The overprojected ( Pinocchio ) tip and the ptotic

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1 Featured Operative Technique Management of the Overprojected Nose and Ptotic Nasal Tip William E. Silver, MD, FCS; and Giancarlo F. Zuliani, MD The overprojected ( Pinocchio ) tip and the ptotic tip are two of the most challenging nasal deformities to correct during rhinoplasty. Combined with careful preoperative assessment and a thorough understanding of tip dynamics, however, one can achieve a harmonious facial aesthetic. The crucial anatomy of the nasal tip relates to the size and shape of the lower lateral cartilages (LLCs) and their intimate relationships with the caudal septum and upper lateral cartilages (ULCs). Modifications of nasal tip rotation and projection should attempt to preserve or reconstruct major tip support mechanisms, thereby eliminating postoperative changes caused by scar contracture. Many authors have discussed ways to deproject the tip and shorten the nose. 1-5 Common to many of these procedures is disruption of the domes and medial crura. With this loss of tip support, scar contracture has led to an increased incidence of postoperative ptosis, notching, pinching, and bossae. In addressing the overprojected nose, the senior author (WES) has used a method by which the medial crura are cut, overlapped, and tucked up into the dome. The procedure is therefore termed a medial crural tuck-up (MCTU). 6 This approach allows for a stable medial crus without the use of a columellar strut graft and resists anterior or posterior movement of the tip during healing. For the extremely ptotic nose (for which traditional methods of cephalic trimming, caudal septal shortening, or lateral crural overlay will not suffice), the LLC to the ULC suspension (LUCS) has proven to be the most consistent and durable technique. oth techniques are easily taught and learned; they also produce consistent, reproducible results. Dr. Silver is a facial plastic surgeon in private practice in tlanta, G. Dr. Zuliani in an merican cademy of Facial Plastic and Reconstructive Surgery (FPRS) sponsored fellow in tlanta, G. Ensuring consistent and reproducible results during cosmetic tip rhinoplasty can be extremely difficult. The unpredictable forces of wound contracture and scarring have humbled even the most experienced rhinoplasty surgeons in various cases throughout their careers. rmed with a knowledge of tip dynamics, however, one can combat the various nasal tip deformities with reasonable accuracy. In this article, we present techniques that are specifically used to correct tip overprojection and tip ptosis. The medial crural tuck-up is a procedure that can be used to deproject the nose while maintaining an overall harmonious tip aesthetic. The lower to upper lateral cartilage suspension has been used in our practice to specifically modify the droopy nasal tip. oth procedures have produced excellent long-term results. (esthetic Surg J 2009;29: ) PREOPERTIVE EVLUTION Photographs are obtained at exactly half-scale, with the patient in the Frankfort horizontal plane. Measurements are made on the photographs to determine the desired amount of nasal tip movement. ecause photos are analyzed at half-scale, any preoperative measurements are then multiplied by two in order to give the surgeon the correct amount of necessary surgical reduction. Nasal projection is measured from the alar facial groove to the tip-defining point. s described by Simons, 7 nasal tip projection is considered ideal if the distance from the base of the columella to the nasal tip is in a 1:1 ratio with the height of the upper lip from subnasale to the vermillion border. If the nasolabial angle is to be unchanged, the amount of tip deprojection provided by the MCTU will be equal to the amount of cartilage overlap of the medial and lateral crura. Using a lateral photograph, the nasolabial angle is measured by drawing a line from the most anterior to posterior points of the nostril and then bisecting it with a vertical line dropped along the upper lip. droopy or ptotic tip is defined as one with an angle of < 90 in men and < 100 in women. The measured amount of cephalic rotation desired is then used to suspend the cephalic border of the lateral crura of the LLC over the caudal border of the ULC provided by the LUCS. MEDIL CRURL TUCK-UP TO DECRESE NSL TIP OVERPROJECTION ll photographic measurements are recorded and taken to the operating room along with drawings of our proposed modifications. If the nasolabial angle is to remain the same as the preoperative measurement, then the amount of the overlap of the anterior portion of the lateral crus of the LLC over the posterior portion of the LLC will remain esthetic Surgery Journal Volume 29 Number 3 May/June

