Cartilage splitting techniques in rhinoplasty
Specific Applications of Cartilage Splitting Techniques in Tip Plasty
Division of lower lateral cartilages in rhinoplasty has long been maligned for producing unnatural results and unpredictable outcomes. The original manifestation of this technique resulted from the Goldman tip rhinoplasty, stereotyped by the narrowed, pinched appearing noses of previous decades. However more recently, use of several modifications of this technique in the properly selected patients have minimized negative stigmata associated with cartilage splitting. With proper execution of technique and appropriate selection of patients, lower lateral cartilage splitting techniques can provide consistent, natural appearing results.
Goldman originally described his technique in a 1957 landmark paper. (1) Transecting the domes across the apex, as he described it, was a novel alternative technique intended to help refine and maintain natural nasal tip appearance without the requirement of grafts or implants. Unfortunately, dividing the cartilage without reapproximation often led to tip asymmetries and an overly narrowed nasal tip. Since this first description, newer insight into nasal tip dynamics has broadened the application and use of division of lower lateral cartilages as an adjunctive tool in rhinoplasty.
Anderson originally described the nasal tripod theory to provide a simple explanation of tip dynamics. (2) According to this model, the cartilaginous framework of the lower third of the nose is compared to a tripod that is attached to the facial frontal plane. The two individual lateral crura represent two legs of the tripod, and the conjoined medial crura and caudal septal attachments correspond to the third leg. By lengthening or shortening any or all legs of the tripod, the changes that will be effected in tip projection and rotation can be predicted. For instance, techniques that augment or lengthen the medial crural segment enhance projection. Shortening the medial crura or disrupting their septal attachments without reduction of lateral crural length, decreases projection and rotation of the nasal tip. Shortening the lateral crura and maintaining or lengthening the medial crural segment would be expected to increase rotation.
Although a useful model, the surgeon must however recognize that it is only a model and must be tailored for each individual nose. Nasal tip dynamics are based on many intervening factors which include the consistency and shape of the lower lateral cartilages, the soft tissue envelope, and the septum. For example, a thick-skinned ptotic nose with long lateral crura and short, weak medial crura, may not rotate as expected with lateral crural overlay due to the thick skin of the nose and the small size of the medial crura. Conversely, in a patient with a long medial crura and short lateral crura, counterrotation may prove difficult.
In general, techniques that preserve the integrity of the alar cartilage anatomy and minimize excision should be considered as first-line methods of modifying the nasal tip. However, cartilage splitting techniques can be effective in specific nasal deformities. Proper nasal analysis allows the surgeon to identify which area is problematic and the subsequent surgical solution. Recognition of variant nasal anatomy can be difficult for the inexperienced rhinoplasty surgeon, but is often necessary to achieve an acceptable rhinoplasty outcome. This article will help in analyzing recognition of these specific nasal deformities in which cartilage splitting techniques may improve the ultimate outcome. In addition, technical details will be given in order for the reader to produce the achieved results.
Excessively long lower lateral cartilage
Typically, in patients with excessively long lateral crura relative to medial crus length, the nose will tend to have a downward angulation to it or “hooked” appearance. The patient with an overly long lateral crus patient may exist coincidentally or independently from the tension nose or overly long nasal septum, and must be distinguished from a ptotic nasal tip. The ptotic nose is caused by relaxation of the relationship between the lower lateral cartilages and septum. The ptotic nose will not have a downward snarl in appearance and the nasal tip support is often weak. The nasal tip will often rotate on physical exam without difficulty. On the other hand, in the patient with excess long lateral cruses, the surgeon will encounter resistance to tip elevation on physical exam due to the length and strength of the lateral crus.
The surgical solution to correct overly long lateral crura is to shorten their length. Surgeons who neglect to address the long lateral cartilage with appropriate modification will invariably lead to an unsatisfactory, underrotated nasal tip.
The lower lateral cartilages can be shortened by them laterally without overlap. Kridel and Konior first described the technique of lateral crural overlay. (3) In their original description, the lateral crura are separated from the underlying vestibular mucosa. Then, precise division of the lateral crus lateral to the dome is performed and overlapped. Another technique, described by Adamson and others is to divide the attachments of the most posterior part of the lateral crus, the hinge, from the pyriform aperture, with or without excision of the cartilage. (4) However, this may lead to cartilage asymmetries and predispose the patient to external nasal valve pinching and collapse.
The authors (MC, AS) prefer to use nonabsorbable suture tied away from the vestibular mucosa. Preservation of vestibular mucosa is necessary to prevent possible cartilage erosion or infection. Splitting occurs lateral enough from the dome so that dome binding sutures can be placed without difficulty and excess bulk is not created in the domal area. If the split occurs too far lateral, aka near the hinge region, the there is less impact in deprojection and rotation.
