Cephalic Trim Rhinoplasty is a minimally invasive cosmetic surgery procedure that reshapes the nose and improves the overall facial appearance in patients. This guide reviews all of the aspects of Cephalic Trim Rhinoplasty, including septal extension graft, transdomal suture, and columellar strut graft.
Are you thinking about a Cephalic Trim Rhinoplasty? You are not alone, and in this guide we review what to expect from the treatment, including aspects such as septal extension graft, transdomal suture and columellar strut graft.
Cephalic Trim Rhinoplasty
A cephalic trim rhinoplasty is a minor surgical procedure that can significantly improve the appearance of your nose. It involves trimming the cartilage at the front of the nose in order to reduce its size and reshape it into a more appealing shape.
What is a cephalic trim rhinoplasty?
A cephalic trim rhinoplasty is a cosmetic surgery that improves the appearance of your nose. It involves removing skin from the top of your nose, which can help reduce the size of your bulbous tip or make it appear more refined.
You may be a good candidate for this procedure if you have:
- A bulbous tip (protruding tip) that makes it difficult to breathe through your nose, especially when sleeping on your side
- A large bump at the top of your nose where it meets with other facial features
Cephalic trim rhinoplasty recovery
After surgery, you will be in a splint for three weeks. This means that you’ll need to wear it at night and during the day while sleeping. You may feel some discomfort from wearing the splint if it’s too tight or uncomfortable around your nose. If this happens, talk with your doctor about how to adjust it so that it doesn’t hurt anymore.
After surgery is over and you’ve recovered from anesthesia, there are some additional steps that need to be taken before returning home: Your doctor will want you off any non-steroidal anti-inflammatory medications (such as ibuprofen). They can cause swelling of the face after surgery and interfere with healing processes by preventing blood flow through vessels in areas affected by inflammation caused by injury or infection (think frostbite). Also remember not take any other pain killers such as aspirin unless specifically prescribed by a doctor–they could lead up into further damage on top of what was already done during this procedure!
Cephalic trim rhinoplasty risks and considerations
The risks of cephalic trim rhinoplasty include:
- Nosebleeds or blood clots
- Scars that are too wide or uneven, which can cause deformity or disfigurement of the nose (this is rare)
The considerations for cephalic trim rhinoplasty include:
- A consultation with a board-certified plastic surgeon is recommended to discuss whether this procedure is right for you and what its limitations are. If you’re interested in undergoing this type of surgery, it’s important that your surgeon has experience performing cephalic trim rhinoplasties as well as other cosmetic procedures on Asian patients. The benefits associated with having an experienced team working on your case include less time spent under general anesthesia and fewer complications during recovery
A cephalic trim rhinoplasty can improve the appearance of your nose but it comes with risks and side effects.
A cephalic trim rhinoplasty is a surgical procedure used to improve the appearance of your nose but it comes with risks and side effects. The cephalic trim rhinoplasty is also called an open septorhinoplasty. This procedure can be performed in combination with other facial cosmetic surgeries such as facelifts, browlifts and eyelid reduction surgery so that all of these procedures work together as one treatment plan for you.
The cephalic trim rhinoplasty is a popular procedure because it has been shown to improve both the shape and size of your nose without affecting its function or causing any discomfort after surgery.
septal extension graft
Proper nasal tip projection and rotation have a strong impact on nasal aesthetics. Septal extension graft (SEG) is one of the tools employed to improve tip projection and rotation when performing rhinoplasty. This graft typically overlaps the existing caudal septum in the midline position, lengthening it and facilitating the repositioning of the tip.
The authors sought to describe the technical evolution of the SEG in endonasal rhinoplasty and evaluate the reliability and long-term efficacy of the current technique.
The authors evaluated presurgical and postsurgical photographs of the nasolabial angle and nasal proportions in 60 patients who underwent endonasal rhinoplasty with SEG.