2 the same as the measured decrease in the nasal tip projection during the MCTU. If the nasal tip is to be rotated superiorly, the amount of overlap of the anterior portion of the LLC over the posterior portion of the LLC is increased according to the amount of desired rotation. n external incision is used to expose the alar cartilages and nasal dorsum. The alar cartilages are then separated in the midline. Modifications of the nasal septum or dorsum may either be performed before or after addressing the tip structures. Using a caliper, the deprojected measurement is drawn out from the dome posteriorly onto each medial crus. The measurements should be equal on both sides unless one medial crus is longer than the other. In that case, the extra length is taken into consideration and a longer measurement is made posteriorly onto that medial crus. The medial crura are then cut along the lines that were previously drawn. This line should be parallel to the slope of the dome, in order to allow the cut ends of the posterior portions of the medial crura to fit exactly into the niche of the domes upon completion of the tuck-up. The vestibular skin is then separated from the anterior portion of the incised medial crus with sharp scissors. The separation reaches into the undersurface of the dome. The posterior portion of the medial crus that is left attached to vestibular skin is then tucked into the exact undersurface of the dome. This allows the upper portion of the medial crus to overlap the lower portion on its medial side. These overlapped portions are sutured together with two horizontal mattress sutures of 5-0 polydioxanone (PDS) (Figure 1). There is a small redundancy of vestibular skin in the dome region after this dissection. This excess does not need to be trimmed, because the skin redrapes and adheres to the dome within two to four weeks. The same procedure is repeated on the contralateral side. ttention is now turned to the lateral crura of the LLC. Following the tripod model of tip dynamics, we must correct the surgically created tip ptosis by performing a lateral crural overlay to cephalically rotate the tip. 8 The amount of lateral crural overlay will be equivalent to the amount of medial crural overlay. To allow this, sufficient vestibular skin is freed from the underside of the LLC. The anterior segment is then placed over the posterior stable portion of the LLC and sutured in place through both cartilaginous segments and vestibular skin, using 5-0 PDS sutures in the horizontal mattress fashion. Two sutures are usually used (Figure 2). If further shortening of the nose is desired, this overlay will need to be greater than the original deprojection measurement. When placing sutures for the overlapping of the lower lateral crura, it is important to ensure that they are placed laterally enough that the sutures will not need to be cut if a cephalic trim is necessary. ny residual tip work should then be performed. This includes interdomal sutures used to reconstitute the domes and any cephalic trimming that may be necessary for tip refinement. The last step in correcting the overprojected tip is decreasing the ala and sill of the nostril. Upon completion of the deprojection, a widened nasal base is left. The same measurement that was used to deproject the C D Figure 1. The posterior portion of the cut medial crus, with attached vestibular skin (), is tucked up into the niche of the dome (). s a result, the anterior leg overlaps the posterior leg on its medial side (C). D, n intraoperative demonstration of the procedure outlined in -C, showing the right medial crura being tucked up into its domal niche. Note the proposed markings for incision on the left-sided tip structures. 254 Volume 29 Number 3 May/June 2009 esthetic Surgery Journal

3 C Figure 2., n incision is made over the lateral lower lateral cartilage., Sharp dissection proceeds anteriorly; the lower lateral cartilage is then transposed over the posterior limb and sutured in place (C). dded bulk in this region also serves to reinforce the external nasal valve. D, The posterior portion of the lateral crus is identified. The same measurement for the medial crural tuck-up is used here. line is drawn anteriorly at this level. second line is drawn anteriorly from the first, again using the same measurement as the medial crural tuck-up. These lines and the markings for the alar reduction can be clearly seen in this intraoperative photograph. Figure 3., n incision is made in the alar crease and a second incision is made just above the most inferior portion of the alar rim at the same predetermined measurement as the medial crural tuck-up. In addition, a triangle section of the sill is removed., C, Lateral and basal views (respectively) highlighting the reduction in the surgically created alar flaring after deprojection. D C nose is again used to decrease the alar rim. fter reduction of the ala and sill, the skin on the side of the alar crease incisions is slightly undermined to remove any tension upon closure. These incisions are closed with multiple buried mattress sutures of 5-0 PDS suture (Figure 3). If necessary, osteotomies are performed at this point. The incisions are closed and a routine dressing is applied. Management of the Overprojected Nose and Ptotic Nasal Tip LOWER LTERL CRTILGE TO UPPER LTERL CRTILGE (LUCS) SUSPENSION To correct excessive tip ptosis and ensure that the tip stays in the desired position, the LUCS is employed. The desired suspension is determined during the preoperative analysis. The measured amount of cephalic rotation desired is the measurement used to suspend the cephalic border of the lateral crura of the LLC over the caudal border of the ULC. Volume 29 Number 3 May/June

