Bilateral alar marginal incisions and an inverted V-shaped midcolumellar
incision are made. The nasal skin is elevated from
the alar cartilages in the supraperichondrial avascular plane up
to the radix. Wide undermining is necessary to allow a favorable
redraping advantage for the lengthy skin–soft tissue envelope
that characterizes the overprojected nose. Dorsal profile
adjustments, if needed, precede tip work finalization to
minimize disruption of the reconstructed nasal tip.
Cephalic trim of the lower lateral cartilages, leaving at least
a 6-mm-wide strip (depending on the intrinsic cartilaginous
strength), is then performed to promote tip refinement. The
level of deprojection necessary is then reevaluated. When
increased rotation is desired, LCO is performed (Figure 5).
Figure 5. Lateral crural overlay (LCO) allows for controlled retrodisplacement along with increased rotation. Computer-generated images (A and B) illustrate a representative result of LCO. Preoperative and 18-month postoperative photographs show the frontal (C and D, respectively), profile (E and F, respectively), base (G and H, respectively), and three-quarter (I and J, respectively) views of a patient who underwent LCO, cephalic trim, full-transfixion incision, and double-dome suture.
The nasal tip is repositioned to an aesthetically pleasing position.
The incisions in the repositioned lateral crura are then
planned so as to cross the central-lateral portion of each lateral
crus. The cartilage cut extends in a straight line from the
cephalic to the caudal crural margin, with care taken to stay at
least 1 cm away from the dome. Before making the cartilage
cut, the vestibular skin is elevated from the overlying lateral
crus for approximately 5 mm on each side of the planned rotation
point. Release of the vestibular skin also releases tethering
forces that could restrict tip rotation, and it allows for safe
transcartilaginous suture placement. In patients who have
overprojection and downward displacement of the tip, the free
anterior segment of the lateral crus is rotated and undergoes
retrodisplacement over the stationary, posteriorly based lateral
crural flap. With the overlay, superior rotation of the tip functionally
shortens the lateral crura. The integrity of the divided
lateral crus is then reestablished with 6-0 permanent transcartilaginous,
horizontal mattress sutures. One can judge the
resultant rotation and make adjustments in the amount of
overlay and placement of the sutures as needed. After tip rotation,
the inferior corner of the lateral crural transection margin
may extend below the existing caudal alar cartilage margin and
may be excised with a blade to create a smooth inferior alar
cartilage border.
On the other hand, if the nose is overrotated or if the reason
for increased projection is secondary to overelongated medial
crura, the decision is made to proceed with MCO
(Figure 6).
Figure 6. Medial crural overlay (MCO) allows for controlled retrodisplacement with a decreased nasolabial angle. Computer-generated images (A and B) illustrate a representative result of MCO. Preoperative and 1-year postoperative photographs show the profile (C and D, respectively) and base (E and F, respectively) views of a patient who underwent MCO, cephalic trim, and double-dome suture.
Incisions cross the central portion of each medial
crus. Unlike other Lipsett-like transection techniques,MCOrequires
no cartilage to be excised. As such, there is no need to predetermine which portion of the medial crus needs to be removed.
As with LCO, before making the cartilage cut, the vestibular
skin is elevated from the overlying medial crus, therebY permitting safe transcartilaginous permanent suture placement.After rechecking the ideal tip projection, the integrity
of the medial crus is reestablished by overlapping and stabilizing the cartilage with 6-0 permanent transcartilaginous, horizontal
mattress sutures. The 2-point fixation obtained with this
suturing technique gives excellent long-term stability while allowing
deprojection of the nasal tip into proper position. Moreover,
the overlapping of the medial crural segments adds structural
strength to the medial crura.
When more deprojection is required than can be effected
by LCO or MCO, a combination of both techniques can be used
to effect retrodisplacement of the nasal tip without significant
changes in tip rotation (Figure 7).