The study demonstrated a clear improvement in tip projection and rotation at the 1-year follow-up. The mean preoperative nasolabial angle was 93.75° ± 9.45° compared with 101.1° ± 5.3° following surgery. Although both were normally distributed, the range of the postoperative nasolabial angle was narrower than 1-year preoperatively (standard deviation = 5.3° vs 9.45°, respectively). The Crumley ratio, utilized to describe nasal proportions, presented significant changes in nasal proportions: 3.84 preoperatively and 4.04 postoperatively (95% confidence interval = −0.24 to −0.149; P < 0.001).
The utilization of SEG in endonasal rhinoplasty has significantly changed since first described in 2006. The adaptations made to this technique render it more reliable, and our study demonstrates its efficacy in improving tip projection and rotation over the long-term.
transdomal suture
The authors use 5 basic suture techniques in tip plasty: transdomal, interdomal, lateral crural mattress, columella-septal, and intercrural, incorporating these techniques into a simple algorithm to control tip cartilage shape. They then introduce the universal horizontal mattress suture, designed to control all undesirable nasal cartilage convexities/concavities, and provide a new suturing technique that can be applied in all patients in whom a change of cartilage shape, including tip cartilages, is desired. They also apply these suture techniques in patients undergoing closed and secondary rhinoplasty.
If rhinoplasty is arguably the most difficult operation in aesthetic plastic surgery, tip plasty has been described as its most difficult aspect. Traditional techniques of excision, scoring, and crushing cartilage to remove unwanted convexity or bulbosity have been associated with complications such as alar retraction, rim collapse, inspiratory breathing problems, and, most notably, supratip and polly beak deformities.
Suture techniques to control tip shape were created along with the first rhinoplasty procedures. Plastic surgeons, working in the 20s, used rather complicated stitch patterns to secure the tip complex to the caudal septum in an effort to prevent the tip from dropping after surgery.
Over the decades, suture techniques were introduced intermittently, but to a limited extent. It was not until the early 80s that there was a surge in suture techniques to control tip shape. Tardy et al1 introduced one of the first techniques—a suture to reduce the width of the domes in the closed approach. Daniel2 popularized a dome control suture for the open approach. Tebbetts,3 more than anyone else at the time, suggested a change in our approach to cartilage control by suggesting nondestructive techniques. A number of suture techniques to control virtually every part of the nasal tip complex became available.4–18
The beginning rhinoplasty surgeon might be confused by the many nasal tip suture techniques available and the many different names used for essentially similar techniques. Here, I will provide a simple algorithm, using the most commonly understood terminology19 that can be applied to almost all types of nasal tips. I will also provide a new and basic technique of suturing that has general applicability to all situations in which the surgeon wants to change the shape of the cartilage.
It must be acknowledged that there are other such algorithms that also work very well. These include Daniel’s2 3-suture algorithm and the algorithm by Rohrich and Adams20 for the boxy tip and a more generalized algorithm by Guyuron and Behman.18
Because suture techniques are intended to change the shape of tip cartilages, the assumption is that there is cartilage of sufficient size and integrity to permit the application of suture techniques. When cartilage is missing or extraordinarily weak, grafting is necessary. Tip grafts, columellar struts, spreader grafts, and lateral crural struts will not lose their significant roles in rhinoplasty simply because suture techniques are available.21
Fundamental Principles of Suture Tip Techniques
Use a Model to Facilitate Suture Sculpting
Once the skin flap is reflected and the tip cartilages are visible, decisions have to be made about what to resect and what to contour with sutures. Fundamentally, tip plasty is biological sculpting, with cartilage used as the medium. For the beginning surgeon, this task can be daunting; having a model to reference makes the task much easier. Memorizing images of what should be drawn or sculpted, including lengths and angles, is reasonable but more tedious.
