Rhinoplasty Dr Bashar Bizrah Article on: Principles of Tip Surgery Part 7: Tip Asymmetry

Definition:

Unbalanced nasal sidewalls and tip due to anatomical asymmetry of the tip cartilagenous components. (Figs. 8 – 43,47,53,54,64,66,79,80,81,82)

Causes:

1. Nasal septum deviation.
   Caudal septum dislocation causes asymmetry of the tip and nares, due to loss of septocolumella support and displacement of the dome cartilage to the affected side by the deviated superior septal angle. The dislocated caudal septum narrows the affected nostril.
2. Lateral and medial crura deformities. (Fig. 8 – 29)
   – One concave lateral crura and other convex.
   – Weak, short or small lateral crura can be congenital, traumatic, or iatrogenic.
   – Short and weak medial crura which can be congenital, traumatic or iatrogenic.
   – Dome asymmetry:
   One dome sharply defined and the other obtuse.
3. Postcleft tip asymmetry:
   Usually one alar cartilage is underdeveloped, lateral crus is distorted, medial crus is short, the tip deviates to the affected side, the affected side is lower, columellar nostril angle is obtuse, nostril sil is missing and septum deviated toward the normal side anteriorly then toward affected side posteriorly, columella deviated toward the affected side, bridge deviated toward normal side, affected nostril axis is horizontal with wide floor. There may be cleft lip, scar or notch. (Figs. 8 – 79 to 82)

Management:

The aim is to achieve as much symmetry as possible, projection and definition of the tip and alar sidewalls.

Technique:

Our main classical and key technique is (New dome creation/ suture fixation/ scoring/ columellar strut/ tip grafts unit) with the following modifications:

1. Cephalic trimming of the lateral crura on the affected side may not be necessary, the lateral crura may be weak or short.

Fig. 8 - 30. Correction of tip asymmetry:
B. Tip plasty in dome asymmetry
C. Tip plasty in unilateral cleft nose
Note: Half an anchor tip graft and double Batten grafts. /Fig 17 - 23)

2. To straighten and achieve symmetric medial crura with maximum support of tip projection, the I-beam medial crura sandwich graft technique is highly recommended. A portion of the affected lateral crura is borrowed in order to achieve bilateral equal medial crura, columellar struts are inserted between the two medial crura and sutured. Tip grafts are sutured on the caudal borders of the intermediate crura. (Fig. 8 – 30)
3. To achieve strong, profound and symmetrical lateral crura, Batten grafts are considered, conchal and septal grafts shaped similar to lateral crura are positioned to cover the lateral crura surface and vestibular skin of the undermined cartilage. This strengthens the lateral crura and provides symmetrical tip support. Double Batten grafts may be needed. (Fig. 8 – 30 and Fig. 17 – 23)
4. When lateral crura is concave and the other convex. On the concave side, a turnover graft is considered, the excised cephalic portion of the lateral crus is turned over and sutured to the concave surface resulting in a straight and more defined crura. Convex lateral crura may be straightened by suture fixation and scoring. (Fig. 8 -31)
5. When one dome is angulated or buckled and the other obtuse.
   After a new dome creation, scoring and suture fixation, in order to achieve symmetry, the elongated dome is trimmed with preservation of vestibular skin. The trimmed portion is above the level of suture fixation, then a tip graft is applied to avoid a pointed tip and sharp domal edges.
6. A bilateral or unilateral nares narrowing is considered if needed to achieve bilateral symmetrical nares, as much as possible.
7. Single, double, triple, long or special shape, half an anchor or anchor tip graft may be indicated according to the deformity and asymmetry to be corrected. The anchor shaped tip graft elevates the collapsed alar rim. (Fig. 8 – 30 and Fig. 17 – 23)
8. In postcleft patient:
   New dome creation. Suture fixation of normal side, I-beam and undermining affected lateral crus, columellar strut, double Batten grafts (one on undermined vestibular skin and one long to cover both the remaining lateral crus and the graft on vestibular skin). Long tip graft with half an anchor shape. The anchored part is doubled to achieve tip symmetry and prevent alar retraction. The nostril floor is narrowed and usually the old scar revised. (Fig. 17 -23)

Fig. 8 - 31. A turnover graft when one lateral crura is concave and the other convex, the excised cephalic portion of the lateral crus is turned over and sutured to the concave surface resulting in a straight and more defined crura.