Figure 7. Lateral (LCO) overlay and medial crural overlay (MCO) can be combined when more significant deprojection is needed. Computergenerated images (A and B) illustrate a representative result after LCO and MCO are combined. Preoperative and 1-year postoperative photographs show frontal (C and D, respectively), profile (E and F, respectively), and base (G and H, respectively) views of a patient who underwent LCO, MCO, full-transfixion incision, and cephalic trim.
In these cases, LCO precedes
MCO. This order allows for control over the extent of
deprojection and allows the surgeon to exactly determine what,
if any, changes are desired in tip rotation.
In those patients who have overprojection and preexisting
tip asymmetries or overly thick skin, the surgeon may decide
to proceed with dome truncation, as described by Kridel and
Konior5 (Figure 8). With dome truncation, after conservative
cephalic trim is completed, the vestibular skin underlying
the angle of the domes is elevated for approximately 1 cm. Blunt
forceps are then introduced between the vestibular skin and
the dome cartilages. The alar cartilages are then elevated behind
the existing domes to delineate the precise location of the
tip-defining point. With the alar cartilages tented up, the overprojected
distance is subtracted from the most forward projecting
point of the domes and marked. The measurement is
critical as it marks the new tip-defining point, which in turn
will define the ultimate tip projection.
A 6-0 permanent mattress suture is placed across the dome
through the lateral and medial crura, with care taken to bury
the suture within the vestibular pockets. This suture is placed
immediately posterior to the desired defining point of the tip
and must be oriented parallel to the intended dome plane of
dome truncation. By placing this suture just below the proposed
truncation, the relationship between the lower lateral and
medial crura is maintained so that rotation will remain unchanged.
The overprojected alar domes are then excised by transecting
the lobular cartilages along the previously marked projection
line, just anterior to the stabilizing sutures. This cut
should be oriented just above and slightly oblique to the dorsal
profile line, so that the inferior margin of the recreated crural
junction lies slightly anterior to the cephalad margin. This
arrangement achieves maximal lobular refinement and produces
a supratip break along the new profile line. A stable and
well-tailored lobular cartilage complex minimizes the chance
for notching, valve collapse, or tip asymmetry. As with the combination
of LCO and MCO, where the medial and lateral crura
are shortened by overlay, nasal rotation remains unchanged (as
predicted by the tripod theory) while achieving deprojection
because dome truncation allows for equivalent amounts of the
medial and lateral crura to be excised.
The nasal skin is then redraped, and the tip is reevaluated
for position and definition. If greater tip refinement is desired,
a 6-0 permanent suture is placed in a double-dome fashion. If
any concerns exist regarding loss of tip support after completion
of the alar alterations described herein, the medial crura
should be reapproximated with buried 6-0 permanent mattress
sutures. Should even further deprojection be needed, the
hemitransfixion incision is converted to a full transfixion. The incision is made at the junction of the septal cartilage and membranous
septum and causes tip retrodisplacement by releasing
the attachments from the medial crural footplates to the caudal
septum. The nasal incisions are then carefully closed. The
alar base should then be carefully evaluated to ensure that alar
flaring has not occurred owing to the retrodisplacement. Occasionally,
alar wedge excisions may be required to decrease
the excess alar length and flare. The nose is then taped to provide
nasal tip support, and a splint is placed over the dorsum.
The splint is removed after 1 week, and the nose is retaped for
approximately 5 days to help support the tip during the early
postoperative period.
to the cephalad margin. This
arrangement achieves maximal lobular refinement and produces
a supratip break along the new profile line. A stable and
well-tailored lobular cartilage complex minimizes the chance
for notching, valve collapse, or tip asymmetry. As with the combination
of LCO and MCO, where the medial and lateral crura
are shortened by overlay, nasal rotation remains unchanged (as
predicted by the tripod theory) while achieving deprojection
because dome truncation allows for equivalent amounts of the
medial and lateral crura to be excised.