To facilitate sculpting, a model has been developed that constitutes a good approximation of what the tip cartilage framework should look like after a conventional tip plasty (Figure 1). The lateral crus are flat and 6 mm wide to minimize chances of inspiratory collapse. The dome is about 6 to 8 mm above the dorsum to compensate for the thick supratip skin.
A model facilitates the sculpting of tip cartilages by providing the approximate lengths, widths, and angles of an operated tip cartilage that has received cephalic trim of the lateral crus and narrowing of the domes. Note the following: (1) the tip is about 6 to 8 mm above the dorsum, (2) the angle of dome divergence as the axis of the domes separate, and (3) the domes do not touch one another; there is approximately a 3-mm separation between the cephalic end of the domes.
The angle of domal divergence, defined as the angle made by the medial crura as they splay apart (as seen on basal view), is apparent.22 A separation of about 3 mm between the cephalic ends of the domes is evident, which should serve as a reminder that the domes are not to be squeezed together.
Leave a 6-mm Wide Lateral Crus
As a general rule for bulbous broad tips, it is best to excise part of the cephalic lateral crus so that the remaining lateral crus is 6 mm wide, a width sufficient for structural integrity, which also enables suture techniques to control unwanted convexity.
Note the Delayed Effects of Sutures
Harris et al23 noted that cartilage that is cut or scored will show signs of warping within 15 to 30 minutes. Similarly, cartilage that has been manipulated by sutures can show minor changes during the course of the operation. It takes time for the cartilage to reach a state of equilibrium. Therefore it is important to reexamine the sutured areas before closing the nose.
Follow Guidelines for Suture Type and Size
For many years the senior author (R.G.) believed that permanent sutures would be necessary to achieve a permanent effect on cartilage contour. That has simply not been proven true. Polydioxanone (PDS) sutures work just as well as permanent sutures and have the benefit of not causing stitch reactions (by protruding through the skin) or microabscesses that manifest as a bad odor noted by the patient. As for suture size, 5-0 PDS is empirically the size of choice for tip cartilages.
Make Use of the Universal Horizontal Mattress Suture
Although there are many specific suture techniques to control the shape of tip cartilages, the general principle is to modify unwanted convexity or concavity.24,25 A horizontal mattress suture will reduce unwanted curvature of any nasal cartilage (including the septum), provided the cartilage is not more than 10 mm wide (Figure 2). The first purchase must be made perpendicular to the long axis of the cartilage, and the second purchase must be made at 6 to 8 mm from the first purchase. For cartilages thicker than 0.5 to 1 mm, the interval between purchases should be closer to 10 mm. The benefit of controlling cartilage shape with sutures is enhanced by the fact that the strength of the sutured cartilage is increased. A single suture has been demonstrated to increase the strength of .5-mm thick–cartilage by approximately 50%. Scoring to achieve the same degree of cartilage control may work but drastically reduces the strength of the cartilage and runs the risk of collapsing it.
A horizontal mattress suture applied to the convex surface (A) of any cartilage strip that is 10 mm or less will remove most of the convexity (B) and give the cartilage increased strength (C).
Lateral Crus Resection
Before any suture technique is begun, the cephalic part of the lateral crus needs to be resected, leaving the lateral crus at about 6 mm wide and amenable to suture techniques that can completely remove unwanted convexity. There are exceptions to this rule, such as when a patient has preexisting alar retraction or when the nose needs lengthening. In such cases, resecting any lateral crus is contraindicated. However, for average primary and occasional secondary nose surgery in which the nose has a broad, wide, or bulbous tip, narrowing is required and most easily accomplished when starting with a lateral crus that is about 6 mm wide. Although the actual dome can be closer to 4 mm, the main body of the lateral crus should be 6 mm so that it will not collapse and is amenable to manipulation by suture techniques.
The 5 Suture Algorithm
There are 5 basic suture techniques used in tip plasty that the authors have found most useful.
