Polygonal Analysis of Nasal Tip Problems: A Surgical Algorithm
Polygonal Analysis Of Nasal Tip Problems: A Surgical Algorithm
ABSTRACT
Goals/Purpose: Tip and columella surgery are among the most critical steps in rhinoplasty, whether aesthetic or functional. Disfiguring of the tip and columella results in an inferior overall surgical result even in the most attractive nose, making understanding and hence reconstruction of this area mandatory for any rhinoplasty surgeon.
Although most nasal anatomies possess lower lateral cartilages of adequate length, tip grafts are used commonly to correct deformities. Thorough understanding of the nasal tip dynamics can enable manipulation of the tip cartilages without extra grafting and hence correction of many well-known deformities.
The ellipse model of the lower lateral cartilage promotes a methodical analysis and understanding of the dome dynamics, where the lateral crural steal procedure can be employed to increase tip rotation and change tip projection.
The nasal tip variations can be classified as: lateral crura of normal or increased length; a normal, short or elongated infralobule polygon; a normal, short or long columellar polygon; dislocated high, hanging or normal footplate polygons; and various combinations of them. Precise planning and wise combined utilization of the following techniques enables an extensive correction of all the deformities through a few simple steps.
Methods/Technique: Three maneuvers are used to various extends to correct nasal tip and columellar deformities, including the "lateral crural steal" procedure, "footplate setback" and "middle crura overlap" procedure. A modification of the latter, namely the "anterior overlap" procedure is used in certain cases.
1. Nasal tip deformities are handled with primary focus on the lateral crural length. A long lateral crural polygon can be managed by using the lateral crural steal procedure. A positive side effect of this procedure is to increase the infralobule polygon length, hence this effect can be utilized to correct a short infralobule polygon at the same time.
2. Highly positioned footplates can be handled by the footplate setback maneuver. In cases of overprojected noses with long medial crura and short infralobules, the footplates are setback to reduce tip projection. Predetermined setback of the footplates at the beginning of the operation enables the lateral crural steal procedure to increase projection (compensate for the lost projection caused by footplate setback) in addition to tip rotation and correction of the infralobule length.
3. The medial crura overlap procedure is utilized to reduce tip projection in cases with overprojected long medial crura but an adequate infralobule polygon length. This maneuver does not cause a gain or loss in the infralobule polygon length. In cases with a hanging columella, the overlap procedure is modified as an "anterior overlap" procedure to correct this deformity.
Results/Complications: Combinations of the lateral crural steal procedure, footplate setback and the overlap procedures altogether results in achievement of the desired tip rotation, correction of the infralobule/nostril ratio and maintaining the planned tip position, all without use of any tip graft or dome division.
Conclusion: The aforementioned techniques are powerful tools for correction of deformities in the nasal tip and columella area. Wise and planned combination of these techniques can help manipulate these problems to achieve an overall pleasant and satisfactory outcome in the nasal tip area.