Dr. Kridel in Vogue Magazine, where he was
the only facial plastic surgeon noted for Texas.
Dr. Kridel voted top doc for women by H Texas Magazine.
Dr. Kridel named as a Super Doctor in Texas Monthly Magazine.
To bring new focus on the radix, our algorithm for the overprojected
nose begins with evaluation of the radix (Figure 3).
Often what is needed to bring the nasal tip back into proper
balance with the remainder of the patient’s profile is a radix
graft rather than deprojection. For that reason, we stress the
importance of the radix by placing it at the top of the evaluation.
In these cases, overprojection is not the problem, and a
simple radix graft will restore balance.
Figure 3. Algorithm developed to help simplify the approach to deprojection. Analysis begins with evaluation of the radix. Asterisk indicates that full-transfixion incision can be added to these procedures to allow further retrodisplacement. MCO indicates medial crural overlay; LCO, lateral crural overlay.
Once the radix has been evaluated and the nose has been
defined as truly overprojected, attention can then be turned to
the next step. If minimal deprojection is needed, the surgeon
can make a simple full-transfixion incision to effect the desired
retrodisplacement. However, when more pronounced
deprojection is necessary, the surgeon must evaluate rotation.
In the classic nasal tripod theory, a standard way to effect
retrodisplacement of the tip is to shorten one or both of the
legs of the tripod (Figure 4).
Figure 4. Computer-generated images demonstrate the Anderson tripod theory. Analysis of the nose must allow for the subtleties. If part A is a normal nose, shortening of the lateral crura (B) results in an increase in rotation and subtle deprojection. Shortening of the medial crura (C) results in a decreased nasolabial angle and retrodisplacement. Finally, if the medial and lateral crura are shortened equally (D), there is a resultant retrodisplacement without change in rotation.
However, if one shortens only
one of the legs, a change in rotation will ensue. One can take
advantage of this principle to accomplish retrodisplacement and
a change in rotation by selecting the proper technique. Kridel
and Konior4 showed that when overprojection is accompanied
by tip ptosis, LCO (which shortens the lower lateral crural
leg) permits incremental retrodisplacement with increased
rotation. On the other hand, MCO, which shortens the medial
crural leg of the tripod, leads to controlled deprojection and
decreased rotation. When used together at the same surgical
intervention (to shorten both tripod legs), MCO and LCO can
effect large amounts of retrodisplacement with little effect on
rotation. These 2 techniques, alone or in combination, accomplish
the needed retrodisplacement in most patients. It is relatively
uncommon to need further deprojection than can be accomplished
with MCO or LCO alone. Large increments of
retrodisplacement can be achieved with these techniques, and
therefore the surgeon needs to consider that the skin–soft tissue
envelope must be able to contract down to the newly deprojected
cartilaginous support structure or one will risk losing
refinement in tip definition.
In those patients with a tension nose deformity, we recommend
that attention first be directed to lowering the overdeveloped
cartilaginous dorsum, which often tents up the tip artificially.
Thereafter the surgeon can follow the same algorithm
for deprojection. In our experience, most of these patients require
increased rotation and experience excellent results when
treated with LCO.
In the rare situations when further deprojection is required
than can be accomplished with LCO or MCO, the surgeon
can choose 1 of 2 separate options. To effect retrodisplacement
while maintaining rotation, MCO can be combined
with LCO. On the other hand, as indicated in the last arm of
our algorithm, it has been our experience that when significant
tip asymmetry is present or when the patient has thick skin,
dome truncation can be used to accomplish much of the same
deprojection in a slightly easier 1-step maneuver. Finally, any
one of the procedures can be combined with a full-transfixion
incision to cause another incremental decrease in projection.