Transdomal Suture
The transdomal suture is perhaps the single most important suture technique for bringing the tip cartilages under control (Figure 3). Local anesthesia, by hydrodissection, is applied deep to the cartilages to prevent the needle from penetrating the lining and causing suture exposure. Standing at the head of the patient’s bed, one simply grasps the dome with a Brown-Adson forceps, squeezes it gently, and applies a mattress suture, beginning on the medial side of the dome. It is important that the transdomal suture is centered on the width of the cartilage; otherwise, it may result in unexpected and frequently undesirable changes in the lateral crus. To be certain that the vestibular skin has not been penetrated, it is helpful to temporarily leave the needle in place (as it passed through the dome cartilage) and then use the needle holder to palpate the underside of the dome to check for needle exposure.
A, The transdomal suture is a horizontal mattress suture that narrows the dome and therefore the nasal tip. B, Intraoperative view of transdomal suture of right tip as seen from the head of the bed. Note improvement to tip of width on the right side.
It is easy to see that the domes have an axis and orientation — a cephalic and caudal end. The dome no longer looks like a small parachute as it did before resection of the cephalic lateral crus. The axes of the 2 domes form an angle of domal separation that is about 60 to 90 degrees. If for some reason the angle is abnormal, it can be altered by removing the suture, regrasping the dome so that the axis angle is altered, and then reinserting the transdomal suture.
Interdomal Suture
The interdomal suture provides tip strength and symmetry (Figure 4). This stitch is particularly important if the domes are weak and tend to splay apart; however, the purpose of the interdomal suture is not to bring the domes in contact with each other.
A, An interdomal suture brings the 2 tips together, prevents them from splaying, and contributes to the narrowing of the nasal tip. The purchase is made approximately 3 mm posterior to the domes. Usually the cephalic ends of the domes are allowed to be separate from one another by about 3 mm. B, Intraoperative view of interdomal suture.
As the model indicates, there is usually about 3 mm between the cephalic ends of the domes, a distance that is not absolute (Figure 4, A). If the domes are large and divergent, you might want less distance between the cephalic ends of the domes so that overall the tip is not too wide. To achieve that end, a 5-0 PDS suture (Ethicon, Somerville, NJ) is applied between the middle crura (on the cephalic side) and about 3 to 4 mm below (posterior) to the dome. The overall nasal tip width is controlled by the interdomal suture, as well as the transdomal sutures. In men, a wider tip width is planned for than in women, controlled by both the interdomal and transdomal sutures.
Lateral Crural Mattress Suture
The underside of the lateral crus is infiltrated with anesthesia and a horizontal mattress suture (5-0 PDS) is applied at the apex of the lateral crus convexity (Figure 5). Standing at the head of the patient’s bed, the lateral crus is grasped with a Brown-Adson forceps, and the needle is passed on one side of the forceps perpendicular to the long axis of the lateral crus. The lateral crus should be slightly folded around with the forceps so that the smallest possible purchase can be made with the needle. Typically, a C-3/P3 needle (Ethicon) is used.
A, Lateral crural mattress suture. This is a universal horizontal mattress suture applied to the most convex surface of the convex lateral crus. It is frequently necessary to apply a second lateral crural mattress suture posterior to the first to flatten out the entire lateral crus. B, Intraoperative view.
A second purchase is made on the other side of the forceps at a distance of about 6 to 8 mm from the first purchase. The resulting knot is cinched until the convex crus flattens. Tying the knot too tightly may cause unwanted concavity of the lateral crus. There is frequently residual convexity in the posterior aspect of the lateral crus, which should, accordingly, receive a second mattress suture. Occasionally, a third mattress suture may be necessary to achieve a straight lateral crus. Each suture provides an approximately 30% increase in strength to the lateral crus.24,25
Columella-Septal Suture
The principle of the columella-septal (CS) suture is evident in similar suture techniques that also attempt to secure the tip cartilages to the caudal septum to effect both tip projection and rotation. With this suture technique, a large needle is passed between the leaves of the middle crura. (There are many fibers between the middle crura, allowing for very good purchase.)
