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The Tongue-in-Groove Technique in Septorhinoplasty Page 01 Page 02 Page 03 Page 04 Page 05

To determine the appropriateness of the TIG technique, the nose is analyzed for projection, acuity of the nasolabial angle, degree of columellar show, and amount of deviation of the columella and caudal septum. A full transfixion incision is created and the mucoperichondrium is elevated from the septum bilaterally in a posterior direction for at least 4 mm to expose both sides of the caudal end of the cartilaginous septum (Figure 2) If septal deviations are present, the elevation of the mucoperichondrial flap is continued back to the bony cartilaginous junction on one or both sides. The deviated portion of the cartilaginous septum is then incised with the Cottle elevator, and the contralateral mucoperichondrial flap is elevated in the area overlying the section of cartilage to be removed. Efforts are made to preserve at least a 1-cm strut of dorsal and caudal cartilaginous septum to maintain nasal support. Any bony septal deviations are removed with the Becker scissors and polyp forceps. Nasal crest deviations are removed using the curved chisel and mallet after the laterally overlying mucosa has been elevated. A portion of the removed cartilage is crushed, replaced between the mucoperichondrial flaps, and secured in this position with a series of 4-0 chromic mattress sutures.

	Fig. 2. A full transfixion incision is made at the caudal border of the cartilaginous septum and the mucoperichondrium is elevated bilaterally to expose several millimeters of cartilaginous caudal septum.

Caudal septal deviations often require partial separation of the posterior junction of the cartilaginous septum and the bony vomer; or a minimal resection of cartilage along the nasal floor at the maxillary crest to allow the septum to swing back to a midline position (Figure 3). To complete this horizontal “swinging door” maneuver (not to be confused with Metzenbaum’s10 vertical swinging door maneuver), a suture is usually placed between the straightened caudal septum and the soft tissue or the periosteum overlying the nasal spine (Figure 4).

	Fig. 3. Caudal septal deflections often require partial separation or excision at the posterior junction of the cartilaginous and bony septum and a horizontal cartilage resection at the floor at the maxillary crest to allow the septum to swing back into the midline.

	Fig. 4. To complete the horizontal swinging-door maneuver, additional septal cartilage and bone are removed if crooked, and the straightened caudal end of the septum is sewn to the soft tissue or periosteum overlying the nasal spine.

At the completion of any required septoplasty techniques, retrograde dissection is performed between the medial crura using fine forceps and tenotomy scissors to create a pocket (Figure 5 and Figure 6). The medial crura are then advanced cephaloposteriorly, placing the denuded caudal septum into the potential space created between them. If there was excessive width to the columella preoperatively, soft tissue from the dissected pocket may be removed to help in the narrowing. The results of the initial trial placement will determine if any caudal septal cartilage excision is necessary (Figure 7). Because of the space created between the medial crura, caudal-septum trimming is not usually indicated. Once any required cartilage trimming is completed, the caudal septum is again placed into the groove between the medial crura, and the nose is examined while the columella is gently held in place (Figure 8) Once the precise desired relationship of the medial crura to the septum is obtained, these structures are fixed with a series of sutures between the medial crura and the caudal septum (Figure 9) Typically 3 or 4 chromic sutures are placed in a through-and-through fashion using a straight needle. Alternatively, permanent (Prolene polypropylene; Ethicon Inc, Somerville, NJ) or semipermanent (PDS polydioxanone; Ethicon Inc) sutures may be placed in a buried fashion prior to membranous closure. An external approach with dissection between the caudal aspect of the medial crura offers more complete exposure to facilitate buried suture placement (Figure 10)

	Fig. 5. The transfixion incision and retrograde dissection between the medial crura. Inset, Diagrammatic display of the groove created between the medial crura.

	Fig. 6. The dissection technique diagrammed in Figure 5 is demonstrated on a patient.

	Fig. 7. Caudal septal cartilage resection can be performed in addition to the tongue-in-groove technique in cases of overly long and downwardly projecting caudal septa.

