Rhinoplasty Dr Bashar Bizrah Article on: Principles of Tip Surgery Part 2: Modified Vertical Dome Division Without Delivery Of The Lateral Crus (The Bizrah Modification)

The Joseph rhinoplasty, as discussed, has many unpleasant effects, the dropped tip, pollybeak, asymmetry, alar collapse, hanging columella and wider nares. The Goldman’s tip has also ended in problems such as pinching, notching, retraction, asymmetry, alar collapse and pointed tip. However, the author high}y recommends the technique of new dome creation, scoring, suture fixation, columellar strut and tip grafts. It has the most predictable results, because of the preservation of the continuity of the lateral crus and obtaining a strong tripod of conjoined lateral to medial crura supported by columellar and tip grafts, thus reducing very much the possibility of asymmetry, alar collapse, dropped tip, pinching, notching and alar retraction. However, because of the lateral crus marginal incision and lateral crus delivery, there may be unavoidable minor problems due to wound healing and contracture such as mild notching, pinching and dimpling. In order to avoid even these minor problems, the author has developed a new technique which is largely based on the Goldman’s tip and the I-beam of medial crura but without lateral crus delivery. This is in order to keep an intact alar rim and avoid any problems along the alar rim such as notching, retraction, collapse or asymmetry. The author has been applying this technique for the last two years. In his opinion this technique is very useful to achieve tip projection, definition and refinement in the following situations:

1. Tip underprojection
2. Short columella
3. Mild tip bulbousity
4. In revision cases: when lateral crus delivery is technically difficult.
5. The congenital pre-existing mild alar pinching and dimpling. In these situations, alar delivery will cause more deformity.

Technique:

The principles are:

– Vertical dome division
– Medial crus delivery and I-beam
– No lateral crus delivery (Figs. 17 – 28, 29)

1. Marginal columella incision from mid-columella and up to the level of the external soft triangle at junction of intermediate to lateral crura. There is no marginal incision along the caudal margin of the lateral crura.

Fig. 8 - 18. The Bizrah modification of vertical dome division without delivery of lateral crus. Columellar strut is inserted into a pocket and sutured to both medial crura in order to obtain tip projection and definition. /Figs. 17 - 28,29)

Fig. 8 - 19. Bizrahs technique for underprojected tip
- Vertical division of lateral crus.
- Medial crura delivery through columellar marginal incision.
- No lateral crura delivery - no lateral crura marginal incision.
- Columellar strut is inserted in a pocket between the delivered medial crus.
- Tip graft sutured to the caudal margin of the intermediate and medial crura

Fig. 8 - 2 1. A 25-year-old man w ith a wide, long nose and underprojected tip. Situation was managed by medial and lateral osteotomies, modified vertical dome division (Bizrahs modification of the Gold mans tip), medial crura delivery, columellar strut and tip grafts without delivery of the lateral crus.

2. Vertical dome division:
   The incision is now extended from the external soft triangle at a right angle backwards to meet the internal soft triangle dividing the vestibular skin and cartilage.
3. The bilateral intermediate and medial crura are delivered to one side.
4. A pocket is created between the medial crura and a columellar strut is inserted and sutured to both medial crura. (Fig. 8 -18)
5. When required a shield tip graft is positioned and sutured to the caudal margin of the intermediate and medial crus. The grafts should be crushed and bevelled in order to avoid demarcation. (Fig. 8 -19)
6. The re-oriented complex structure of medial and intermediate crura with columellar strut and if required tip graft is pushed back inside the nose into a normal position. The transfixion and marginal incisions are closed with 4/0 Dexon. Then two septocolumellar sutures are used to fix the medial crura/ columellar strut complex to the caudal septum.

Advantages:

1. Preservation of the entire alar rim of the alar sidewalls. Thus preventing, alar retraction, notching, collapse, dimpling and asymmetry.
2. The trimming of cephalic lateral crus is made more visible, more accurate and has better control.
3. Less postoperative oedema and crustation.
4. More natural looking alar sidewalls.
5. Stretches the alar sidewalls and reduces the alar flare.
6. Achieves adequate tip projection, elevation, definition and refinement.
7. Corrects mild to moderate tip bulbousity, when combined with conservative retrograde cephalic trimming of the lateral crura (ten mm to be preserved).
8. Corrects overprojecting tip. This is achieved by conservative trimming of the proximal ends of the lateral crura and superior ends of the intermediate crura. The author believes that lateral and medial crura overlay technique is best for correction of the overprojected tip.

Disadvantages:

1. It should be avoided in tip asymmetry.
2. Not recommended in situations of boxy and trapezoid tip.
3. Not suitable for drooping tip.
4. It should be performed in a very precise, accurate and symmetrical way. Otherwise, unilateral or bilateral alar collapse, pinching, notching or retraction might occur, which will require revision with Batten grafts. Anyone unwilling to work carefully to attain a stable symmetrical structure should not attempt this technique.
5. Although very mild pinching is expected, because there is a small area just lateral to the dome which is not supported by cartilage, but this mild pinching may be desirable for more tip definition.

Special inter-lateral crus suture for Broad Fatty Tip

A mattress suture may be applied joining the two medial ends of the lateral crus when using the Bizrah modification. Thus, the bilateral lateral crus will be joined in the middle of the dome obtaining tip narrowing an_d stretching the alar sidewalls and the nares. It provides a strong cartilagenous support for the tip and prevents any unsupported area of the skin on the dome and medial alar rim, reducing any possible chances of notching and pinching. As well, the joined lateral crus at the dome acts like a cap graft preventing over-rotation of the tip graft. The author found this mattress suture very useful in a broad fatty tip as it stretches the alar sidewalls and reduces the flare of the nares. Together with the modified tip technique of vertical dome division without lateral crus delivery, it achieves adequate tip narrowing and definition in a conservative manner with little postoperative oedema.

Follow-up:

The two-year follow-up of over one hundred twenty cases of the Bizrah modification has shown outstanding results. The author believes that the future will prove that this is the technique of choice for accomplishing tip projection and refinement in selective cases. (Figs. 8 – 20,21,49,65,74,77,78)