The needle is then passed through the anterior septal angle, which is usually at a more anterior level to the CS entry (Figure 6). In recent years the senior author has noted that 2 bites of the anterior septal angle are preferable because, occasionally, a single suture may pull out. The needle is then passed back between the leaves of the middle crura. If there is a transfixion incision, a clamp is placed between the tip cartilages and caudal septum to prevent overtightening of the knot. As the knot is slowly tightened, it pulls the tip cartilage up against the caudal septum, correcting any existing hanging columella and also providing a small amount of tip projection. We emphasize “small amount” because the CS suture is not a replacement for the columellar strut. The CS suture should be thought of as a suture technique that fine tunes the position of the tip cartilages with respect to the caudal septum.
A, Columella-septal suture. B, Intraoperative view. Two purchases of the anterior septal angle should be taken to achieve a good purchase. Also, care should be taken not to tie the knot too tightly because that action could cause columellar retraction.
Intercrural Suture
Not infrequently the middle crura splay at their caudal ends yielding what will undoubtedly be a wide columella. When inserting a columellar strut, the middle crura also tend to separate or splay. Consequently, an intercrural suture, which is simply a mattress suture (referred to by Guyuron as a middle crus suture and by Daniel as a domal equalization suture) can be used to reduce the width of the cartilages in this location (Figure 7). A 5-0 PDS is used to take a purchase of the inside of the middle crus (from posterior to anterior) on one side and then another purchase on the contralateral side. The knot will be located between the middle crura. Care is taken not to tie the knot too tightly to avoid overly narrowing the normal middle crus width. Again, use of a model helps to determine what is a normal width in this region. If a columellar strut has been placed between the middle crura the needle simply picks up the strut in its path from one middle crus to the other.
A, The intercrural suture brings the caudal aspect of the tip cartilages together and therefore narrows the columella. The suture is applied at the middle crus level. Care is taken not to tie the knot too tightly and cause an overly narrow columella. B, Intraoperative view of needle being passed from one middle crus to the other.
Universal Horizontal Mattress Suture
The universal horizontal mattress suture serves to control any strip of cartilage provided that it is not more than approximately 10 mm wide. This has been demonstrated in L-shaped struts of the septum. In terms of tip plasty there are 2 situations (other than the convex lateral crus) in which the horizontal mattress suture can be helpful:
Tip Grafts
Occasionally, aesthetic surgeons see patients in whom the tip graft of septal cartilage has been inadvertently overscored to lend some curvature. Fortunately, a horizontal mattress suture (5-0 PDS) applied to the scored (hyperconvex) side of such a damaged graft can completely correct it (Figure 8).
Excess curvature of a tip graft due to overscoring septal cartilage, or a naturally hyperconvex cavum concha graft, is corrected by a horizontal mattress suture applied to the convex surface.
On occasion, you may attempt to use concha cavum for a tip graft but then discover that it is too convex. Under those circumstances, a horizontal mattress suture of 5-0 PDS is simply applied to the hyperconvex side, and the knot is tied tight until the hyperconvex graft is converted to a slightly convex graft.
Distorted Lateral Crura
Not uncommonly, patients complain of a bump inside the nose that is bothersome to the touch or interferes with their airway function. In such a case, the patient is referring to a curling of the posterior aspect of the lateral crus that protrudes into the vestibule. Although there are several ways to correct this problem, one of the easiest and most effective is to make an incision on both sides as well as the posterior side of the lateral crus. This delivers the posterior aspect of the entire lateral crus. Essentially, a composite flap of vestibular skin and lateral crus is delivered into the vestibule (Figure 9). A 5-0 PDS is applied on the convex side. A second horizontal mattress suture may be required to straighten out the lateral crus. The flap is simply returned to its bed.
