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The Tongue-in-Groove Technique in Septorhinoplasty
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CASE 1
This case illustrates the application of the TIG technique in a droopy nose with columellar show. Preoperatively, this 26-year-old woman (shown in Figure 15) had a droopy nose with an acute nasolabial angle and excess columellar show. The TIG technique achieved nasal tip rotation and reduction of the columellar show. The desired correction was obtained without excision of any cartilaginous septum. Approximately 2 mm of membranous septum was excised bilaterally. The TIG technique was used in combination with a conservative cephalic trim of the lower lateral cartilages, removal of a dorsal hump, and osteotomies. The patient maintained a stable degree of nasal tip rotation and a desirable amount of columellar show 3 years postoperatively.
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Fig. 15. Case 1. A and C, The preoperative appearance of the patient with a droopy nasal tip and hanging columella. B and D, The postoperative appearance of the patient 9 months after surgery. |
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CASE 2
This case illustrates the use of the TlG technique to help maintain the straightening of a deviated caudal septum in conjunction with a cosmetic rhinoplasty, which also required a lateral crural overlay technique and spreader grafts. This 41-year-old man presented with nasal airway obstruction as well as a desire to improve his appearance (Figure 16) The patient had a severely deviated caudal septum that deformed the medial crus resulting in near total airway obstruction on the right side. He underwent a swinging-door septoplasty via a full transfixion incision. A TlG technique was used with retrograde dissection between the medial crura, and the straightened caudal end of the septum was placed between the medial crura. Preoperatively, he had a wide columella, particularly at the base. A large amount of soft tissue was excised from the area between the medial crura during the retrograde dissection. These maneuvers resulted in a straightened and thinned columella, improving both the nasal airway and the appearance of the nasal base. The patient’s nose was also narrowed through the middle third, with airway obstruction necessitating bilateral spreader grafts. A lateral crural overlay technique6 was also used to rotate and deproject the tip. At 5-year follow-up, the patient maintained a good nasal airway and a pleasing appearance of the nose.
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Fig. 16. Case 2. A, The preoperative base view of the patient. B, The 1 1/2-year postoperative appearance of the patient's nasal base. See Figure 10 for intraoperative placement of this patient's caudal septum in the groove between the medial crura using the tonque-in-groove technique and visualized throuqh the external approach. |
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CASE 3
This case illustrates the TIG technique used solely for correction of a hanging columella without altering the tip projection or rotation. This 28-year-old woman presented with a unilateral nasal airway obstruction and a desire to improve the appearance of her nose, mainly to lower the dorsal hump to a straight line and to correct the hanging columella (Figure 17) The patient did not want a turned-up nose. Results of examination showed the nasal septum to be internally markedly deviated to the left side with near total obstruction on that side. The patient had excess columellar show and a convex nasal dorsum. An additional finding was a hypermobile tip, which boxed down on smiling. A septoplasty was performed via a full transfixion incision and combined with an external-approach rhinoplasty. The TIG technique was used mainly to obtain the desired degree of correction of the excessive columellar show. The groove between the medial crura was created with a constant depth anteriorly to posteriorly to allow the movement of the columella cephalically without changing much of the nasal tip rotation. Following that, excision of 3 mm of the redundant membranous septum was performed on each side. Additional maneuvers included a conservative trim of the cephalic margins of the lower lateral cartilages, suturing the anatomic domes together, excision of the dorsal hump, and narrowing of the nasal dorsum by osteotomies.
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Fig. 17. Case 3. Preoperative (A) and early postoperative (B) (6 weeks after surgery) views. Note that the excess columellar show has been corrected with establishment of a double break and with minimal rotation of the nasal tip. |
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CASE 4
This case illustrates the use of the TIG technique to rotate a droopy tip and retrodisplace an overly projecting nasal tip and simultaneously reduce a small amount of columellar show (Figure 18). This 27-year-old woman presented for cosmetic correction of a large, droopy, overly projecting nose. She also had paranasal sinus disease with polyps that were addressed at the same surgery by another physician. At surgery, the caudal cartilaginous septum was trimmed, a medial crural pocket was developed, and the medial crura were sutured to the caudal end of the septum with permanent sutures after the medial crura were positioned on the septum so as to rotate and deproject the tip simultaneously. The excess membranous septum was excised, the dorsum reduced, and osteotomies were performed.
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Fig. 18. Case 4. The tongue-in-groove technique alone was used to rotate and deproject (retrodisplace the tip) the nose. Some trimming of the caudal septum was needed. A, C, and E are preoperative and B, D, and F, postoperative views. |
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CASE 5
This case illustrates the use of the TIG technique to narrow a wide columella and simultaneously help maintain the correction of a caudally deflected nasal septum (Figure 19) This 29-year-old man presented with nasal airway obstruction, a crooked nose, a caudally deflected nasal septum, and such a wide columella that his nostrils were narrow slits. At surgery, a medial crural pocket was developed and the intervening soft tissue resected. A horizontal swinging-door septoplasty was used to place the caudal septum back into the midline and between the medial crura, which were sewn to the caudal septum with septocolumellar sutures. No caudal cartilaginous septum was removed. A 3-mm section of membranous septum was excised on the left where this membrane had been stretched by the septal deflection, and 2 mm removed on the right side. By 7 years after surgery, the patient maintained correction of the septal deflection as well as satisfactory long-term narrowing of the columella.
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Fig. 19. Case 5. The tongue-in-groove technique was used to help maintain the correction of a deviated caudal septum in the midline and to narrow a wide columella. Note the slitlike nostrils (A) and the improvement apparent in the 7-year postoperative photo (B). The profile (C) shows a slightly retracted lower columella, which was improved by sewing the feet of the medial crura more inferiorly on the straightened caudal septum (D). |
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