THE IMPORTANCE OF THE CARTILAGINOUS FRAMEWORK IN PLASTIC SURGERY OF THE NOSE By ROBERTO FARINA, M.D., OSVALDO DE CASTRO, and RICARDO BAROUDI, M.D. Hospital das Clinicas, Brazil As far as plastic surgery of the nose is concerned, the cartilaginous framework is au-important, since the shape of the nose tip depends on its structure, position, and size. Cartilagines Alares Majores (Alar Cartilages).--There are two symmetrically opposed to each other and made up of two crura, the crus mediale and the crus laterale. The crus laterale (lateral crus) is continued in the crus mediale (medial crus) through what is called the cupola (dome) of the cartilago alaris major. The side of the nose takes its conformity from the crus laterale, hypoplasia of which can cause the side of the nose to collapse. On the other hand, if one of the crura lateralia is more developed than the other or if there is no symmetry between the positions of these two crura, the result may be asymmetry of the nose side or nostrils. The medial crura are responsible for the height or length of the pars mobilis septi (sub-septum or columella) and, consequently, for the height of the nose base. If one of the medial crura is more developed than the other or if there is no symmetry between their positions, the result may be asymmetry of the columella. In the same way, if there is a development of connective tissue which sets the crura medialia apart, there may be a thick or a bifid columella. The cupola of the alar cartilages is responsible for the shape of the nose tip. The angle (cupola) formed by the lateral crus and the medial crus is also responsible for what is called the columello-alar angle. A rhombic columello-alar angle suggests a very wide cupola, i.e., the angle between the medial crus and the lateral crus is superior to 45 degrees. A thin-tipped nose means that the columello-alar angle is acute, i.e., inferior to 45 degrees. A rhombic-tipped nose means that the columello-alar angle is superior to 45 degrees. In this case there is also a larger quantity of connective tissue between the cupola:, between the medial crura of the alar cartilages, and even between their lateral crura. On the other hand, the shape of the columello-nasal angle (the angle formed by the intersection of two lines--one parallel to the columella and another parallel to the back of the nose) depends a great deal on the structure of the medial crura of the alar cartilages. A columella line gracefully broken in its upper third is responsible for a "flit-up " nose. In plastic surgery of the nose, treatment is frequently directed to the cartilages of the nose tip, especially to the alar cartilages. The surgical treatment of the alar cartilages, their two crura, and cupola is doubtless the most delicate and ingenious part of the plastic surgery of the nose. Generally speaking, if a nose has a big tip and a long columella, it is necessary to reduce the columello-alar angle formed by the lateral and medial crura of the I6o
CARTILAGINOUS FRAMEWORK IN PLASTIC SURGERY OF THE NOSE 161 alar cartilages. This means that the whole cupola must be taken away and that both crura must be partially reduced. The more that is taken away from the medial crus (close to the cupola) the shorter will be the columella, and, as a consequence, the height of the nasal base will be shorter. In cases where the columella is the normal length, and even in cases where it is less long than usual, it is not advisable to take the whole cupola away. Disturbance of continuity of the alar cartilages may cause more or less serious deformities of the nose tip: asymmetry of the nostrils, asymmetry of the columello-alar angle, asymmetry of the alto, pinched-in nostrils, and asymmetry of the nose tip itself. FIG. I FIG. 2 FIG. 3 Fig. I.IDorsal view of alar cartilage, medial and lateral crura, and cupola. Excision (at the level of the cupola) of a triangle of cartilage whose top ends a millimetre away from the front of the cupola. There is no break of continuity of this cartilage. Fig. 2.--Resection of all cupola cutting through the alar cartilage to shorten the height of the nose base. Fig. 3.--Resection of a segment from the antero-inferior free border of the septal cartilage to shorten the nose. Some writers complicate the cutting of parts of the alar cartilages by making "hockey stick" excisions. To simplify the technique, and to achieve adequate results, the writers recommend excision (at the level of the cupola) of a triangle of cartilage whose top ends a miuimetre away from the front of the cupola of the alar cartilage. As there is no break of continuity of the alar cartilages, perfect symmetry of the columello-alar angles is retained. Moreover, the triangular excision of the cartilages reduces their natural and back prominences, leaving the length of the columella and consequently of the height of the nasal base untouched. It also produces a harmonious profile of the nasal dorsum without the inconvenience of the slight convexity that usually appears on the back of the nose after an operation (Fig. I). In the case of a rhombic nose it is also necessary to cut away the whole connective tissue above the lateral crura of the alar cartilages, as well as the tissue inserted between the cupolm and even between the medial crura of the alar cartilages. In this way a rhombic-tipped nose is converted into a more harmonious one (Fig. 2).
