FOCUS ON TECHNIQUE A Closed Rhinoplasty Technique to Narrow and Rotate the Nasal Tip

Geoffrey R. Keyes, MD, FACS In Aesthetic Rhinoplasty, Jack Sheen described four important landmarks on the nasal tip. These landmarks the right and left domes, the point of tip differentiation or supratip breakpoint, and the columellar-lobular junction or columella breakpointhave proved invaluable in defining tip aesthetics. Later, Sheen added the concept of the angle of divergence and the angle of rotation to tip analysis. Rhinoplasty usually requires some form of tip modification to improve the appearance of the nose. When the aesthetic requirements call for narrowing the angle of divergence, by bringing the domes closer together, and increasing the angle of rotation, several surgical maneuvers may help achieve these goals. Traditionally, suture techniques and cartilage grafts have been used. All procedures that improve nasal tip appearance have potential pitfalls that can lead to less than ideal outcomes. Cartilage grafting may unintentionally produce nasal tip irregularities as edema and skin contracture resolve over the graft. Suture techniques effectively enhance results, but have limitations when significant nasal tip rotation is required. Another approach for narrowing and rotating the nasal tip is splitting the middle crus (Fig. 1). Technique Using the closed, or endonasal, approach, the middle crus is separated from the medial crus, low enough on the middle crus to maintain the curvature of the domal segment of the middle crus (Fig. 2). Releasing this segment allows controlled rotation of a chondromucosal transposition flap into the desired anatomic position. Preserving the domal junction with the domal segment of the middle crus prevents tip pinching. The weakened tripod of the lateral, middle, and medial crus is then supported by inserting a strong columellar strut. One might look at the nasal alar cartilages as a visor that, when properly positioned in relationship to the dorsum and columella, creates an aesthetically pleasing appearance. Before positioning the tip, pulling the chondromucosal flap inferolaterally improves visualization and access to the upper lateral cartilages and dorsum (Fig. 3). One infrequent complication of this technique is the development of a bossa, or knuckling of the lower lateral cartilage at the nasal tip. Thin skin and an incision too close to the dome can result in contractural healing forces acting on weakened cartilages. This irregularity can be readily managed through a rim incision, with resection of the protruding edge of the cartilage. Fig. 4 A-F
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Patient Example Although this technique is most useful in closed primary rhinoplasty, this patient demonstrates its effectiveness in secondary rhinoplasty. He was unhappy with his drooping nasal tip and columellar show after the primary surgery. With this technique, his tip was rotated cephalically and narrowed, effecting a more pleasing appearance (Fig. 4, A through F). Reference

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Sheen JH, Sheen AP. Aesthetic Rhinoplasty, 2nd ed. St Louis: Quality Medical Publishing, 1997.