If the posterior end of the lateral crus protrudes into the vestibule, it is corrected by releasing the entire posterior aspect of the lateral crus, (A) delivering it into the vestibule, and (B) applying a 5-0 PDS suture on its convex side to straighten it out.
Suture Algorithm in Closed (Endonasal) Rhinoplasty
Any suture technique executed in the open approach may also be executed in the closed (endonasal) approach. However, it is more difficult to do so, particularly if the tip cartilages are not adequately delivered. To deliver the tip cartilage, both an intercartilaginous and transfixion incision are needed along with a marginal incision that continues toward the inside of the upper columella. Dissection should be extensive as is necessary to allow the dome to be delivered through the nostril. Doing so makes it possible to apply transdomal and lateral crural mattress sutures (Figure 10). In general, a judgment about suture technique efficacy can only be made after the dome is replaced within the skin sleeve. However, a judgment about lateral crural mattress suture efficacy can be made by delivering the dome and then pressing down on it with the index finger to determine whether the lateral crus buckles easily. If so, another mattress suture or two may be necessary. Applying the intercrural suture requires the delivery of both domes through one nostril. The columellar-septal suture can be applied from the columellar rim incision by allowing the needle to penetrate between the leaves of the middle crura.
In the closed (endonasal) approach, the lateral crural mattress suture can be used to remove tip convexity and bulbosity, provided that the tip is adequately delivered through the vestibule for proper exposure.
Suture Techniques in Secondary Rhinoplasty
When opening a nose in secondary surgery, there may be little anatomy to observe. Frequently, there is just a mass of scar tissue mixed in with cartilage, making it difficult to discern whether there is any substantial cartilage. The domes, often not identifiable, are one round mass. The distinction between the upper lateral crura and lower lateral crura is also blurred. Before proceeding with the recommended suture algorithm, it is essential to create a semblance of two arches as noted in the model (Figure 1). First, the caudal border of the lateral crus is identified as best as is possible. Then a line 6 mm parallel to that border is marked, and the scar tissue and cartilage that exist between it and the upper lateral cartilage are removed. That maneuver yields the semblance of lateral crus. Next, a number 15 knife is used to split the domal mass down the middle. No attempt is made to dissect out the middle crura (that would be far too tedious). Moreover, the resulting 2 halves will be strong enough, even if the division slices through one of the middle crura. The net result of the above maneuvers is 2 arches (often a mixture of scar and cartilage) that can now receive suture techniques. In most cases the scarred framework can be worked with just as in a primary situation. If, after placement of transdomal, interdomal, and lateral crural mattress sutures the tip still lacks support or definition a tip graft is applied.
Postoperative tip shape has been improved because of suture techniques developed by various surgeons over the years. At the very least, the suture techniques have solidified the tip complex to better support a tip graft. Results are presented in Figures 11 and 12.
A, C, E, Preoperative views of a 35-year-old woman complaining of a broad bulbous tip. B, D, E, Postoperative views 13 months after transdomal, intercrural, and lateral crural mattress sutures and columella-septal suture techniques are used to control tip shape. Note that 4 of the 5 sutures in our recommended algorithm were used. With an open approach, the cephalic aspect of the lateral crus was resected, leaving a 6-mm lateral crus. A humpectomy with spreader flaps26 was also performed.
A, C, E, Preoperative views of a 23-year-old woman who complained of a broad ill-defined nasal tip. B, D, F, Postoperative views 20 months after transdomal, intercrural, lateral crural mattress suture, and columella-septal suture techniques are used to control tip shape. The patient also underwent humpectomy and received spreader flaps.
columellar strut graft
Employing a columellar strut in rhinoplasty is a powerful tool to achieve stability of the tip especially when the nose ligaments are dissected or the medial crus (MC) of the lower lateral cartilages are weak. A columellar strut helps to avoid several complications and provides an extra degree of structural integrity on the lower third of the nose.1,2 Topkara,3 Robotti,4 and Rodrich5 recently described some surgical options for a stable strut. The new columellar strut should be suitable for the natural columellar anatomy. We present our approach to this strut, which addresses the important angles to obtain an aesthetically pleasing result.
