First, the nose is carefully analyzed with regard to length, projection, acuteness of the nasolabial angle, and tip definition. Significant septal deviations are then corrected via a complete transfixion incision. A complete transfixion incision is preferred, especially when a lowlying caudal septum contributes to inferior tip positioning. This approach allows the surgeon to trim the prominent caudal septum and any redundant mucosa along the membranous septum. To encourage maximal tip rotation, the transfixion cut is usually biased to remove more cartilage anteriorly. The incision line is then closed using interrupted 5-0 chromic suture.
An open rhinoplasty approach is favored with this tip technique as it allows direct visualization and precise restructuring of the alar cartilage complex (Figs 1 and 2).
Fig. 1. Schematic diagram of the operative sequence. Preoperative, Typical alar cartilage configuration in a nose with severe tip ptosis. The lateral crura are long and tend to force the nasal tip inferiorly. A, A conservative cephalic trim can be performed first to promote tip refinement. A straight line cut is made on the central lateral crus that extends between the cephalic crural margin and the caudal crural margin. B, The nasal tip is rotated superiorly. This maneuver shortens the lateral crus (posterior arrow), resulting in overlay of the free transected crural segments. C, The opposed lateral crural segments are stabilized with two 5-0 polypropylene transcartilaginous horizontal mattress sutures placed in a side-by-side fashion. This suturing technique firmly locks the tip into the desired position. Note the triangular cartilage irregularity that develops along the inferior crural margin as a consequence of the anterior lateral crural segment being rotated upward. D, The inferior lateral crural margin is tailored with a scalpel to remove the protruding cartilaginous irregularity. Postoperative, The nasal tip demonstrates significant superior rotation with the lateral crural overlay technique.
Fig. 2. Operative sequence of the controlled lateral crural overlay technique. Top left, Preoperative profile view demonstrating a long nose with nasal tip ptosis. Top right, The alar cartilages are well exposed through the open rhinoplasty approach. The lateral crura are noted to be long with a definite downward orientation. A line (arrows) is marked out on the midportion of each lateral crus between the inferior and superior crural borders. Center left, After the vestibular skin is elevated from below the lateral crus, the cartilage is transected. Center right, The left lateral crus is shortened following suture stabilization of the transected crural margins. As a consequence of this, the left dome is rotated superiorly. Bottom, Immediate postoperative profile changes reveal nasal shortening with significant tip rotation.
Bilateral alar marginal incisions and an inverted V-shaped midcolumellar incision are made. The nasal skin is elevated from the alar cartilages with dissection proceeding superiorly to the radix. Wide undermining along the vertical dimension of the nose is necessary to create a favorable redraping advantage for the lengthy skin sheet that characterizes the long nose with severe tip ptosis.
Dorsal profile adjustments usually precede tip work in order to avoid interrupting the delicately reconstructed nasal tip. Nasal humps are reduced, while saddlelike depressions are augmented with custom-tailored cartilage onlay grafts. A prominent septal angle can encourage inferior tip displacement by forcing the interdomal fibrous attachments, and consequently the tip, downward. In those cases, the overdeveloped septal angle is trimmed in order to release the inferior force on the alar cartilages and allow superior tip rotation, in addition to adjusting the dorsal profile line. Osteotomies are performed if the nose needs narrowing.
Following completion of the dorsal alterations, the cephalic margins of the lower lateral crura are conservatively trimmed to promote tip refinement, with the surgeon taking care to preserve a 5- to 6-mm-wide complete strip. Overaggressive resection of the alar cartilages could compromise tip support, creating a potential for future alar pinching, alar collapse, or bossa formation. The inferior margins of the upper lateral cartilages are trimmed of any remaining scroll or recurvature remnants in order to promote further tip rotation. Conservation is warranted here, however, as overaggressive resection in this region could lead to inspiratory nasal valve collapse.
