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

The TIG technique, like most nasal techniques today, is a revisitation and modification of techniques described years ago. Motivated by a desire to prevent the tip drop that frequently resulted after rhinoplasty, Rethi¹¹ described “embracing flaps” in 1934. In his technique, he elevated the septal membranes, particularly in the area of the anterior septal angle as well as along the caudal aspect of the septum. He described placing the exposed septum between the medial crura and securing it in this position with transfixion sutures. Gustav Fred¹² described the “invaginating technique,” used to maintain nasal tip projection. Through a transfixion incision, the caudal septum was denuded and placed in a shallow groove created in the middle of the columellar tissue. He emphasized that this groove should never be extended to the level of or between the medial crura. Jacques Joseph13 described the technique of changing the position of the nasal tip projection by advancing the medial crura and then placing septocolumellar sutures to maintain the new position.

Years ago, Brown and McDowell¹⁴ criticized the surgical implantation of the septal cartilage between the medial crura as being anatomically incorrect and creating an unsightly, thick columella. The techniques of Rethi¹¹ and Fred¹² were also criticized for eliminating the flexible “buffer” that the membranous septum provides and for causing dysfunction of the depressor septi nasi muscle^{15 ,16} It was a widely held opinion that partial or complete removal of the membranous septum would result in great discomfort to the patient and a displeasing appearance, particularly with changes of expression.

Anatomically, the medial crura are loosely connected by fibrous tissue to each other and to the caudal septum. The membranous septum consists of 2 layers of loose areolar tissue transversed by the depressor septi nasi muscle. It provides a soft tissue interface between the rigid cartilaginous septum and the semirigid columella. Most septoplasty and rhinoplasty techniques include division of this muscle without reports of deleterious effects. In fact, in cases of a downwardly mobile and droopy tip, loss of this depressor function is desirable.

Many current rhinoplasty techniques rely on placement of cartilaginous grafts between the medial crura.⁷ Clinical experience does not support the criticism that placement of columellar struts results in a wide or unpleasing appearance to the columella. Additionally, excision of any excess soft tissue from the area between the medial crura prior to placement of the relatively thin caudal septum into this area, combined with medial crural suture approximation, may result in reduction in the width of an abnormally thick columella (Figure 18, A-D).

	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.

Clinical experience with the technique over the past 10 years has not shown that the loss of flexibility of the membranous septum is a concern for our patients. It can be argued that the rigidity resulting in the columella is similar to that resulting from placement of plumping grafts and columellar struts, both of which techniques are widely used. With the TIG technique, our patients have not complained of a bothersome sensation even with facial animation and expression. In our experience, patients in whom columellar struts and plumping grafts have been placed are more likely to report an abnormal “rigid sensation” in the upper lip. An anatomic description by Converse¹⁷ in 1955 documented that the lower end of the medial crura “embraced” the caudal septal cartilage. Bernstein⁸ confirmed this anatomic relationship 20 years later. Thus, even in normal anatomy the columellar structures and cartilaginous septum are not totally separate structures. Clinically, the degree of connection between the medial crura and the septum varies widely. Furthermore, the loss of this flexible interface can help prevent the tip drop that commonly occurs after nasal surgery. Creation of a transfixion incision, often used in standard rhinoplasty techniques, disrupts fibrous connections between the medial crura and cartilaginous septum. The TIG technique restores strength to this area by using sutures and bringing the cartilaginous structures together.

The TIG technique preserves the integrity of the cartilaginous structures and maintains projection of the nasal tip. Most tip-rotation techniques involve incising or excising the cartilaginous framework. The TIG technique provides a more controlled rotation than maneuvers that rely on unpredictable healing and contracture to obtain rotation. The surgeon can place the caudal septum into the groove between the medial crura and intraoperatively visualize the effect on the nasal appearance. Because the technique does not rely upon any cicatricial effect, the intraoperative appearance closely approximates the expected long-term result. Similarly, this technique provides a predictable and immediately visible method of correcting excess columellar show. Postoperative nasal tip drop should not occur because the technique actually increases nasal tip support.

