8/13/2019 A Closed Rhinoplasty Technique to Narrow and Rotate the Nasal Tip

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FOCUS ON TECHNIQUE

A Closed Rhinoplasty Technique to Narrow

and Rotate the Nasal TipGeoffrey R. Keyes, MD, FACS

InAesthetic Rhinoplasty,1Jack Sheen described four important

landmarks on the nasal tip. These landmarksthe right and leftdomes, the point of tip differentiation or supratip breakpoint, andthe columellar-lobular junction or columella breakpointhaveproved invaluable in defining tip aesthetics. Later, Sheen added theconcept of the angle of divergence and the angle of rotation to tipanalysis.

Rhinoplasty usually requires some form of tip modification toimprove the appearance of the nose. When the aestheticrequirements call for narrowing the angle of divergence, bybringing the domes closer together, and increasing the angle of

rotation, several surgical maneuvers may help achieve these goals.Traditionally, suture techniques and cartilage grafts have beenused. All procedures that improve nasal tip appearance havepotential pitfalls that can lead to less than ideal outcomes.

Cartilage grafting may unintentionally produce nasal tipirregularities as edema and skin contracture resolve over the graft.Suture techniques effectively enhance results, but have limitationswhen significant nasal tip rotation is required.

Another approach for narrowing and rotating the nasal tip issplitting the middle crus(Fig. 1).

TechniqueUsing the closed, or endonasal, approach, the middle crus is

separated from the medial crus, low enough on the middle crus tomaintain the curvature of the domal segment of the middlecrus(Fig. 2).

Releasing this segment allows controlled rotation of achondromucosal transposition flap into the desired anatomicposition. Preserving the domal junction with the domal segment ofthe middle crus prevents tip pinching. The weakened tripod of thelateral, middle, and medial crus is then supported by inserting astrong columellar strut. One might look at the nasal alar cartilagesas a visor that, when properly positioned in relationship to thedorsum and columella, creates an aesthetically pleasingappearance.

Before positioning the tip, pulling the chondromucosal flapinferolaterally improves visualization and access to the upperlateral cartilages and dorsum(Fig. 3).

One infrequent complication of this technique is the development ofa bossa, or knuckling of the lower lateral cartilage at the nasal tip.Thin skin and an incision too close to the dome can result incontractural healing forces acting on weakened cartilages. Thisirregularity can be readily managed through a rim incision, withresection of the protruding edge of the cartilage.

Fig. 1

Fig. 2

Fig. 3

Fig. 4 A-F

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8/13/2019 A Closed Rhinoplasty Technique to Narrow and Rotate the Nasal Tip

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Patient ExampleAlthough this technique is most useful in closed primaryrhinoplasty, this patient demonstrates its effectiveness insecondary rhinoplasty. He was unhappy with his drooping nasal tipand columellar show after the primary surgery. With this technique,his tip was rotated cephalically and narrowed, effecting a morepleasing appearance(Fig. 4, A through F).

Reference

1. Sheen JH, Sheen AP.Aesthetic Rhinoplasty, 2nd ed.StLouis: Quality Medical Publishing, 1997.

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