By shortening the posterior portion of the nasal tripod, the lateral crural overlay will both deproject and rotate the nose. Its ideal use is in the long nose with an acute nasolabial angle. Most patients with excessively long lateral cartilages tend to have flat, long, firm cartilages. The exceptions are those with long and convex lateral crura. The overlap of the cartilages may reduce convexity of these cartilages in select cases and obviate the need for lateral crural strut placement.
Prominent infratip lobule
The prominent infratip lobule is a difficult challenge to the rhinoplasty surgeon. There have been a paucity of articles published describing infratip lobule deformities and their subsequent management in the scientific literature.
The relationship between the infratip lobule and the surrounding tip structures (nasal tip lobule, columella, soft tissue triangles) is complex. The terminology to describe nasal topography is often vague and inexact. The nasal tip lobule is often seen as a diamond shaped structure from the frontal view with the domal highlights or tip defining points serving as apices of the diamond. The columella is the corresponding soft tissue medial to the apex of the nostrils on base view. The infratip lobule is located between the nasal lobule and the columella and is most typically “lunate” (crescent moon) shaped in appearance. (Figure 1) Confusion may arise on lateral view of the nose of identifying the infratip lobule. The apex of the nostril is typically inferior to the normal ovoid arch created by the nostril. The infratip lobule corresponds to the same latitude as the apex of the nostril and not the more superiorly placed arch of the lower lateral cartilage.
The lateral view on the ideal nose will demonstrate a subtle double break, with a gentle angulation at the columella. The prominent infratip lobule will produce a more prominent curve in this region. On frontal view, the prominent infratip lobule will manifest clinically as a bottom heavy nasal tip. The patient tends to have an unrefined quality to the nose. This problem must be distinguished from a hanging columella. Appropriate anatomic analysis will demonstrate that the prominent infratip lobule will typically be located superiorly and anteriorly in relation to a hanging columellar deformity.
The structure primarily responsible for the prominent infratip lobule length is the overly long intermediate crus. (Figure 2-6) A variety of techniques are available for correction of the prominent infratip lobule. These include sutures placed between the internal crus and the septum, with or without strut graft. However, this can leave the infratip lobule looking too straight with loss of the elegant double-break. Overlap of the cartilages will shorten the intermediate crus while preserving a double-break. This can be accomplished by division just inferior to the dome with overlap of the underlying cartilage. Overlap of cartilages underneath the domes can create abnormally round domal highlights. Intradomal sutures can compensate for this. The overall effect of reduction of the prominent infratip lobule is decrease in projection and yield a variable degree of rotation caudally.
Gunter, Rohrich, and Friedman describe overlap of the intermediate crus in “excessively vertical” intermediate cruses and note movement of the anterior columella superiorly. (5) Patients who benefit from this procedure are those with overly projected, overly rotated noses.
Long medial crus
The overly long medial crus will lead to an overly projected nose, sometimes termed the “Pinocchio nose”. In patients with overprojection of the nose, the diagnosis of the cause is paramount. (Figure 7-9) Excess caudal septal height can contribute to the extra projection as well.
Any maneuvers which decrease projection may be used in management of the long medial crus. The surgeon should set the projection of the nasal base by the technique which they are most comfortable. The division and overlap of the medial crus is incorporated when other maneuvers do not sufficiently deproject the nose.
Overlap of the medial crus as a means of deprojecting the nose was first described by Lipsett. (6) The original procedure involved division of the medial crus inferior to the dome without overlap and reconstitution of the cartilages through an endonasal approach. Division of the dome medial to the apex created a laterally based chondrocutaneous flap consisting of part of the medial crus, the dome, and all of the lateral crus with the underlying mucosa and vestibular skin coverage. In repositioning the medial edge of the chondrocutaneous flap more posteriorly, the overprojected, acutely angled nasal tip was retroactively displaced and reshaped. The chondrocutaneous flap and skin were reported to be “already adhered” after 10-12 h using tape and a compression sling; however, the durability of this reconstructive technique must be questioned.
The modern adaptation, aka the Lipsett Maneuver, is usually employed through an external approach with overlap and suture reconstitution of the medial crural cartilages. This procedure will provide further strength to the medial crus due to the overlap. Most patients will need either a columellar strut or tongue in groove procedure to further stabilize the nasal base.