Columellar show has been defined as the distance on lateral view between the highest point of the alar rim and the caudal aspect of the columella. Optimally, this distance should be between 2 and 4 mm.¹⁸ Extreme excess columellar show has been referred to as a hanging columella.Failure to address this sometimes-subtle deformity will substantially detract from the aesthetic balance of an otherwise successful rhinoplasty. Correction of excess columellar show is typically attempted by excising a portion of the caudal septal cartilage. More aggressive techniques directed at trimming or even completely excising the medial crura have been recommended.^{11, 19} These techniques, which weaken the columellar structures, may result in undesired foreshortening of the nose, loss of nasal tip support, columellar retraction, or distortion. The TIG technique allows correction of excess columellar show while preserving the medial crus and minimizing caudal septal excision. Adamson et al ²⁰ have noted that a key to successful correction of the hanging columella is maintaining support of the medial crura. Not only does the TIG technique avoid weakening the columellar structures, it actually strengthens columellar support.

Nasal surgical techniques to correct caudal septal deviation are limited by the need to maintain septal support of the nasal tip. Techniques that rely on excision or morselization of deviated septal cartilage, if applied to the caudal septum, may result in nasal tip drop. Additionally, because of the proximity to the vestibule, even minor residual deviations may be visible to the patient and physician. Long-term satisfactory correction of the deviated caudal septum is thus particularly challenging. The TIG technique, by allowing positioning of the newly straightened caudal septum between the medial crura, helps maintain this correction. This maneuver should help strengthen nasal tip support and thus may allow application of more aggressive techniques to “remove the memory” of the caudal cartilage.

In summary, the TIG technique reduces excess columellar show, provides adjustable controlled nasal tip rotation and projection, and helps maintain the correction of caudal deviation. The technique is typically used in combination with other septorhinoplasty maneuvers to achieve the desired functional and cosmetic result. It is particularly useful in a patient who has the combined indications of excess columellar show and an acute nasolabial angle. The maneuvers described in this article may provide a particularly gratifying solution to the challenging deformities of extreme excess columellar show (hanging columella) or a greatly deviated caudal septum.

REFERENCES

1. Simons RL. Nasal tip projection, ptosis, and supratip thickening. ENT. 1982; 61:452-455.
2. Kridel RWH, Konior RJ. The underprojected tip. ln: Aesthetic Facial Surgery. Krause C, Mangat D, Pastorek N, eds. Philadelphia, Pa: Lippincok-Williams & Wilkins; 1991:191-228.
3. McCollough EG, Mangat D. Systematic approach to correction of the nasal tip in rhinoplasty. Arch Otolaryngol Head Neck Surg 1981;107:12-16.
4. Webster RC. Advances in surgery of the tip. Otolaryngol Clin North Am. 1975; 10:615-644.
5. Kamer F. Surgery of the nasal tip. Facial Plast Surg. 1987;4:249-262.
6. Kridel RWH, Konior R. Controlled nasal tip rotation via the lateral crural overlay technique. Arch Otolaryngol Head Neck Surg. 1991;117:411- 415.
7. Kridel RWH, Konior R, Shumrick K, Wright W. Advances in nasal tip surgery: the lateral crural steal. Arch Otolaryngol Head Neck Surg. 1989;115:1206-1212.
8. Bernstein L. Aesthetics in rhinoplasty. Otolaryngol Clin North Am. 1975;8:705-715.
9. Kridel R, Lunde K. Nasal septal reconstruction: review and update. Facial Plast Surg Clin North Am. 1999:7:105-113.
10. Metzenbaum M. Replacement of the lower end of the dislocated septal cartilage. Arch Otolaryngol. 1929;9:282-296.
11. Rethi A. Operation to shorten an excessively long nose. Rev Chir Plast 1934,2:85-87.
12. Fred GB. The nasal tip in rhinoplasty: use of the invaginating technique to prevent secondary drooping. Ann Otolaryngol 1950;59:215-223.
13. Joseph J. Rhlnoplasty and Faclal Plastic Surgery With a Supplement on Mammaplasty. Milstein S, trans. Phoenix, Ariz: Collumella Press; 1987:135.
14. Brown JB, McDowell F. Plastlc Surgery of the Nose. St Louis, Mo: Mosby-Year Book Inc; 1951:38.
15. Stovin JS. The importance of the membranous nasal septum. Arch Otolaryngol. 1958;67:540-544.
16. Converse JM. Reconstructive Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1967:694-828.
17. Converse JM. The cartilaginous structures of the nose. Ann Otol Rhinol Laryngol 1955;64:220-229.
18. Powell N, Humphreys B. Proportlons of the Aesthetic Face. New York, NY: Thieme-Stratton Inc; 1984:30.
19. Armstrong DP. Aggressive management of the hanging columella. Plast Reconstr Surg. 1980;65:513-516.
20. Adamson PA, Tropper GJ, McGraw BL. The hanging columella. J Otolaryngo. 1990;19:319-323.