4 Through an open approach, the LLC is exposed and separated in the midline. Dorsal and septal modifications are then performed. Suspension of the LLC first requires the sharp dissection of the vestibular mucosa from the cephalic borders of both LLC. The surgeon then slides the LLC over the ULC in the exact amount that the tip is to be rotated superiorly. It is sutured in place with two laterally placed 4-0 PDS mattress sutures. This maneuver also serves to reinforce the lateral nasal valves, which reduces or eliminates postoperative lateral nasal valve Figure 4. The most cephalic portion of the lateral crura of the lower lateral cartilage is identified and the vestibular mucosa is dissected from this cartilage. This area is the suspended over the caudal border of the upper lateral cartilage. collapse (Figure 4). fter repeating the procedure on the opposite side, the caudal septum is then shortened to allow for tip rotation. Interdomal sutures are then applied. The amount of LLC that lies above the lateral profile is then resected. Lateral osteotomies are also performed if needed. The incisions are closed and a routine dressing is applied. Clinical examples of these procedures are shown in Figures 5, 6, and 7. CONCLUSIONS oth the MCTU and LUCS have been employed by the senior author (WE) for more than 15 years in more than 100 primary and revision cases. These procedures adhere to modern rhinoplasty paradigms by using cartilage sparing techniques and they can be used on patients with thin nasal skin. They are relatively easy to perform and provide stable, predictable results. We have seen relatively few complications from both the MCTU and LUCS. The few problems we have encountered have involved a minimal degree of postoperative nasal valve collapse after performing the MCTU. Less than 3% of patients experienced such problems, and only one required operative intervention. It is precisely this reason combined with the predictability of the long-term postoperative results that makes these procedures worthwhile to learn and master. DISCLOSURES Dr. Zuliani is affiliated with Premier Image Cosmetic and Laser Surgery P. Figure 5., Pretreatment view of a 20-year-old woman who desired cosmetic rhinoplasty primarily to reduce the size of her nasal tip. Her tip was deprojected using the medial crural tuck-up (MCTU) technique. The MCTU measurement was exactly the same as the lateral crural overlay, which maintained her preoperative nasolabial angle., Posttreatment view one year after MCTU. 256 Volume 29 Number 3 May/June 2009 esthetic Surgery Journal

5 Figure 6., Pretreatment view of a 38-year-old woman who desired cosmetic rhinoplasty to correct both an overprojected nose and a ptotic nasal tip., Posttreatment view 1 year after medial crural tuck-up (MCTU). Her nasal aesthetic was much improved after functional and cosmetic rhinoplasty employing the MCTU technique. ecause of the ptotic tip and the need to cephalically rotate the nose, 9 mm of lateral crural overlay were performed. The MCTU and alar base reduction measured 5 mm. Figure 7., Pretreatment view of a 72-year-old woman with an excessively ptotic nasal tip. She subsequently underwent cosmetic rhinoplasty with a lower lateral to upper lateral cartilage suspension of 4.4 mm., Posttreatment view five years after medial crural tuck-up. The patient was still showing a greatly improved nasolabial angle. Her results demonstrate the overall durability of this technique. The patient also underwent a face lift in the time between the pre- and postoperative photographs. Management of the Overprojected Nose and Ptotic Nasal Tip Volume 29 Number 3 May/June

6 REFERENCES 1. Safian J. The split-cartilage tip technique of rhinoplasty. Plast Reconstr Surg 1970;45: Lipsett EM. new approach surgery of the lower cartilaginous vault. M rch Otolaryngol 1959;70: McCurdy J. Reduction of excessive nasal tip projection with a modified Lipsett technique. nn Plast Surg 1978;1: Close LG, Schaefer SD, Schultz. The over-projecting nasal tip: Precise reduction without rotation. Laryngoscope 1987;97(8 pt 1): Soliemanzadeh P, Kridel RW. Nasal tip overprojection: lgorithm of surgical deprojection techniques and introduction of medial crural overlay. rch Facial Plast Surg 2005;7: Chegar E, Silver WE. nalysis of nasal tip de-projection using the medial crural tuck-up technique. rch Facial Plast Surg [submitted]. 7. Simons RL. Nasal tip projection, ptosis, and supratip thickening. Ear Nose Throat J 1982;61: nderson JR. reasoned approach to nasal base surgery. rch Otolaryngol 1984;100: ccepted for publication January 29, Reprint requests: Giancarlo F. Zuliani, MD, Premier Image Cosmetic and Laser Surgery, 4553 N. Shallowford Rd., Ste. 20-, tlanta, G E- mail: gfzuliani@gmail.com. Copyright 2009 by The merican Society for esthetic Plastic Surgery, Inc X/$36.00 doi: /j.asj Volume 29 Number 3 May/June 2009 esthetic Surgery Journal