Surgical Anatomy
Regarding the lower lateral cartilage stability and tip aesthetics, there are several angles described to consider (Figure 1): the inter-domal angle α (between the top of the dome, transversal plane), which is 80° to 90° in men and 90° to 100° in women6; the columellar-lobular angle θ (columellar break point, sagittal plane), which is 30° to 45° in women7; and the MC division angle ς, (columellar break point, transversal plane), which has, to our knowledge, never been highlighted in the literature. We consider 3 different options to create an anatomic γ columellar strut graft.
Several angles should be considered regarding the lower lateral cartilage stability and tip aesthetics. (A) The interdomal angle α and the medial crus division angle ς (columellar break point, at the transversal plane). Notice that the interdomal angle α narrows in a downwards direction: it is wider at the upper part (red), intermediate at the columellar break point (yellow), and narrower at the end of medial crus (green). (B) The columellar-lobular angle θ (columellar break point, at the sagittal plane).
Surgical Technique
The senior author (S.T.) performed all surgeries included in this study under general anesthesia with an endonasal approach. After infiltration of local anesthetic solution (1/100,000 adrenalin) to the incisions, undermining of the nasal framework in a submembranous fashion was performed. The concept of anatomic columellar strut grafting includes 3 options:
Keystone γ columellar strut (Figure 2): after blunt dissection of the medial limbs of the upper lateral cartilages from the septum, the amount of dorsal reduction was calculated; approximately 3 mm of cartilage of the dorsal septum was removed with septal scissors while protecting the cartilage that goes under the bone at the keystone area; the entire upper lateral cartilages were preserved, as autospreader flaps may be needed.
Lower septal cartilage γ columellar strut (Figure 3): after the regular septoplasty in subperichondrial plan, the lowest part of the septum over the maxillary crest was exposed and harvested with the 3-mm vertical length.
Tailor-made anatomic γ columellar strut (Figure 4): a septal cartilage strip was tailored to the desired size and γ shape with a longitudinal cut-up incision (partial thickness) to mimic the horizontal limbs.
This 23-year-old female in whom the keystone γ columellar strut was applied. (A) The keystone excision material after dorsal hump removal. (B) The bone part (upper) and the keystone γ columellar strut achieved after the separation of the bone (lower). (C) Inset of the graft with the maintenance of interdomal angle α and medial crus protection.
In this 28-year-old female patient, the lower septal cartilage γ columellar strut was employed. (A) The lower septal cartilage γ columellar strut resembles the keystone cartilage angles. (B) Inset of the graft with the maintenance of interdomal angle α and medial crus protection.
This 30-year-old female in whom the senior author utilized a tailor-made anatomic γ columellar strut. (A) A septal strip is harvested from the septum. (B) Caudal septal insertion. (C) Inset of the graft with the maintenance of interdomal angle α and medial crus protection.
After intradomal sutures (hemi-transdomal fashion), lateral crural steal, and MC overlap (if needed), the anatomic γ columellar strut graft was placed into the pocket formed between the MC, which were sutured to the graft one by one utilizing several loop sutures for each of them (Figures 2C, 3B, and 4C). Lateral crural steal is applied if there is an excessive lateral crus, which allows us to determine a new domal point. MC overlap is applied if there is excessive MC due to lateral steal procedure or by primary cause.
METHODS
The patients included in our study were both primary and revision cases in whom an anatomic γ columellar strut was employed; they underwent operated between January 2015 and December 2018 performed by the senior author (S.T.). This study was conducted in accordance with the guidelines set forth in the Declaration of Helsinki. Written informed consent was obtained from all patients. Skin thickness was accessed and based on its thickness, the strut was chosen (Figure 5).
A clinical algorithm to approach the columellar strut in rhinoplasty according to both the skin quality of the patient and the available material.