I62 BRITISH JOURNAL OF PLASTIC SURGERY If the patient is a woman, it is interesting in some cases to give the columella a turned-up (" tilt-up ") shape. In this case it is enough to make an excision, symmetrically, from the anterior (inferior) border of the medial crura of the alar cartilages, of a small fragment shaped like a scalene triangle, its base up. In this way the upper third of the columella can be given a graceful turn (" tilt-up "). Cartilagines Nasi Laterales (Upper Laterals) and Cartilago Septi Nasi (Septal Cartilages).--To reduce the length of the nose there are two requirements : FIG. 4 Fro. 5 FIG. 6 Fig. 4.--Profile view of a hump nose. Profile view of the lateral nasal cartilage and Mar cartilage. A, triangular excision of cartilage at the level of the cupola without break of continuity of the alar cartilage. D, excision of the mesial border of the lateral nasal cartilage. Fig. 5.--Straight profile coming after the cartilaginous excisions represented on Fig. 4. Fig. 6.--EC =removal of nasal bone, dorsum of nasal septal cartilage, and of the medial border of the lateral nasal cartilage. Triangle CDF =excision of the inferior border of the lateral nasal cartilage and of the superior border of the alar cartilage. ABC = excision of a triangle of cartilage from the cupola (dome) without break of continuity of the alar cartilage. (I) reduction of the length of the septal cartilage by the excision of a wedge or upper base from ks lower border ; (2) simultaneous reduction of the front border of the upper lateral cartilages and of the posterior border of the lateral crura, so that its total may be nearly equal to the dimensions of the wedge taken away from the septal cartilage. The reduction of those two cartilages must also be in the shape of two scalene triangles whose bases are turned to the median line of the nasal dorsum (Fig. 3). Finally, to reduce the bony cartilaginous convexity of the nasal dorsum it is necessary to take away, in addition to the bony part : (a) a larger or smaller segment of the dorsum of the septal cartilage, as the case may be ; (b) a more or less rectangular fragment of the median end of the upper laterals, its dimensions depending on the circumstances (Figs. 4, 5, and 6). Figs. 7 to I3 illustrate the results of the principles enumerated.
CARTILAGINOUS FRAMEWORK IN PLASTIC SURGERY OF THE NOSE 16 3 FIG. 7 Before.--Long nose and hump nose. Asymmetry of nostrils. Square box-like tip. Treatment.--Excision of a strip from the dorsum of the nasal septal cartilage. Total resection of the cupola of the alar cartilage according to Fig. 2. Fracture of frontal process of maxilla. After.--Nose shortened. Symmetry of nostrils. Normal tip nose.
16 4 BRITISH JOURNAL OF PLASTIC SURGERY FIG. 8 Before.--Nose already operated upon elsewhere. Excess of the cartilaginous component of the nose. Square box-like tip. Hypertrophy and hanging alto of the nose. Treatment.--Excision of a strip from the dorsum of the septal nasal cartilage. Treatment of the lateral nasal cartilage according to Fig. 6. Resection of all cupola of the alar cartilage according to Fig. 2. Fusiform excision from and parallel to the inferior border of the ala of the nose. After.--Straight dorsum. Nose tip narrowed. Reduction to get arch-like form of the alto.
CARTILAGINOUS FRAMEWORK IN PLASTIC SURGERY OF THE NOSE Fit. 9 Before.--Deviated and h u m p nose. Treatment.--Resection of the osteo-cartilaginous dorsum. T r e a t m e n t of the lateral nasal cartilage and nasal septal cartilage according to Figs. 3 and 6. T r e a t m e n t o f the cupola o f the alar cartilage according to Fig. I. After.--Shortened nose without losing its former characteristics. 16 5
166 BRITISH JOURNAL OF PLASTIC SURGERY FIG. IO Before.--Hypertrophy of the cartilaginous framework of the nose. Square box-like tip. Asymmetry of nostrils. Treatment.--Resection of strip of the dorsum of the septal nasal cartilage. Triangular resection of cupola according to Fig. I. After.--Thinned and triangular tip nose. Symmetry of nostrils.
CARTILAGINOUS FRAMEWORK IN PLASTIC SURGERY OF THE NOSE 16 7 FIG. I I Before.--Hump of dorsum. Bulky tip~ long nose. Treatment.--Triangular excision of cupola according to Fig. I. Hump removal. Partial excision of the lateral nasal cartilage and septal nasal cartilage according to Figs. 3 and 6. After.--Normal nose. Symmetry of nostrils. Thinned and triangular tip nose. Angulated "tilt up" of columella.
168 BRITISH JOURNAL OF PLASTIC SURGERY FIG. I2 Before.--Prominent and convex dorsum of nose. Long nose and long nasal base (long columella). Treatment.--Partial resection of the dorsum and inferior border of the nasal septal cartilage. Lateral nasal cartilage reduced. Total resection of the cupola according to Fig. 2. After.--Straight dorsum. Nasal base less high. Long nose shortened.
CARTILAGINOUS FRAMEWORK IN PLASTIC SURGERY OF THE NOSE 169 FIG. 13 Before.--Elongated nose and square box-like tip. Treatmem.--Hump dorsum reduced. Treatment of lateral nasal cartilage, septal nasal cartilage~ and alar cartilage according to drawings 4 and 5 and I. Fracture of frontal process of maxilla to get thin dorsum. After.--Thin straight dorsum and triangular nasal base. SUMMARY The writers study in detail the cartilaginous framework of the nose and the importance of excisions made on it. They consider that the cartilagines nasi laterales, cartilagines alares majores, and cartilago septi nasi must be carefully treated after previous and meticulous planning. Each case requires special treatment according to the deformity it presents. This refers especially to the alar cartilages, and any break in their continuity at the cupola must be avoided as far as possible. To achieve this, the writers excise a triangle at the level of the cupolm, without complete division. The equilibrium, naturalness, and contour of the nose tip depend on careful manipulation of its cartilaginous elements. 2F