Section 4 Plastic and Reconstructive Problems

Plastic and Reconstructive Surgery s !PRIL

Beaty et al. have also quantitatively measured the impact of selected surgical maneuvers on nasal tip support. Their findings indicate that the nasal tip is cantilevered, almost suspended, at the anterior septal angle by the association of the septum with the nasal domes through central suspending liga- ments. Disruption of this ligamentous structure alone resulted in a 35 percent decrease in tip sup- port. 5 Gassner et al. and Westreich et al. have also found the anterior septal angle to be the most supportive structure in their quantitative nasal tip tissue resilience/cartilage elasticity studies. 6,7 Finally, the cantilevered spring theory of West- reich and Lawson describes a spring-loaded tri- pod that gains its stability from a rigid abutment. In this model, the paired lower lateral cartilages have a single point of dominant fixation, usually along the caudal septum, around which the elastic tripod will rotate. Unlike preceding models, the rigid abutment is not located at the feet of the tri- pod but rather at the septum, the strongest mid- line element of the nose. 8 One aimof primary open rhinoplasty is to recon- stitute the ideal nasal anatomy when this anatomy is less than ideal. We therefore suggest that if (1) a proper anterior septal angle position is created, (2) a central suspending ligament repair is performed, and (3) the scroll area is preserved or reconstructed, the desired nasal tip position and stability can be consistently achieved without a columellar strut graft. We present a series of 100 consecutive primary open rhinoplasties performed with special attention to restoration of native tip support elements but without the use of columellar strut grafts. PATIENTS AND METHODS Medical records and digital images from 100 consecutive primary open rhinoplasty patients (84 female and 16 male patients) operated on by the first author (O.B.) from July of 2011 to October of 2012 were retrospectively reviewed for patient demographics, surgical techniques, complica- tions, and postoperative columellar deformities (Table 1). All patients underwent an open rhinoplasty approach without the use of a columellar strut, tongue-in-groove technique, septocolumellar sutures, or columellar/medial crural reinforce- ment of any kind. Nasal tip support and projec- tion were provided by (1) precise adjustment of the anterior septal angle using a septal extension graft if necessary, (2) a median suspension suture between the distal insertion of the Pitanguy liga- ment and the middle vault, and (3) reconstruction

Table 1. Surgical Techniques Characteristic Total no. of rhinoplasties Septal surgery Septoplasty/septal harvest

No.

100

88 34 80

Caudal trim

Dorsal reduction

Anterior septal jig-type extension without using a graft

6 4

Septal extension graft Middle vault Unilateral spreader grafts Bilateral spreader grafts Upper lateral fold-in flap Upper lateral caudal trim

18

5

79 36 13 76 11

Osteotomies

Unilateral lateral Bilateral lateral No osteotomy Dorsal camouflage

Recycled dorsal hump

80

Temporal fascia

4

Lower lateral cartilages Cephalic trim Horizontal repositioning Lateral crural steal Lateral crural overlay Nasal tip Hemitransdomal sutures

91 22

4 4

100 100

Interdomal sutures

Medial crural transfixion sutures

84

Tip grafts

0 0 6

Columellar strut Alar base reduction Alar rim grafts

64

of the scroll attachments by primary ligament repair or by using a horizontal mattress type lower lateral cartilage–to–upper lateral cartilage suspen- sion suture (Fig. 1). Nasal tip was refined with suture techniques only; no tip grafts were used. All 100 patients had a complete set of digital images, including (1) a preoperative series, (2) a preoperative morphed right profile image, and (3) a late postoperative (8 to 12 months) series. Digital photographs were obtained using a stan- dardized setup with the patient seated at a fixed distance from the camera. Morphed right profile images were created using Virtual Plastic Sur- gery Software (Version 1.0; Kaeria EURL, Paris, France). Digital images were processed by using open-source GNU Image Manipulation Program, GNU Public License Version 2.8. Patient satisfac- tion regarding long-term postoperative nasal tip elasticity was assessed subjectively by means of an e-mail survey in December of 2013. Survey results were tabulated by an unbiased observer. Analysis of Nasal Tip Projection Nasal tip projection was measured on pre- operative, morphed, and postoperative right