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An Objective Evaluation
Hossam M. T. Foda, MD; Russell W. H. Kridel, MD
Objective: To access objectvely the effect of 2 cartilage-modifyng technique, lateral crural steal (LCS) and lateral crural overlay (LCO),on the degree of nasal tip projection and rotation.
Design; A prosprective trial using computer imaging techniques for assessment.
Settings: Half of the patients were seen at a university hospital and the other half at a private practice.
Patients: A selected series of 30 patients seeking rhinoplasty mainly for nasal tip repositioning.Only patients with no history of previous nasal operations were included.
Intervention: All patients were operated on using an external rhinoplasty approach. Only one of the 2 techniques was adopted for eash patient. The technique selected depended purely on clinical judgement.
Main Outcome Measures: The nasofacial angle and the Goode ratio were used to assess tip projection, and the nasolabial angle and rotation angle were used to assess tip rotation.
Resukts: The use of the LCS technique resulted in an increase in both nasal tipprojection and rotation, but the use of LCO technique resulted in an increase in tip retation and a decrease in tip projection (P<.001). Additionally, the LCO technique resulted in significantly higher degrees of rotation than the LCS technique (P<.001).
Conclusion: The LCS procedure is indicatedwhen moderate increase in nasal tip projection and rotation is desired. The LCO technique is useful in patients where severe underrotation is associated with overprojection.
Arch Otolaryngol Head Neck Surg. 1999;125:1365-1370
From the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngollogy-Head and Neck Surgery,Alexandria Medical School, Alexandria, Egypt (Dr Foda); the Department of Otolaryngology and Communicative Sciences, Baylor College of Medicine, and the Department of Otolaryngology-Head and Neck Surgery, University of Texas Health Science Center at Houston (Dr Kridel). Dr Kridel is also a private practice in Houston.
Succesful surgical control of the nasal tipis considered the most dificult step in any nasal plastic procedure. Repositioning of the nasal tips depends mainly on changing the degree of nasal tip projection or nasal tip rotation, or both.
The nasal tip projection refers to the posterior-anterior extension of the tip from the vertical plane. Tip rotation is defined as movement of the tip along a circular arc, with its radiumaintined from the facial plane. Many quantitative methods for measuring the nasal tip rotation and projection have been reported1-3 in the literature.
Nasal tip repositioning techniques can be divided into 2 categories: those that modify the existing alar cartilages and those that augment the nasal lobule with grafts or implants. The lateral crural steal (LCS)4 and lateral crural overlay (LCO)5 are 2 alar cartilage-modifying techniques described for altering the degree of nasal tip projection and rotation.
In the LCS technique, the lateral crura are advanced onto the medial crura, resulting in an increase in the lenght of the medial crura at the expense of the lateral crura. With the LCO technique, the lateral crus is shortened by vertically transecting it and overlapping the cut edges. The aim of our study was to analyze prospectively, in an objective manner, the effect that the LCS and LCO have on the degree of nasal tipprojection and rotation.
RESULTS
The initial study group comprised 9 men (30%) and 21 women (70%); the mean age was 32.5 years. Twenty-eight patients (93%) returned 6 months after the operation for reevaluation of the degree of nasal tipprojection and rotation.Of these 28 patients, 18 were operated on using the LCS technique and 10 using the LCO technique. Further follow-up of 14 patients 2 years later showed no considerable change in the values of tip projection and rotation that were recorded at 6 months' follow-up.
EFFECTS ON NASAL TIP PROJECTION
The use of the LCS technique was associated with a posoperative increase in the degree of nasal tip projection, as evidenced by the significant increase in the postoperative values of both the GR and NFaA (Table 1) . On the other hand, using the LCO technique was associated with a decrease in the degree of nasal tipprojection, as proved by the significant drop in postoperative values of GR and NFaA (Table1).