RESULTS
In 328 patients, the anatomic columellar strut was employed to support the tip. All 277 patients who completed the first year of follow-up were retrospectively analyzed. The mean follow-up was 18 months (range, 12-26 months). The mean age was 26.4 years old (range, 17-43 years) for 272 females and 56 males. We performed 114 keystone struts, 106 lower septal struts, and 108 tailor-made struts. All the patients presented a stable and aesthetic new tip. The interdomal and MC angles were both maintained (Figure 6).
This 26-year-old female patient (A, C) before and (B, D) 12 months after a rhinoplasty according to our anatomical collumellar strut algorithm. A keystone γ columellar strut was employed.
Cost
This procedure represents no additional cost to the surgery, because our algorithm shows that either the cartilaginous remnants of the dorsal hump reduction or of the classical septal strut may be utilized to provide an aesthetic and supported new tip.
DISCUSSION
One of the most important areas for tip support and aesthetics is the projection and support of both MC of the lower lateral cartilages. The utilization of a columellar strut is a known tool to achieve this and avoid several complications.1-6 For an aesthetic result, the ideal columellar strut should address its natural anatomy.
Sheen and Sheen first described the nose surface aesthetics in 1978, considering the geometric position of the cartilages and its soft tissues.8 After detailed cadaver and clinical examination with surface analysis of the nose, its polygons and several other concepts regarding the tip (supratip break point, infratip breakpoint, columellar breakpoint) were defined.9 Daniel highlighted a dome definition angle with both a convex segment along the lateral dome and a concave one at its junction with the MC.10 Toriumi defined the importance of highlights and shadows; for a more natural tip, he proposed the creation of a horizontally oriented tip highlight that transitions smoothly from the tip lobule to the alar lobule.11
Although these artistic approaches make sense to create an aesthetic tip, we still lack adequate published details about all the ideal angles to achieve it. The regular strut commonly employed to support the tip seems to cause an aesthetically operated appearance because the interdomal angle α may be destroyed when both domes are sutured together in a straight line, which is more often due to misapplied sutures. The closure of the angles and how this affects nasal aesthetics is somehow difficult to understand for inexperienced surgeons; however, according to the senior author’s experience (S.T.), employing a normal columellar strut causes more pointed tips because it eliminates the angles between the MC as well as the infra-lobular segment, requiring a rim graft to the soft triangles to correct this pinching deformity. Thus, utilizing an anatomic columellar strut protecting these angles leads to an ideal and natural shape and eliminates the operated appearance of the tip. Dorsum cartilage is utilized because it perfectly fits the space between both MC. This space under the columellar defining point is diamond shaped; below it, the shape becomes narrower, so we may define this entire structure as trapezoid shaped (Video, available online at www.aestheticsurgeryjournal.com). Naturally, the MC division angle ς should also be addressed. Our algorithm considers 3 options for an aesthetic γ-shaped anatomic columellar strut: (1) The keystone γ columellar strut: The shape of the dorsal septal cartilage at the keystone is angled in both vertical and horizontal planes. The vertical arm acts like a columellar strut that protects the interdomal angle α (goes to the posterior part of the MC), whereas the horizontal part may be employed as a shill graft. Moreover, because the horizontal and vertical limbs create a γ-shaped structure, together they may also provide an MC division angle ς; (2) Lower septal cartilage γ columellar strut: According to our clinical observations, both the angle of the keystone cartilage between the vertical and horizontal parts and the angle of the lowest part of the septal cartilage between the vertical and horizontal limbs over the maxillary crest are very close to 30° to 40°, resembling the interdomal angle α. Of course, individual difference makes sense. (3) Tailor-made anatomic γ columellar strut: Additionally, we can achieve an anatomic γ tailor-made strut by incising to the caudal part of a regular strut harvested from the remaining central septum when neither of the previous options is available or in thin-skinned patients.