The overall surgical principles involved in the treatment
of the overprojected nose were clearly elucidated
by Tardy et al8 and many others. The surgeon can (1)
reduce excessive tip support mechanisms, (2) reduce overdeveloped
anatomic components, and (3) normalize adjacent
anatomic components. In the 1930s, Joseph9 and
Safian10 first described deprojection of the nasal tip by
shortening the medial and lateral crura. Since then, refinement
of the procedure via more conservative measures,
which included maintaining vestibular skin, suturing
divided components, and overlapping these
components, have variously been developed for the lateral
crura.5,11,12 Meanwhile, Lipsett13 pioneered shortening
of the medial crura in 1959. Similar modifications as
with the lateral crura have subsequently been described
by Berman,14 McCurdy,15 and Parkes et al.16Nowwe would
like to incorporate our 12-year experience with a technique
that we have defined as MCO.
The elegance of both LCO and MCO lies in the fact
that no bridges are burned. Because no cartilage is excised,
the surgeon is left with the flexibility to modify the
result on the operating table. If too much deprojection
is seen, the overlapping sutures can be released and reapproximated
with less overlay. Furthermore, some have
argued that excision of portions of the medial crura results
in a high risk of tip contour irregularities—notching/
bossae—as a result of displacement and distortion of the
transected, weakened cartilage17; Webster and Smith18 encountered
this difficulty with their lateral crural flap technique.
With LCO and MCO, time has shown that because
no cartilage is excised, and because sutures are used
to control and maintain the correction, the overlapped
crura maintain their integrity for years without buckling
or any of the other associated complications. Moreover,
with overlapping of cut cartilage segments, more
strength is imparted to the correction. On the other hand,
when cartilage segments are excised and sewn end to end
as other authors advocate, the edges migrate with time
and afford little stability. Our experience has shown that
with MCO and the overlap suturing of the cut ends, tip
support can be maintained or obtained without the need
for a columellar strut. Because the edges are overlapped,
we are not relying on a simple fibrous union, and there
is much less likelihood of development of notching or
collapse. In fact, the only case of MCO that needed revision
in our experience was secondary to partial resorption
of irradiated cartilage and not due to any tip irregularity
arising from MCO.
Numerous authors have pointed to the tripod theory
and suggested that when the medial crura are shortened
in relation to the lateral crura, there would be a high tendency
for alar flaring. That has not been our finding when
MCOis used. In fact, no cases whenMCOwas used alone
necessitated alar base reduction. Even more surprising
was our finding that in our entire experience with deprojection,
only 7.5% of the patients needed alar base reduction,
and many of these patients desired this reduction
before deprojection.