PATIENTS AND METHODS
PATIENTS
Thirty patients requesting rhinoplasty with tiprepositioning were enroled in the study.Only patients with no previous nasal surgery were included, and each was operated on using either LCS or LCO as the only tip-modifying technique. The decision as to wich technique to use was made according the preoperative clinical evaluation of the patient´s nadal tip deformity.
All patients were subjected to computer-assisted nasal analysis using imaging software (Uniplast Windowriter, version 1.0; United Digital Systems; Winston-Salem, NC) on an IBM-compatible personal computer. The system also included a video camera, grapgics tablet and stylus.
With the patient seated at a fixed distance from the video camera, the profile view of the face was captured with the head in a natural position. The images were the analyzed, starting by indentifying the standard reference points1-3 (Figure 1, A) needed for evaluating the degree of nasal tipprojection and rotation: the glabella, the most anterior portion of the forehead in the midsagital plane; the nasion, the most posterior point at the root of the nose in the midsagital plane; the tip, the most anterior point of the soft tissue chin; and the alar point, a point on the alar-facial groove where a horizontal line passing through the tip intersects with a vertical line dropped from the nasion. Quantitative evaluation of the degree of nasal tip projeciton and rotation was then performed using the cephalometric menu of the software, wich automatically measures the distance between any 2 pints or the angle between any 3 points.
The nasofacial angle (NFaA) and the Goode ratio (GR) were used to evaluate the nasal tip projection. The NFaA was measured at the intercept of the glabella to the pogonon line with the nasion-to-tip line (Figure 1,D), and the GR was calculated by dividing the distance from the nasion tothe tip (Figure 1,C). The nasal tip rotation was measured using the nasolabial angle (NLA) and the tip rotation (RA) (Figure 1, B). The NLA was measured at the intercept of the columellar point to the subnasale line with the labrale superius line, and the RA was measured at the intercept of the tip to the columellar point line with a line tangent to the columella.
At a minimum of 6 moths after surgery, the patients´images were recapturated by the computer imaging system, and the previously calculated measurements were reevaluated and compared with their preoperative values. (Figure 2, A and B) .
SURGICAL TECHNIQUE
The external rhinoplasty approach was used in all patients because it allows an accurate, unobstructed appraisal of cartilaginous framework of the tip in its natural, undistorted position, and it permits precise modification and suture fixation of the alar cartilage complex. This approach also help to maintain nasal tip support by avoiding the disruption of tip support mechanisms that happens when using endonasal approaches.
Bilateral alar marginal incisions are connected by an inverted-V transcolumellarincision, and the columellar skin flap is elevated off the medial crura. The skin elevation is continued upward over the bony cartilaginous pyramid in the avascular plane just superficial to the perichondrium and periosteum until reaching the nasofrontal angle. Any dorsal adjustments needed are made befire modifying the nasal tip cartilages to reduce the risk of inadvertent disrupsal tip cartilages to reduce the risk of inadvertent disruption of the delicate reconsructed alar cartilage complex. To maintain the nasal tip support,the medial crura are secured to each other using 5-0 polydioxanone horizontal mattress sutures. In patints with wide lateral crura, a conservative cephalic trim of the lateral crura is performed, leaving a strong, intact caudal margin of al least 5 mm.
Lateral Crural Steal
The vestibular skin is undermined from the unsurface of the alar cartilage, starting at the junction of the medial and lateral crura (Figure 3, B), then proceeding both laterally and medially for about 5 mm to ach side to allow free lateral crural mobilization without restriction by the underlying skin attachments. The lateral crus is advanced medially in a curvilinear fashion on to the medial crus and fixed in its new position using 5-0 permanent mattress sutures just bellow the newly established dome (figure 3, C). following independent creation and fixation of the right and left domes, assitional narrowing and refinement are accomplished using a transdomal mattress suture placed through the entire tip complex .
Lateral Crural Overlay
An incision is planned so as to cross the midportion of the lateral crus on each side (Figure 4, B). The cartilage cut extends in a straight line from the cephalic to the caudal crural margins. Before the cartilage cut is made, the vestibular skin is elevated from the undersurface of the lateral crus for about 5 mm on each side of the planned cartilaginous incision. The free proximal and distal ends of the transected lateral crus are then overlapped and fixes with a 5-0 permanent transdomal suture is placed in a horizontal mattress manner to approximate the domes.
