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Nasal Tip Surgery
An accurate diagnosis is essential to any type of surgery. In nasal tip surgery, this necessitates a complete facial analysis in addition to nasal analysis. Once the diagnosis is made, the goals are determined.
The treatment plan should always involve understanding:
1. Anatomic variations of the soft tissues and cartilaginous framework of the tip as well as their contribution to the external appearance.
2. Factors that are responsible for nasal tip support.
3. The effect of surgical modifications on the surgical result.
The treatment plan should be individualized. Tip modifications often involve modifications in other parts of the nose to achieve aesthetic balance with the rest of the nose and the face.
Tip positions can be changed by modifying the lower lateral cartilages (alar cartilages). Suturing the tip cartilages together if they are flared or bulbous can result in a small amount of increased tip projection and definition. Sculpting the tip cartilages by reducing the bulk of the tip cartilages in the lateral crura may also further define the nose. Cartilage grafting to these tip cartilages can also modify their shape and define them as well as strengthen them. A columellar strut-type graft can be placed to increase tip projection using an endonasal or open approach. This graft also adds strength to the nasal tip and prevents a drooping nasal tip in the future. When a columellar strut is used, additional tip projection can be gained by advancing the lateral crura (part of nasal tip cartilages) medially and suturing these to the columellar strut (so called lateral crural steal). If further tip projection is desired, a tip graft can be placed. In secondary or revision rhinoplasty, the amount of tip projection required often necessitates use of cartilage grafts obtained either from the septum, ears or ribs. Sometimes a tip is overprojected and requires decreasing the projection to create more balance with the chin. Decreasing tip projection may require cutting the tip cartilages in the domal region and overlapping them or disrupting the fibrous ligaments of the lower lateral (tip) cartilages.
In cases where the tip defining points are too far apart and the tip is wide, the distances between the tip-defining points can be reduced by suturing the medial walls of the tip cartilages together at the region called "domes" or by resecting a margin (cephalic) of the medial and lateral crura (components of tip cartilages). Reducing tip fullness can be accomplished by trimming the top (cephalic) margins of the lateral crura, suturing the domes together or placing cartilage grafts to reshape a convex cartilages of the tip (lateral crural strut graft or tip graft). In female rhinoplasty, it is pleasant to create a supratip break above the tip. To do this, the tip defining points should be placed higher than the septal angle, depending on skin thickness. Additionally, the supratip skin needs to be conservatively defatted to allow better redraping in this area.
Surgical Approach: the big question - Open versus closed rhinoplasty?
Dr. Rizk performs both and feels both approaches have their indications. However, that being said, the 3d high definition telescope system has dramatically increased the accuracy and precision of the endonasal rhinoplasty (closed approach). The external approach (open) is used in cases of revisions with extensive scar tissue where major grafting is needed with large grafts that cannot be placed adequately and secured with an endonasal approach. The open rhinoplasty incision, when performed correctly, heals in an imperceptible manner.
The Nostrils (alae) - Modifications of the nostrils is the last part of nasal tip surgery performed at the end of the procedure. The reason for this is alterations in the nasal tip projection and cartilages actually makes the nostrils smaller and it is necessary to achieve ideal tip position first in the procedure and then modify the nostrils and reduce them, if necessary, at the end of the procedure.
Narrowing of the alar bases can be performed by removing a pie shaped section of the nostril and bringing the remaining nostril in closer to the columella. In order to do this and still maintain an adequate airway for breathing, it is necessary to first reduce the width of the central structure called columella. A wide columella may block the breathing if nostrils are brought in so a wide columella must be addressed at the same time. A nostril may be wide as measured by an imaginary vertical line dropped from inside of the eye down to the nostrils. If the nostril is outside this line, they need to be brought in. A nostril may also be too large, too thick or have a very large curvature and various incisions inside the nostril address these different nostril abnormalities. Dr. Rizk never puts the incision outside the nostril in-between the junction of nostril and face; instead, he hides the incision on the inside of the nostril to avoid scar visibility. Additionally, the height of the nostril can be modified as well, especially when deprojecting a nose or in cases of cleft noses where the nostrils are significantly asymmetric. When the tip is deprojected and brought closer to the face, often the nostrils will flare a little and require a conservative alar base reduction. Modification of alar base (especially narrowing the nostrils) is finalized after tip configuration and position are complete and the airway patency is assessed and addressed. Both of these parameters affect decisions regarding the necessity and degree of alar base modifications.
