Rhinoplasty Dissection Manual - part 6 ppt

If the cephalic edge leads the caudal edge of the lateral crus despite proper placement of domal suture , a small cephalic wedge of the cartilage may be excised , and the edges sutured,

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Surgery oj the Nasal Tip

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Figure 10, continued

90 RHINOPLASTY DISSECTION MANUAL

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Figure 10, continued

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Surgery oj the Nasal Tip

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93 Surgery oj the Nasal Tip

Figure 10, continued

B Figure 11 If the cephalic edge leads the caudal edge of the lateral crus despite proper placement of domal suture , a small cephalic wedge of the cartilage may be excised , and the edges sutured, which repositions the cephalic edge lower in relation to the caudal edge In this figure, one lower lateral cartilage illustrates the wedge excised, and the other illustrates the edges resutured (A) B: The effect of this maneuver on the relationship between the cephalic and caudal edge is illustrated

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Figure 12 A, 8 : Lateral crural steal When the horizontal mattress domal sutures take a larger bite of lateral crus,a portion of the lateral crus is"borrowed" by the medial crus.The "medial crural"1eg of the tripod is lengthened,whereas the"lateral crural" legs of the tripodare shortened (see Appendices A and F) This results in increased projection and rotation Tip refinement also is achieved, as with a standard domal suture C-F: Rotation of this patient's nasal tip was achieved by using the lateral crural steal tech­ nique and by suturing medial crura back on overly-long midline caudal septum

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Surgery oj the Nasal Tip

Lateral Crural Steal

Lateral crural steal (Fig 12) is an effective method for increasing tip projection and rota­

Further Refinement with Dome Division with Intact Vestibular Skin and Suture

Reconstitution

tour (8)

Remove the transdomal sutures to perform this maneu ver Divid ing the dome by verti­

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96 RHINOPLASTY DISSECTION MANUAL

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simple interrupted stitches Mattress stitches in this situation may result in overnarrowing

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Lateral Crural Overlay

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Figure 15 (left and above) A-J: Lateral crural overlay Great care must be taken

to perform this technique symmetrically

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98 RHINOPLASTY DISSECTION MANUAL

Tip Graft

Carve a shield-shaped tip graft from the harvested septal cartilage The width generally

ing edge and thinner at the base One may consider cutting the graft larger at the leading

caudal margins of the medial/intermediate crura that have been stabilized by the sutured­ in-place columellar strut An excessively thick tip graft will increase fullness in the infratip

usually applied Place the lower sutures first

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Figure 16 A-E: Tip graft width generally varies from 8 mm to 12 mm at the leading edge The length varies from 8 mm to 15 mm, and thickness typically varies from 1 mm to 3 mm

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Surgery oj the Nasal Tip

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Figure 17 A: The tip graft is sutured to the caudal margins of the medial/intermediate crura Four to six

6-0 PDS sutures are typically placed Place the middle sutures first B, C: Intraoperative photographs il­

lustrating placement of tip graft

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Figure 17, continued D-K: Preoperative (D, F, H, J) and postoperative (E, G, I, K) photographs of a patient who underwent application of a tip graft The tip graft was used to increase tip projection and pro­ vide a bidomal shape to the nasal tip Please refer to text for a more detailed discussion of tip grafts

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Surgery oj the Nasal Tip

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Figure 17, continued

When placing a tip graft in a patient whose dome s have been divided (and suture recon­

stituted),apply the tipgraft so thatit camouflagesthe caudal aspectof the cut domes (Fig

18), decreasing the risk that this point will be palpable or visible after surgery

Figure 18 If a tip graft is applied in a patient with divided domes, the caudal aspect of the cut domes should be hidden behind the tip graft to decrease the risk of a palpable or visible point after surgery

102 RHINOPLASTY DISSECTION MANUAL

Cap or Buttress Graft

tients with thick skin and an underpr ojected tip, a longer tip graft can be projected 2 mm to

4 mm above the existin g dome In these and other appropriate cases, a cap or buttress graft placed behind the leading edge of the tip graft may be useful to support the graft (particu­ larly softer, pliable auricular cartilage tip grafts) and toprevent excessive cephalic rotation

of the graft under the tensionof closureof the skin/soft-tissueenvelope.Buttressgrafts are

sutured to the tip graft and both domes by using 6-0 PDS or Monacryl suture (Fig 19) The buttress grafts should create a smooth transition from the edge of the tip graft to the caudal margin of the lateral crura (2)

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Figure 19 A-D: Buttress or cap graft

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Surgery oj the Nasal Tip

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Figure 19, continued E-L: Preoperative (E, G, I, K) and postoperative (F, H, J, L) pho­

tographs of two patients who had tip grafts with cap-graft placement Cap grafts were placed

to support the leading edge of the grafts , prevent cephalic rotation of the graft, and ensure

a smooth transition from the edge of the graft to lateral crus

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Figure 19, continued

105 Surgery oj the Nasal Tip

Alar Batten Graft

The external nasal valve is composed of the cutaneous and skeletal support of the mobile

alar side-wall Overaggressive resection of the lateral crura during rhinoplasty and the sub­

sequent postop erati ve soft-tissue contraction may lead to internal and/or external nasal

valve compromise Cephalic positioning of the lateral crura also will leave suboptimal

structural support in the mobile alar side-wall (external valve collapse)

Alar batten grafts , typically of curved septal or auricul ar cartilage, placed to support the

alar rim, can correct internal or external nasal-valve collapse (Fig 20) (l0-12)

Create a precise pocket for an alar batten graft The graft is typically placed caudal to the

lateral crura at the point of maximal lateral nasal wall collapse Fashion a graft from har­

vested auricular or septal cartilage, and insert it into the precise pocket The pocket is sub­

cutaneous and is placed at the point of maximal supraalar collapse Auricular cartilage is

preferred becau se of the curvature of the cartilage The convex side of the graft is oriented

laterally to correct the supraalar pinching If this pocket is too superficial, the graft may be

palpable or visible.When placed via an external rhinoplasty approach, secure the graft with

a suture applied medially from the graft to adjacent soft tissue or lateral crus

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Figure 20 A: Alar batten graft

Figure 20 , continued B, C: Intraoperative photographs illustrate location of alar batten graft placement,

centered around the point of greatest weakness and concavity of the alar sidewall The alar batten graft

in this case has been fashioned with autogenous auricular cartilage

Figure 20, continued D, E: Alar batten grafts may be placed via a precise pocket endonasal rhinoplasty

approach

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Surgery oj the Nasal Tip

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Figure 20, co ntinued F-T: Prima ry rhinoplasty patient with cephalic positioning of the lateral crura requiring alar batten grafts Preoperative photographs (F-I)

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Figure 20, continued As demon­

strated on base view (J), gentle inspi­

ration results in valve collapse