Nasal Tip Delamination: A Technique for Nasal Tip Projection and Control in Rhinoplasty.

BACKGROUND: Control of tip projection and rotation is critical to a successful rhinoplasty. Suture techniques that change the relationship of the medial crura to the caudal septum can effectively manage tip position, but may be technically challenging or require specialized sutures. The authors present a technique ("tip delamination") that allows symmetrical exposure of the medial crura and caudal septum for accurate placement of projection control sutures using commonly available suture materials.
METHODS: We describe a novel technique to completely expose (or delaminate) the medial crura of the lower lateral cartilages to allow for 360-degree access to and manipulation of these critical structures. We present a case series of 3 patients.
RESULTS: Exemplary cases with 1 intraoperative video will be reviewed to demonstrate how tip delamination allows for more precise control of the medial crura and nasal tip.
CONCLUSIONS: Nasal tip delamination is a simple technique for manipulating the medial crura and nasal tip in rhinoplasty procedures. Nasal tip delamination adds minimal time and morbidity to the procedure and offers significant control for the surgeon, with beneficial outcomes for the patient.

INTRODUCTION

Control of tip position is vital to optimize rhinoplasty outcome. Many authors have delineated strategies for tip projection control.[1-7] For example, Daniel described columella septal sutures and septal rotation sutures, which move the tip relative to the caudal septum.[4] Guyuron discussed the importance and effect of 9 different suture techniques to define and position the nasal tip, including a medial crura anchor suture.[1,2,6] Tebbetts described a projection control suture to increase or decrease tip projection (cephalad medial crura to caudal septum), and a tip rotation suture to rotate the tip cephalad (cephalad border of the medial or middle crus near the columella to dorsal septum near the septal angle).[3,5]

However, all strategies to reposition the tip using sutures to the caudal septum are limited by the soft tissue envelope surrounding the medial crura, making exposure and accurate suture placement difficult. In this article, we describe a novel technique to completely expose (or delaminate) the medial crura to allow for 360-degree access to and manipulation of these critical structures, using a case series of 3 patients.

Surgical Technique

Tip delamination procedures are performed via an open approach. A right-side hemitransfixion incision. exposes the caudal septum and allows for septal harvest, if necessary. A staggered midcolumella incision extended through bilateral marginal incisions allows exposure of the tip and dorsum. Dorsal work is completed before tip modification and positioning. Projection control sutures are placed after all other tip maneuvers are complete, including modification of the caudal septum either through resection or augmentation with a septal extension graft. The mucosa adjacent to the medial crura is injected with 0.25% marcaine with 1:200,000 epinephrine. In addition to anesthetic and vasoconstrictive properties, this also adds an element of hydro-dissection. After exposure of the caudal septum, the medial crura mucosa is elevated starting at the anterior columellar border, with a #15 scalpel. Therein, the dissection is continued bluntly with an iris scissor until the scissor emerges from the hemitransfixion incision (Fig. 1). This is performed bilaterally. The mid-portion of the medial crural complex is now exposed in a 360 degree manner. For tip control, a 5-0 PDS suture, on a P-3 needle, is placed through the right medial crura, strut graft (if present), and left medial crura (Fig. 1). The needle is then reversed and the blunt end passed under the left side mucosa to emerge from the hemitransfixion incision. The desired vector for tip movement is estimated and the suture passed through the caudal septum left to right. The needle is reversed, and the blunt end passed under the right-side mucosa to be tied anteriorly. (See Video [online], which displays tip control suture.) The orientation of the suture on the medial crura relative to the caudal septum determines the direction of tip movement. Suture placement that increases rotation and projection is referred to as a “positive vector,” while sutures that derotate and reduce tip projection are described as having a “negative vector.” Occasionally more than 1 suture must be placed to refine the columella septal relationship.

Fig. 1.

Nasal tip delamination. A, Blunt elevation of the mucosa. B, Tip control suture. A suture is placed right to left through the medial crura, reversed, and the blunt end passed under the left-side mucosa to emerge from the hemitransfixion incision. The desired vector is estimated, and the suture passed through the caudal septum left to right. The needle is reversed, and the blunt end passed under the right-side mucosa to be tied anteriorly.

Video 1.

Video 1 from "Delamination of the medial crura: a technique for access the nasal tip projection and control in Rhinoplasty"

RESULTS

Case Examples

Case 1: A 28-year-old patient with a dorsal hump and under projecting flat tip (Fig. 2). Tip projection and rotation increased with tip-shaping sutures and tip projection suture placed via delamination with 1-mm positive vector.

Fig. 2.

Postoperative outcomes. Preoperative (A) and postoperative (B) photographs of patient in Case 1.

Case 2: A 29-year-old patient with posttraumatic dorsal irregularity and over projecting tip. Tip is de-projected with a tip projection suture and 2-mm negative vector. (See figure, Supplemental Digital Content 1, which displays preoperative (a) and postoperative (b) photographs of Case 2. http://links.lww.com/PRSGO/B492)

Case 3: An 18-year-old patient with a complaint of dorsal hump and overprojecting dependent tip. Tip recessed with a negative vector tip suture placed by delamination. (See figure, Supplemental Digital Content 2, which displays preoperative (a) and postoperative (b) photographs of Case 3. http://links.lww.com/PRSGO/B493)

DISCUSSION

Open rhinoplasty allows access to modify tip projection and rotation. Traditional techniques have focused on resection or augmentation of the caudal and anterior septum, and manipulation of the medial and lateral crura. Suture techniques (such as the tongue-in-groove technique and deliver techniques) that lever, advance, or recess the medial crura relative to the caudal septum have been described by several authors.[1-6] Although such techniques are helpful for tip control, suturing the medial crura to the caudal septum can be technically challenging. Symmetric placement of a suture through the medial crura from the limited exposure of a transfixion incision alone can be difficult and may necessitate multiple suture attempts, thereby risking damage to the cartilaginous structure of the medial crura. Additionally, suturing from the caudal margin of the medial crura allows for symmetric suture placement but requires a double-armed straight needle and bilateral transfixion incisions. The tip delamination technique described in this manuscript allows for wider exposure and accurate, symmetric suture placement using readily available suture materials. The elevated skin and mucosa facilitate accurate placement of sutures without a concern for tethering the overlying soft tissue, which might affect ultimate results.

Concerns regarding the delamination technique might include those related to increased dissection, namely increased edema, decreased blood supply to the exposed cartilage, and an uncertainty of healing in the “fourth dimension.” However, in the senior author’s 10-year experience with this procedure, this has not been proved to be true. Cartilage is inherently avascular and is not affected by elevating the surrounding skin and mucosa, as we know from numerous other rhinoplasty procedures. The amount of dissection performed with this technique is not significantly increased compared with standard techniques and in combination with a hemitransfixion incision less morbid than other techniques. Unfavorable scarring can be prevented by meticulous dissection of the mucosa to prevent tears. In the senior author’s practice, tip projection has not been changed more than 3 mm, as greater changes can lead to an unnatural result and potential splaying of the lateral crura. No columella scar revisions have been necessary.

CONCLUSIONS

Achieving nasal tip control in open rhinoplasty can be technically challenging. The nasal tip delamination technique significantly improves exposure to the medial crura for enhanced placement of tip-controlling sutures and final results. The technique is safe, adds minimal time and morbidity to the rhinoplasty procedure, and is a powerful tool for any tip rhinoplasty procedure.

PATIENT CONSENT

Patients provided written consent for the use of their images.