Objectives for Nasal Tip Procedures
The objectives for nasal tip surgery are:
1. To obtain satisfactory projection, reduction, or augmentation of the tip by modifying the tip cartilages through resection, incisions, sutures or placement of grafts to change the shape or strengthen the tip cartilages.
2. Obtain equilibrium or balance with the other parts of the nose so the tip is in harmony with the rest of the nasal anatomy and the face. Sometimes, nasal tip cartilages are asymmetric and nasal tip surgery can even the tip cartilages and the nasal tip.
3. If the tip is twisted, nasal tip surgery can improve this condition. Depending on why the tip is asymmetric, correcting it may involve restructuring the tip cartilages, or fixing the underlying nasal septum which supports and may twist the nasal tip.
Modifications of the nasal tip should always be planned in conjunction with possible changes in other structures of the nose because of their intricate relationship.
These include the following:
- Modifications of the dorsum
- Narrowing by sculpting of nasal dorsum
- Reduction of the alar bases
Nasal Tip Support Mechanisms
Mechanisms of the nasal tip support should be assessed in each patient, because they vary with the individual's cartilage anatomy and quality of the overlying skin.
Variables of significance include the following:
1. The size, shape, resistance, integrity, and elasticity of the tip cartilages are all determinants of support mechanisms. Good resistance is a favorable factor. Ethnic noses often have poor tip support and weak tip cartilage and are under-projected and often require cartilage grafting to achieve support and definition.
2. The length and resistance of the tip cartilages (lower lateral or alar cartilages) are important elements of support of the nasal tip. Palpation will demonstrate whether a nasal tip has good recoil and resistance or whether it is easily depressed if cartilages are weak. If the tip cartilages are very short, they should be reinforced with a columellar strut to lengthen the columella.
3. The attachment of the tip cartilage medial crura to the septum is a support mechanism that is important to consider in rhinoplasty surgery.
A factor of varying significance is a cartilaginous hump of considerable size, which can act as a tent pole. Its reduction can cause a noticeable loss of tip projection. Cartilage grafting in selected tip locations can often correct any loss of tip projection that occurs with different aspects of a rhinoplasty. It is the removing from one area, balanced with adding in other areas of the nose that makes a rhinoplasty operation so artistic.
How to Define and Create Nasal Tip Support
The major breakthrough in our understanding of nasal tip surgery over the last decade occurred by observing the results of how older more aggressive rhinoplasties have healed with collapsed and saddled areas. We now appreciate the importance of conservative surgery and less excision of cartilage in the nasal tip. Instead, we use cartilage grafts to achieve definition and support. By minimizing cartilage excision, the results are not minimized; rather cartilage grafting can also achieve dramatic and natural results without compromising the nasal airway and without causing breathing problems. Suture techniques to reshape cartilages are also a powerful tool to reshape and sculpt the nasal tip in a natural way. The nasal skin if thick can also be debulked and defatted internally to redrape better on the new nasal tip architecture to create a more sculpted appearance.
Surgical approaches to change the nasal tip depends on the tip structures, revision or primary surgery, symmetry, strength, skin thickness, definition and projection. Both open (external) and closed (endonasal) methods can be employed and each have their indications. Dr. Rizk uses his technique of 3d tip contouring with high definition camera system and telescopes through small intranasal incisions to achieve a more rapid recovery with tip surgery. His cartilage sculpting techniques are done with a special patented powered micro-sculpting tool which creates smooth natural edges if cartilage grafting is necessary. The key to Dr. Rizk's approach is a customized approach to nasal tip surgery. No two noses look the same and all nasal tip surgery is customized. Dr. Rizk does not use preformed implants in the nasal tip and sculpts and customizes all implants himself.