Foda describes the alar setback technique in which he combines a medial crural overlay with a lateral crural overlay for addressing the overly projected nose. (7)
Asymmetric Nasal tip
The asymmetric nasal tip is the likely sequlae of prior rhinoplasty. However, it may occur naturally. (Figures 10-12) Nasal tip alignment may require overlap of the imbalanced nasal elements. Challenges occur in revision rhinoplasty in that extensive scarring may be present under the vestibular mucosa. Scarring under the vestibular mucosa occurs rarely, after procedures such as lateral crural strut placement and lower lateral cartilage repositioning where the vestibular skin has been dissected free from the under surface of the lower lateral cartilages.
Flared footplates are a common source of complaint in revision rhinoplasty patients. Guyuron found the distance between the footplates ranged from 7.5 to 15 mm and the average length was 5.81 mm. (8) Bilaterally flared footplates may create the illusion of a shorter columella. Unilateral flaired footplates will detract from the overall symmetry of the nose. On base view, the patient will usually have an overly wide nasal base. It is important to distinguish caudal septal deflection from footplate flair, which can be done easily by palpation on physical exam. However, a flaired footplate is often associated with a deflection of the caudal septum.
Most footplate flairs can be addressed with a conservative footplate suture is appropriate in certain patients. The ideal use is underprojected nose with prominent footplate flair. The suture will reinforce the medial crus providing strength to stabilize and sometimes increase projection. For medialization to last, the soft tissue from the footplate and the posterior septum is divided, creating a potential space into which the footplates can be sutured. Guyron found that divergent footplates were often associated with retracted columellar base and spine, and that approximation without resection of soft tissue led to narrowing of the columella base with caudal advancement. (8)
In the overly projecting nose with an obtuse nasolabial angle and flaired footplates, division of the footplates may be preferred to help with deprojection and counter-rotation. The divided footplate then may be reconfigured with a suture across the columella or completely removed. Excising the footplates completely is rarely indicated and may lead to loss of projection.
Prior to excision of the cartilages, the natural dome is identified and marked. When overlapping cartilages, precise amount of overlap is measured with calipers. The overlap takes place with 6-0 permanent horizontal mattress suture. The horizontal mattress suture should be placed so that the overlapping cartilaginous segments act as a fortified singular unit of cartilage, free from any interfragmentary motion. Nylon is preferred because it is non-reactive and nonabsorbable. The cartilage should be separated from the underlying vestibular mucosa and the knot should be tied away from the vestibular skin and cut without a tail to minimize the risk of suture extrusion.
Discussion points/ Conclusion
Nasal analysis plays a key role in determining a rational approach to rhinoplasty. Identifying patients with specific variant anatomy (aka “hooked nose”, flared footplate) will allow an appropriate surgical solution to take place.
Cartilage splitting techniques can be performed with either an open or endonasal technique. However, open techniques maximize visualization and allow easy exposure for these techniques.
Division of the lower lateral cartilages requires precision and introduces another variability of healing in the patient’s surgical outcome. However, in the patient with the overly long lateral, medial, or intermediate crura, it is a powerful technique that effectively and reproducibly corrects aesthetic flaws. The risk of visible stigmata of rhinoplasty is minimized by precise division and reinforcement of the lower lateral cartilages while minimizing excision. Cartilage splitting techniques, maligned for many years, are now a necessary tool in the successful rhinoplasty surgeon’s armamentarium.
1. Goldman IB: The importance of the mesial crura in nasal-tip reconstruction. AMA Arch Otolaryngol 1957 Feb; 65(2): 143-7.
2. Anderson JR: The dynamics of rhinoplasty, in Proceedings of the Ninth International Congress in Otorhinolaryngology. Excerpta Medica, International Congress Series 206. Amsterdam, Excerpta Medica. 1969.
3. Kridel RW, Konior RJ. Controlled nasal tip rotation with the lateral crural overlay technique. Arch Otol Head Neck Surg 1991. 117(4): 411-5.
4. Adamson PA, McGraw-Wall BL, Morrow TA, et al: Vertical dome division in open rhinoplasty. An update on indications, techniques, and results. Arch Otolaryngol Head Neck Surg 1994 Apr; 120(4): 373-80
5. Gunter JP, Rohrich RJ, Friedman RM. Classification and correction of alar-columellar discrepancies in rhinoplasty. Plast Reconstr Surg 1996 97(3):643-8.
6. Lipsett EM: A new approach surgery of the lower cartilaginous vault. AMA Arch Otolaryngol 1959 Jul; 70(1): 42-7
7. Foda HM. Alar Setback Technique: A Controlled Method of Nasal Tip Deprojection. Arch Otolaryngol Head Neck Surg. 2001;127:1341-1346.
8. Guyuron B. Footplates of the medial crura. Plast Reconstr Surg. 1998 101(5):1359-63.
“The nose should fit the face”
A strong jawline would suggest a stronger nose.