 |
| Fig. 1.
(Above) Basic concepts of elliptical excision and repair of the lateral
crura of the lower lateral cartilage. (Below) Reduction convexity of the
lateral crura. |
The skin lining
on the inside of the ala usually adapts readily to the new situation, and therefore
no undermining or resection of this area is necessary. Three to four interrupted
sutures, made with 5-0 nylon and inverted knots, are usually adequate on each
side.
This usually causes
the nasal tip to be lifted cephalically and anteriorly; other alterations to
the alar cartilage, such as trimming the caudal end, may or may not be necessary.
Frequently, suturing the right and left alar cartilages together is necessary
to narrow the tip. The surgeon should strive to create symmetry, eliminate imperfection,
and sculpt anatomy that is as sound as possible. Other needed proce- dures,
such as alterations of the dorsum or osteotomy, can be performed at this time
or before the tip alteration, as the surgeon prefers.
After replacing
the skin flap, repair is done with 5-0 nylon sutures on the columella and 5-0
Vycril sutures (Ethicon, Inc., Somerville, N.J.) on the interior of the nose.
To complete the procedure, nasal packing is performed, and the steri-strips
and splint are applied to the tip and dorsum in the usual fashion.
 |
| Fig. 2.
(Above, left) Bulbous tip, internal appearance, cephalic view. Note dome
shape of the lateral crura. (Above, right) Elliptical excision performed
centrally on the left side. (Below, right) Elliptical excision and repair
completed on both sides. Suture is placed to approximate alar cartilages
medially. |
 |
| Fig. 3.
Twenty-seven-year-old man with bulbous nasal tip deformity who underwent
primary open-approach rhinoplasty with elliptical horizontal excision at
the tip. Preoperative views and postoperative views 4 years later. |
 |
| Fig. 4.
Twenty-seven-year-woman with asymmetic bulbous lower lateral cartilages
who underwent primary open-approach rhinoplasty with elliptical horizontal
excision at the tip. Unequal excisions were performed to achieve symmetry.
Preoperative views and postoperative views 2 1/2 years after surgery. |
CASE
REPORTS
We present two
cases in which this technique, using an elliptical excision, in a horizontal
direction, of the central segment in the lower lateral cartilage, successfully
repaired cartilaginous deformities of the nasal tip.
Case 1
A 27-year-old man
presented with a bulbous-boxy nasal tip deformity (Fig. 3, above and center,
left). He underwent primary open-approach rhinoplasty with the elliptical excision
at the tip. The procedure successfully corrected the bulbous tip deformity and
is still corrected at 4-year follow-up (Fig. 3, center, middle and right, and
below).
Case 2
A 27-year-old woman
presented with asymmetric bulbous lower lateral cartilage (Fig. 4, above and
center, left). We performed primary open-approach rhinoplasty with elliptical
horizontal excision at the tip. Unequal excisions were used to achieve symmetry.
At 2 1/2 years follow-up, the deformity is corrected (Fig. 4, center, middle
and right, and below).
DISCUSSION
The anomalous bulbous
nasal tip is usually the result of excessive fibrous fatty tissue at the nasal
tip or, more commonly, cartilaginous enlargement and excessive arching of the
tip, causing convexity. This cartilaginous deformity, although aesthetically
undesirable, is functional in that it keeps the nostrils open and the nasal
tip high. In a bulbous tip deformity, the lateral crura of the lower lateral
car- tilage is convex or dome-shaped and its suprainferior and anteroposterior
dimensions are enlarged.
To create convexity
in an elastic flat object, one may either increase the dimensions of the central
segment while keeping the periphery constant or tighten the periphery of the
object (like a purse string), causing the central segment to bulge outward.
To reverse this effect, one may reduce the dimensions of the central segment.
This is the basis for elliptical excision of the central segment of the lateral
crura of the alar cartilage (Fig. 1). The second option, releasing the periphery
of the cartilage to flatten it out, may also be done. This may be indicated
in cases of a small nasal tip with small alar cartilages but with excessive
curvature (an uncommon anatomic variation). Aesthetic and anatomic alteration
of the lateral crura logically should address the problem-to decrease suprainferior
excess of cartilage-and, at the same time, decrease the excessive convexity
of the lateral crura (Fig. 1).
For many years,
excisions of the cephalic border of the lower lateral cartilage were used in
endonasal techniques, and later they were used in open-approach rhinoplasty
to correct nasal tip deformities. Trimming of the caudal border was also occasionally
done. Instead, the technique described here advocates an excision of cartilage
from the problem area where there is excessive convexity and suturing of the
remaining portions of cartilages.
A through-and-through
horizontal excision using an endonasal technique was first described in 1985
and has been acknowledged by others (written communication, Rollin K. Daniel,
M.D., April 1995). It was used with limited success and, in fact, has been abandoned
by most who used it (written communication, Richard J. Siegel, M.D., June 1995).
Elliptical excision through an open-approach and repair offers several advantages
(Table 1).
TABLE I
Advantages and Disadvantages of Central Segment
Excision and Repair
|
Advantages
Changes
bulge of the dome where change is needed, at the top
Preserves
anatomically intricate relationship of junction of upper lateral cartilage
and lower lateral cartilage
Preserves
internal value, anatomy, and function
No loose
or free edges of cartilage to warp and deform during healing
Satisfactory,
long-lasting clinical results achieved more consistently than with previous
techniques
Any shape
excision of the nasal tip cartilage is possible with proper design of excision
and repair
Correction
is anatomically sound and repaired cartilage looks like normal cartilage
of a smaller nasal tip
Reduced
need for morselization, scoring, crushing, or other traumatic maneuvers
that often cause late deformity
Tip graft
is rarely necessary
Nasal
tip may be lifted cephalically as desired, in accordance with the shape
of the ellipse
Disadvantages
Usually
requires an open approach
More
technical precision required
|
First, the procedure
removes the most protruding and bulbous portion of the lateral crura, and the
cephalic and caudal portions that remain can be sutured together. It changes
the bulge of the dome where a change is necessary, at the top. It also preserves
the anatomically intricate relationship of the junctions of the upper and lower
lateral cartilages. In the ma- jority of procedures an elliptical excision was
used. However, variations of this central excisions were performed on occasion
where the anatomical deformity dictated. Regardless of the central excision
shape, still there are no free or loose edges of cartilage to warp or deform
during the healing process. Finally, satisfactory, long-lasting clinical results
can be achieved consistently.
We believe the
design of the previous procedure was anatomically incorrect. It interrupted
the anatomic integrity of the lateral crura and left it unrepaired.
Hamid
Massiha, M.D.
3939 Houma Boulevard
Suite 216
New Orleans, La. 70006 Back
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