	Fig. 8. After the creation of the medial crural pocket, the medial crura are advanced onto the denuded caudal septum. A hanging columella is reduced by this method

	Fig. 9. Once the precise desired relationship between the medial crura and the septum is obtained, suture fixation is carrier out.

	Fig. 10. With the external approach, visualization of the position of the septum between the medial crura is readily appreciated. Buried suture fixation is facilitated, and the vestibular skin lining the cephalic portion of the medial crura is separated during this external rhinoplasty maneuver and not as a routine component of the tongue-ingroove technique.

Bilateral membranous septum excision is almost always necessary to remove excess tissue resulting from the TIG placement. Each side of the nose should be evaluated separately to determine the amount of mucous membrane excision needed, since there may be greater excess on one side, particularly after correction of a deviated caudal septum. The membrane excision should take place posterior to the transfixion incision so that only the mucous membrane is excised and not the vestibular columellar skin, thereby reducing the risk of vestibular exposure of mucous membrane, which causes a persistently weeping nose (Figure 11 and Figure 12) If a hemitransfixion incision is initially used, excess contralateral membranous septum can be trimmed with a simple fusiform excision. The incision in the membranous septum is closed with a series of interrupted absorbable sutures (Figure 13). This mucosal excision and the resultant healing provide extra support to the cephaloposterior advancement.

	Fig. 11. The excess membranous septum is trimmed bilaterally after advancing the membrane anteriorly. One must always excise the excess mucous membrane and not the more anterior vestibular columellar skin to avoid a postoperative wet nasal tip.

	Fig. 12. The procedure illustrated in Figure 11 is shown here performed on a patient.

	Fig. 13. The transfixion incision is closed with interrupted absorbable suture.

The created groove may vary in depth along the length of the medial crura. To allow a greater degree of upward nasal tip rotation, the depth of the medial crural pocket and the amount of denuded corresponding caudal septum should be greatest at the dorsal or anterior aspect. On the other hand, to inferiorly rotate the nasal tip or to correct excess columellar show in the posterior region, the deepest portion of the pocket and greatest corresponding advancement should be placed posteriorly. The caudal septum may be variably trimmed when necessary, depending on the correction required. Furthermore, once the caudal septum is placed into the groove, the medial crura may be advanced anteriorly toward the dome cartilages and fixed with sutures in this position to increase and help maintain nasal tip projection (Figure 14).

	Fig. 14. A, To correct a hanging columella,-the medial crura are evenly advanced cephalically onto the denuded septal cartilage. B, To increase projection, the medial crura are advanced anteriorly before being sutured. C, To increase rotation, the medial crura are advanced cephalically with the more anterior portion angled further near the septal angle.

The TIG technique may be used in combination with other rhinoplasty techniques performed through either an external or endonasal approach to the nose. In the subset of 203 patients, 8 also required a lateral crural steal technique7 to increase projection and rotation; 14 also underwent a simultaneous lateral crural overlay technique6 for increased rotation, and 7 also had alar base reduction excisions to reduce flare and/or decrease sill width (Table 1). Placement of the septocolumellar sutures and closure of the transfixion incision may be delayed until after other tip techniques are performed. When caudal deviation is caused by asymmetry of the medial crura, an open approach is typically used to correct the asymmetry before final TIG positioning and placement of the septal columellar sutures. In cases of caudal septal deviation, the deviation should be corrected by freeing up the caudal attachments of the septum at the crest and spine. Once the septum has been straightened, placement of the caudal aspect between the medial crura adds further support to help maintain the septum in the straightened position.

	*AII patients are from the practice of one of the authors (R.W.H.K).

At the conclusion of the procedure, a light, nonadherent, sterile thin pad (Telfa; Kendall Company, Mansfield, Mass) pack may be placed into each side of the nose; the nose is taped, and an external splint is positioned over the dorsum. After the packing is removed on postoperative day 1, the patient begins applying antibiotic ointment with cotton-tipped applicators twice a day to the area of the transfixion incision and into the nose. The external splint is removed after 5 to 7 days, and the nose is retaped for about 5 days to help support the nasal tip in the desired position while new fibrous attachments develop.