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Home > Articles > The Tongue in Groove
Technique in Septorhinoplasty A 1O-Year Experience Russell W. H. Kridel, MD; Bruce A. Scott, MD; Hossam M. T. Foda, MD
Background: Correction of the lower third of the nose is perhaps the most challenging component of performing a rhinoplasty. The tongue-in-groove (TIG) technique provides a method for correcting excess columellar show and maintaining correction of caudal deviation. It is also indicated for controlling nasal tip rotation and projection while preserving the integrity of the lobular cartilaginous complex and may be combined with either the external or endonasal rhinoplasty. It is typically used in combination with other septorhinoplasty maneuvers. The TIG technique consists of a method by which the medial crura are advanced cephaloposteriorly onto the caudal septum into a surgically created space between them. Objective: To determine the effectiveness of the TIG technique to aid in correction of columellar show, a deviated caudal septum, and various tip rotation and projection problems. Setting: Private practices of 2 authors (R.W.H.K., Houston, Tex, and H.M.T.F., Alexandria, Egypt). Patients: The records of 287 patients who underwent TIG rhinoplasties in one private practice from 1989 through early 1999 (n = 203) and in another practice from 1994 through early 1999 (n = 84) were reviewed. Main Outcome Measures: Physician judgment of outcome was based on reduction of columellar show, change in tip rotation or projection, narrowing of the columella, and straightening of a deviated caudal septum as indicated in preoperative and postoperative photographs taken of all but 4 of the 287 patients. Patient judgment of outcome was measured by patient requests for revision and patient comments made during follow-up visits. Results: Of 287 patients, 278 (97%) had satisfactory to excellent results. Only 9 (3%) required revisions related to the TIG technique. Eight of these 9 did not achieve enough reduction of columellar show or adequate rotation or projection. A repeated TIG technique was used in these 8 patients with satisfactory revision results. One of the 9 was overprojected and required revision. Of the 108 patients who had preoperative caudal septal deviation, none needed further surgery. Conclusions: The TIG technique provides a direct, effective solution to columellar show and is a reliable, reproducible method for achieving predictable tip rotation and projection. Furthermore, when used in conjunction with septoplasty techniques, it helps maintain the correction of a deviated caudal septum. Surgical aesthetic mastery of the lower third of the nose has long been recognized as the most challenging component of performing a rhinoplasty. In response to this challenge, surgeons over the years have tried a variety of techniques to rotate, refine, and project the nose. Most successful surgeons today use a variety of methods to obtain the desired correction. The tongue-in-groove (TIG) technique is designed to be used in combination with other surgical maneuvers. Specifically this technique is useful to obtain nasal tip rotation, to predictably adjust tip position, to correct excess columellar show, and to straighten caudal septal deviation. Nasal tip rotation is defined as movement of the nasal tip along an arc with constant distance from the facial plane.1 Nasal tip projection is the height or length from the alar crease to the nasal tip as seen on the profile view, or the posterior-to-anterior distance that the nasal tip extends in front of the facial plane as seen on base view.2 Rotation has typically been achieved through a variety of cartilage-modifying maneuvers based on incising or excising cartilaginous structures.3-5 Often these techniques rely on unpredictable healing and scar contraction of soft tissue to obtain the desired degree of rotation. In addition, techniques that disrupt the integrity of the nasal tip cartilage may result in long-term complications, including alar collapse, alar notching, tip bossae and asymmetry, and loss of nasal tip support. Techniques that reposition the dome cartilages with sutures and achieve rotation and projection through an alteration of tip anatomy have also been described.6,7 The TIG technique is a conservation technique that avoids cartilage excisions and adds support to the nasal tip. The technique can provide a predictable and adjustable degree of rotation and can increase or decrease projection while at the same time reducing the amount of columellar show. Aesthetically, maximum columellar show should not exceed 4 mm, which is the width of the typical medial crus.8 Excess columellar show or a hanging columella may be caused by prominent medial crura, excessive membranous septal flaps, or a projecting caudal cartilaginous septum (Figure 1). A hanging columella needs to be distinguished from alar notching or retraction, which is often an unwanted outcome of a previous rhinoplasty in which overly aggressive resection of the lower lateral cartilages has taken place. This sometimes-subtle deformity, if left uncorrected, can diminish an otherwise pleasing cosmetic result. Correction by other techniques often requires trimming the caudal end of the cartilaginous septum, which, if overdone, can either foreshorten the nose or, paradoxically, lead to tip drop due to a decrease in medial crura attachments.9 Alternatively, use of the TIG technique can reduce a hanging columella with little or no excision of the caudal septum.
Deviation of the caudal aspect of the nose may be related to a deviated caudal septum or asymmetries of the medial crura such as buckling. Correction of deviations in this area can be complex to achieve and difficult to maintain. The TIG technique, when used in combination with septoplasty and/or columellar techniques, will aid in the maintenance of long-term correction of caudal septal deviation. |
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