotation without destroying the tips. These are recommended for patients with a good tip shape, thickness, and symmetry as well as those that need a slight cephalic volume reduction.

The Delivery Approach

The cartilage borders are outlined using no. 15 blade scalpel and a double-hook retraction procedure in the ala. The cut goes from the lateral to media and parallel to the limen vestibule. Afterward, an incision is generated parallel to the caudal edge of the LLC, stopping at the columellar-lobular junction. The soft tissue is removed from the cartilage, and the technique is repeated on the contralateral side. The two openings are linked at the midline and end with a hemitransfixion incision [27]. In more severe tip malformations, this approach enhances the ability to perform radical tip modifications. The delivery approach includes both the IeCIs and IaCIs with an anterior distribution of the LLCs from the nostril as a chondrocutaneous flap. The benefit is the direct conception of the alar [10,23,26].

External Rhinoplasty

External rhinoplasty enhances the exposure of the sutures to provide the most precise diagnosis of the malformation. It comprises the bilateral marginal incisions, which are joined at the mid-columella. To minimize scarring, a mid-columellar incision is created in an "inverted V," as recommended [28]. All challenging issues that require innovative tip effort are best performed using external rhinoplasty, which affords accurate positioning of sutures and grafts. The foremost drawback of this technique is the risk of scarring after the columellar incision. Most of the time, the scar disappears when the suturing is properly done. Sometimes, the surgical site may heal with an abundance of scar tissue, which can pull the nasal structures in an awkward direction. In this case, additional graft support can be provided. In addition, albeit rare, tip edemas may occur, in particular in patients with thick skin. This can be relieved using steroid injections [10,23,24,26].

Operative Techniques

Cephalic Trim

This is frequently excised and is used preceding the columellar strut insert. In the case of boxy tips, a cephalic trim can be accomplished through the separation of the LLCs from the ULCs at the scroll area. Protection of the LLCs is principally necessary for suturing the tip to the LLCs to improve the tip shape [1].

Attention must be focused on the resection of the cephalic part of the alar. The cephalic lateral crura part is removed in (Fig. 97.5) [29]. Furthermore, removal may cause changes to the lateral crura convexity. The alar cartilage is marked with a marking pen to highlight the incision line. Three points are key for marking the incision: (1) the first 6 mm width should be marked at the widest point on the lateral crura; (2) the mark should be tapered to preserve the tip natural width medially; and (3) the mark should follow the caudal border of the lateral crura to preserve the 6 mm width [29].

Columellar Strut Graft

The columellar strut graft is approximately 4 × 25 mm in size, gives strength to an existing nasal tip, and provides additional support tip projection [30]. It has been used to balance and uphold the medial crura shape, alter the columellar degree, and improve the infratip columella-lobule region. There are two fundamental types of columellar strut grafts, which are the floating and fixed grafts. The floating strut is most common and is implanted amid the medial crura. The medial crura are secured to the strut graft with the medial crural suture. Interdomal sutures are frequently positioned to the first suture anteriorly, thus camouflaging the graft. The floating graft can improve tip protrusion/projection approximately 1-2 mm (Fig. 97.6) [1].

Tip Refinement Grafts

After finishing a suture, small tip grafts may be provided to give more enhanced refining [21]. These grafts have routinely been used to "conceal" tip asymmetry. Presently, their use has been extended to contain enhanced infralobule position and tip definition. If possible, the excised alar cartilage can be used as a graft and has minimal risks in contrast to the rigid septal/conchal cartilage grafts. The two most frequently used regions are transdomal and infralobular regions. The transdomal graft has been used to augment tip definition or enhance tip projection. The grafts should be sutured to the alar cartilage at four corners. The infralobular graft is made into a narrowed "shield" and sutured to the alar cartilage. Prior to suturing, the graft may be elevated to enhance the projection or emphasize the tip position. If the top edge is elevated over 1 mm, then a "cap" must be positioned to give ridge support. Intrinsically, these grafts conceal asymmetries and are easy to remove if there are concerns of aesthetics. If the grafts are vital for an asymmetric tip in thin skin patients, then the addition of a

Septal Extension Graft

Byrd et al. [7] documented the septal extension graft to showcase the improved control and maintenance of the tip projection. This graft can be prolonged at different graft positions, and the graft angle is commonly 45° and the tip portion length mean is 6 mm.

This graft accurately regulates the distinction of the domal height and the dorsum plane. A previous report [31] described the "tongue-and-groove method" as effective in creating and conserving the tip during nasal lengthening surgery [31].

Lateral Crural Strut and Alar Contour Grafts

Lateral crural strut grafts [32] are frequently positioned to reorient alar arch, so the lateral crura are presented in the same plane as the caudal and cephalic margins [32,33]. When the caudal margin of the lateral crura is situated below the cephalic margin (LLC malposition), a parenthesis tip [14] may happen. The repositioning often requires the non- Fig. 97.8 Tip refinement grafts palpable lateral crural strut graft in addition to other techniques ( Fig. 97.9). If excessive lateral crural malformations exist, the lateral crural strut grafts [34] may give support and block the impending loss of integrity [1].