At this stage the nasal skin is redraped and the tip rotation gained from the preceding ancillary maneuvers is evaluated. Patients with severe tip ptosis usually continue to exhibit a downward nasal tip orientation, making the following alar cartilage restructuring technique necessary. The nasal tip is gently pushed superiorly to a point that appears aesthetically pleasing. The lateral crura are inspected in their new position, and incisions are planned so as to cross the midportion of each lateral crus. The cartilage cut extends in a straight line from the cephalic to the caudal crural margins, with care being taken to stay at least 10 mm away from the dome. An incision located midway between the dome and the free posterior margin of the lateral crus resides below the relatively thick lateral nasal lobular skin, which helps to minimize the risk of long-term external irregularities that occasionally follows traditional dome-division techniques.
Before the cartilage cut is made, the vestibular skin is elevated from the overlying lateral crus approximately 5 mm on each side of the planned rotation point (Fig 3).
Fig 3. Elevation of the vestibular skin from beneath the lateral crus allows safe placement of the transcartilaginous stabilization sutures, thus minimizing the risk of long-term suture extrusion. Additionally, this maneuver releases restrictive tethering forces along the lateral crus to allow complete mobility of the alar cartilages for nasal tip repositioning.
This maneuver releases restrictive tethering forces that could inhibit tip rotation, and it creates a pocket that allows safe placement of buried transcartilaginous sutures during the reconstructive phase of the procedure. Vestibular skin undermining should proceed to the dome if transdomal suturing is needed for supplementing tip refinement
This alar cartilage restructuring process relies on a firmly bound lateral crural flap posteriorly to support the mobilized domes and to keep the tip reliably locked into its new position. To assure this, the fibrous attachments that secure the posterior lateral crural segment to the piriform aperture must not be compromised or disrupted at any time during the procedure.
The previously marked lateral crural incisions are now made to release the domes from their posterior structural connections, thereby allowing uninhibited repositioning of the nasal tip. In patients with adequate preoperative nasal tip projection, the tip complex is rotated superiorly, with care being taken not to alter the domes’ anteroposterior relationship with the facial plane. When overprojection coexists with tip ptosis, the free anterior segment of the lateral crus is both rotated and retrodisplaced over the stationary, posteriorly based lateral crural flap.
Rotation of the tip superiorly functionally shortens the lateral crura, resulting in overlay of the free proximal and distal ends of the transected lateral crus (Fig 4). After the optimal tip position is determined, the integrity of the divided lateral crus is reestablished by securing the overlapped portions of the cartilage with two side-by-side 5-0 polypropylene transcartilaginous, horizontal mattress stabilization stitches. These sutures take advantage of the previously developed vestibular pocket and never violate the vestibular skin, making late extrusion problems rare. The two-point fixation provided by this suturing technique provides excellent stability for anchoring the nasal tip into the desired position.
Fig 4 Overlay of the transected lateral crus functions to shorten the lateral crus, thereby rotating the nasal tip as predicted by the tripod theory.
Following tip rotation and suture fixation, the inferior corner of the lateral crural transection margin will inevitably extend below the existing caudal alar cartilage border. The protruding triangular segment is removed sharply with a blade to create a smooth, evenly tailored inferior lateral crural margin. Failure to excise this piece can result in long-term irregularities along the lateral nostril rim. When a highly arched alar rim is noted preoperatively, this inferior projection can remain in place to help force the arched rim downward, thereby producing a more natural-apperaring alar margin.
Medial crural struts are considered a routine part of this procedure. In addition to solidifying tip support, they assist in lengthening the conjoined medial crural component of the tripod unit, thereby contributing to further tip rotation. A pocket is developed between the medial crura toward the premaxilla with fine scissors. An autogenous septal cartilage strut that extends from the premaxilla to just below the domes is secured into position with a series of buried 6-0 polypropylene horizontal mattress sutures. The nasal skin is once again redraped, and the tip is checked for position and definition. If additional tip refinement is desired, a 6-0 polypropylene transdomal suture is placed in a double-dome3 fashion, once again with care being taken to keep the sutures buried in the previously developed vestibular pocket. Finally, the nasal incisions are carefully closed.
The nose is meticulously taped to provide maximal superior nasal tip support, and a splint is positioned over the dorsum. The splint is removed after 1 week, and the nose is retaped for about 5 days to help support the tip while new fibrous attachments are being developed between the nasal skin and the underlying nasal framework.
