Rhinoplasty Dr Bashar Bizrah Article on: PostRhinoplasty Probleins and Revision Surgery Part 2: Recommended Tip Techniques

The recommended techniques for the tip, nasal pyramid and the dorsum has been fully described in the previous chapters.

1. Endonasal approach with intercartilagenous and marginal incisions. (Figs. 5 – 1,2)

Fig. 13 - 2. Supportive means to compensate for the loss of the tip support. New dome creation, scoring, suture fixation, columellar strut and tip grafts. The new dome creation, columellar and tip graft will achieve adequate tip projection, elevation, definition, symmetry, stretch the alar sidewalls and reduce alar flare. The preservation of the continuity of the caudal alar cartilage margin by the bound lateral to medial crus is obtained in order to avoid notching, retraction and pinching. The preservation of eight mm of vertical lateral crus is presumed to avoid alar collapse, asymmetry, retraction, dimpling and bossae formation.

2. Septoplasty or obtain septal graft. (Fig. 9 – 3 and Fig. 17 – 9)
3. Alar delivery and cephalic trimming of lateral crus with preservation of eight mm of vertical lateral crura. (Fig. 17 – 12)
4. New dome creation or modified vertical dome division and suture fixation. (Figs. 17 -13,14,28)
5. Columellar strut and shield tip graft. (Figs. 17 -15,16)
6. Crura overlay technique as indicated for flared lateral crura and in overprojection. (Fig. 17 -17)
7. Conservative hump removal. (Figs. 17 -10,11)
8. Osteotomies, lateral, medial and as indicated, intermediate and transverse osteotomies in crooked noses. (Fig. 17 – 18)
9. Supratip and dorsum augmentation as indicated in saddling. (Fig. 17 – 21)
10. Alar wedge resection. (Fig. 17 – 25)

Advantages of the recommended tip techniques:

1. Preserve, support, strengthen and refine the natural anatomy of the tip:
   Preserve the continuity of the alar cartilages, strengthen and support the medial crura and dome cartilages by grafts. They achieve tip projection, definition, elevation, rotation, refinement, narrowing and symmetry. (Fig. 13 – 2)
2. Reduce the major problems related to loss of tip support:
   Columellar strut, single and multiple tip grafts, dome apex suture fixation that binds lateral crura to medial crura preserving alar continuity and the use of septalcolumellar sutures. These manoeuvres are an excellent means of tip support. (Fig. 13 – 2)
3. Reduce major problems related to saddling:
   • Conservative hump removal.
   • Dorsum and supratip grafts as needed. Conservative hump removal: Small hump is best not removed until the end of the procedure, after the desired tip profile has been accomplished. For larger humps it is best that they are under-resected at the beginning of the procedure, then after finishing tip plasty, the hump is reassessed and further lowering with fine refinement is carried out if needed. The author recommends not removing the hump in crooked noses until after osteotomies, in many cases the surgeon gets the impression of a large deviated hump because of the overlapping nasal bones, but after osteotomies and bone repositioning we are faced with a small hump or there may be no hump. In such a case, hump removal at the beginning of the procedure may cause collapse and saddling and need major augmentation and reconstruction with prolonged operative time and unpredictable results.
     Dorsum or supratip grafts:
     Single or layered autografts as indicated. In a severely crooked nose, following septoplasty and osteotomies, there is practically minor dorsum collapse, so supratip and dorsum grafts are highly indicated to achieve the desired dorsum profile and to cover dorsum irregularities and depressions.
4. Reduce the need for alar wedge resection:
   In any cases of planned preoperative alar wedge resection, the author may not need to do it at the end of the operation, because the tip plasty technique of new dome creation, columellar strut and tip grafts stretch the alar rim and reduce the alar flare.
5. Natural looking nose:
   A common concern in the author’s office is the patient telling him “I do not want my nose to look like all the others. I usually can spot rhinoplasty across a room”. An operated looking nose (pinched tip, parrot peak, infantile nose, pig snout and arched rim) in the author’s opinion is an unpleasant result. The patient’s face is their own, but their nose is not, it belongs to a surgeon who did too much or too little, usually the former. Although in the author’s practice some patients still request the retrossae over-rotated nose, in particular Europeans, Lebanese and Syrians his policy is to avoid overprojection and over-rotation but to preserve and support the natural anatomy. The desired profile of the tip and dorsum is achieved by the end of the operation before suturing. Sutures are used to secure and support the desired profile that already has been achieved by reduction and augmentation. It is wrong to try and achieve the rotation and projection by only the use of septocolumellar sutures. Sutures will be absorbed in a few weeks, then the tip will drop down.

Problems related to the recommended techniques:

As mentioned before, the problems related to the author’s recommended techniques are usually minor problems that require short corrective surgical manoeuvres (fifteen minutes adjustment, under local anaesthesia, as an out-patient). All the problems are mainly related to wound contracture and healing, graft displacement or absorption, unequal treatment of both sides of the domal cartilages and the dorsum and rarely due to infection. Surgery should be performed with precision in order to achieve equal treatment of both sides of the tip and dorsum. It is not important how much we trim but how much we leave behind in an equal and symmetrical manner.

The factors maintaining tip symmetry are:

1. Symmetrical marginal incision.
2. Symmetrical alar delivery.
3. Equal dome scoring.
4. Accurate positioned dome mattress sutures.
5. Length of columellar strut:
   Should be positioned above the nasal spine to avoid displacement and deviation.
6. Accurately positioning of the superior mattress suture that binds the bilateral
   intermediate crura to the columellar strut.
7. Accurate positioning of midline tip graft.
8. Lateral crura overlay technique for unilateral or bilateral flared lateral crura.
9. Accurate marginal incision closure.

Wound healing and contracture:

The recommended tip techniques correct and reshape the normal anatomy. They create profound, strong, oriented tripod conjoined lateral and medial crura supported by columellar and tip grafts. Therefore, the problems related to wound healing and contracture are usually minor, such as mild notching, pinching or nares asymmetry. These problems are usually sorted out by insertion of small pocket Batten grafts into the affected area (notching, pinching) or by narrowing the wider nare. Since introducing these techniques the author has never had to revise fully any operation.

Common problems: (5-15%)

1. Mild notching, pinching:
   Usually treated by small pocket incision Batten or rim grafts. (Figs. 13 – 5,6)
2. Nares asymmetry:
   Treated by narrowing the wider side. (Fig. 13 – 3)
3. Tip deviation:
   Treated by adjusting the columellar strut, tip graft, Batten grafts on the weak alar
   side or lateral crura overlay technique on the flared side.
4. Bony dorsum deviation :
   Re-osteotomy under local anaesthesia.
5. Dorsum collapse or depression:
   Fill-in pocket grafts.

Fig. 13 - 3. Summary of possible postrhinoplasty problems.

6. Pollybeak:
   Excising the problem tissue (high dorsum septum or supratip scarred tissue) and tip elevation by septocolumellar suture. (Fig. 13 – 8)

These common problems (5-15 % ) have been further reduced to less than 5 % by the author’s newly developed tip procedure (modified vertical dome division without delivery of the lateral crus), because this method overcomes most of the postoperative healing problems along the alar rim. The advantages of this technique will be further validated by the longterm follow-up.