When it comes to surgery for the wide and bulbous nasal tip, using a load-bearing wall constructed out of autologous cartilage can balance the tension within the existing tip complex to produce durable functional and aesthetic results, a rhinoplasty expert said during an invited presentation at the Triological Society Combined Sections Meeting.
Explore this issue:April 2019
Richard Davis, MD, clinical professor of facial plastic and reconstructive surgery at the University of Miami and Western Section Guest of Honor at the meeting, described the main feature of his approach, a septal extension graft (SEG), used as a “central support tower,” analogous to a suspension bridge with a tower in the middle and suspension cables extending from both sides. “If you use it as an adjunct to skeletal support, a SEG can provide an anatomic tent pole, if you will, from which to suspend the lower nasal side walls,” he said.
Bulbous nasal tips can bring about not just aesthetic problems, but also functional issues, since bulbous cupping of the tip cartilages also causes recurvature.
The “age-old workhorse” of tip refinement—the cephalic trim approach—often produces functional and even aesthetic morbidity, Dr. Davis said, because it destabilizes the skeletal structures of the nose, causing nasal distortion and collapse. “Soft tissue healing forces, which can take decades to complete, will frequently exacerbate progressive deformities such as pinching, retraction, and over-rotation, and often all three will occur in the same patient,” he said.
Tip sutures, another common approach, can pinch off the airway even if there are aesthetic improvements.
You have to individualize. … It’s not a cookbook and you have to think it through, but it works. —Richard Davis, MD
With his “tensioning” approach, Dr. Davis said, the first principle is to keep as much natural skeletal tissue as possible, which will mean more strength and stability over time. The surgeon must then augment naturally deficient or iatrogenically weak noses with structural grafts that are securely suture-fixated to the existing skeletal components, he added. “We’re trying to re-engineer tip dynamics so as to reduce dependence upon bulky and cumbersome grafts that often obstruct the nasal airway.”
The septal extension graft, which serves as a load-bearing wall and central support tower hidden within the central compartment, “will bear the structural load and balance forces in the tip to maintain strength and tone in the side walls.” Tensioning the side wall is a way of creating a “taut, flat, and attractive lateral crus” that will increase resistance to inspiratory collapse without the need for sidewall grafts, he said.
With the septal extension graft, the tip is projected forward but is also buttressed from behind to prevent over-rotation, while also allowing contouring of the silhouette to create the profile contour that the patient wants, Dr. Davis said. You “can put it where you want it, and then you can perfectly position the tip cartilages on this hidden scaffold for the best aesthetic and functional outcome.”
He takes measurements from computer-generated rhinoplasty simulations that are then used to guide placement of the SEG, he said. The repositioning of the lateral crus is then done either with a “lateral crural steal,” in which tension is created when a redundant lateral crus is shortened by laterally repositioning the domal fold, or a “lateral crural lengthening,” in which the lateral crus is elongated to accommodate additional sidewall length by dividing and recruiting the upper medial crus. In both cases, a flat, taut, and attractive side wall with increased resting tone is created to resist inspiratory collapse and eliminate tip bulbosity, he said. “You can tension an over-projected nose, an under-projected nose, or a twisted nose—it doesn’t matter,” he added. “You have to individualize. … It’s not a cookbook and you have to think it through, but it works.”
He acknowledged a common hurdle: patient insistence on a tiny nose. “Keep noses as large as cosmetic tolerances will allow if you want to maintain a satisfactory airway,” he said. “If you’re 10 feet tall, you feel like life is tough at 10 feet, but why would you want me to make you only two feet tall? That’s just a different kind of misery. Somewhere in the middle is happiness, a nose that’s not too big, but also one that’s not too small. That’s where joy lives.”
Thomas Collins is a freelance medical writer based in Florida.