After the nasal tip modifications are completed using the LCS or LCO technique, the nasal skin is redraped to its normal anatomic position, and the transcolumellar and marginal incisions are meticulously closed. Careful taping is needed tomaintain proper positioning of the reconstructed tip complex, and a metal splint is positioned over the dorusum. The splint is removed after 1 week, and the nose is retaped for another 5 days to help support the tip while new fibrous attachments are being developad between the nasal skin and the underlying nasal framework.
Figure 1. Reference points used for evaluating nasal tip projection and rotation (A) and the methods for measuring (B) the rotation angle (RA) and nasolabial angle (NLA), (C) the Goode method, and (D) the nasofacial angle. G indicates glabella; N, nasion; TP, tip; Cm, columellar point; Sn, subnasale; Ls, labrale superius; Pg, pogonion; and A, alar point.
Figure2. Computer.assisted evaluation of the nasolabial angle (NLA), rotation angle (RA), the Goodle ration (GR), and the nasofacial (NFaA)preoperatively (Preop) (A) and postoperatively (Postop) (B).
Figure2. Computer.assisted evaluation of the nasolabial angle (NLA), rotation angle (RA), the Goodle ration (GR), and the nasofacial (NFaA)preoperatively (Preop) (A) and postoperatively (Postop) (B).
Figure2. Computer.assisted evaluation of the nasolabial angle (NLA), rotation angle (RA), the Goodle ration (GR), and the nasofacial (NFaA)preoperatively (Preop) (A) and postoperatively (Postop) (B).
*LCS indicates lateral crural steal; LCO, lateral crural overlay; GR, Goode ratio; and NFaA, nasofacial angle. Significant at P<.001.
EFFECT OF NASAL TIP ROTATION
The use of the LCS and LCO techniques was associated with an increase in the degree of nasal tip rotation. This increase in the degree of rotation evidenced by the significant increase in the posoperative values ogf the NLA and RA (Table 2). When the degrees of rotation achieved by using both techniques were compared, the mean increase in the RA using the LCO technique was significantly higher than using LCS technique (t=4.33).
COMMENT
The successful correction of a nasal tip deformity depends on an accurate assessment of the deformity and the proper selection of the surgical technique to be used. A clear understanding of the effects that each technique has on the dynamics of the nasal appropiate surgical technique to use for each patient.
Despite the large number of publications dealing with nasal tip-modifying techniques, few attempts6-9 have been made to objectively evaluate the effects that any technique has on the position of the nasal tip. Rather, the methods of assessment were always based on subjective judgement by comparing preoperative and postoperative photographs.This was in part because only primitive tools were available to conduct an objective assessment in a standardized reproducible manner. The recent avances in computer graphics technology have made it possible to analyze objectively and accurately the effects of different surgical techniques. In the present study, we used computer imaging to assess, in a quantitative manner, the effect that LCS and LCO techniques have on the degree of nasal tip projection and rotation. To increase te calidity of our observations, more than 1 method of measurement was used to assess tip projection and rotation.
The GR and NFA were used to measure nasal tip projection. The GR, wich relates the tip projection-measured from the alar point to the tip-to the nasal lenght. On the contrary, the NFaA will increase only if the nasal tip is moved forward, provided that the nasion is not surgical altered, wich was the case in all the patients included in this study.
For the measurement of nasal tip rotation, the NLA and the tip RA were used; the NLA is measured at the subnasales
Figure 5. Preoperative view (A) of a patient showing an inadequate degree of tip projection and rotation. The same patient 2 years after the lateral crural steal technique (B) shows maintenance of the gain in projection and rotation.
Figure 6. A patient with an overprojected and underrotades nasal tip before (A) and 1 year afeter (B) being operated with the lateral crural overlay technique.
