Feb 16

Indications for Tip Grafts in Revision Rhinoplasty: the Overshortened Nose, Pollybeak Deformity, Poor Tip Definition, Overresected Nasal Tip, and Loss of Tip Support,

Indications for Tip Grafts in Revision Rhinoplasty

In the revision rhinoplasty patient tip grafts may be necessary if: (1) there is a pollybeak deformity (2) there is an asymmetric tip or nasal bossae (3) there is a poorly defined nasal tip (4) in the overly shortened nose, or (5) there was failure to recognize false tip projection at the time of primary surgery or there was loss of normal tip support mechanisms after primary rhinoplasty. We will explore each of these situations in turn and post representative examples in future blogs.

Underprojected Nasal Tip and Pollybeak Deformity

Perhaps the most commonly utilized purpose for the tip graft in our practice continues to be the one for which it was originally devised. In his exploration of his 30 year experience with tip grafts, Sheen noted that poor tip projection and supratip deformity are very commonly seen in post- rhinoplasty patients. For a long time the principle cause of this supratip deformity was thought to be excessive skeletal tissue in the supratip region. As a result, surgeons used to routinely revise pollybeak deformities by removing even more tissue in the supratip region with a resultant exacerbation of the problem. Sheen’s proposal that the vast majority of these pollybeak deformities were the result of overzealous resection of the nasal dorsum is widely accepted today, and it is thought that the supratip deformity arises as a result of scar tissue deposition which naturally occurs in order to eliminate the dead space produced by overresection.

The factors to consider in patients with postoperative supratip convexities include:

  • overresection of the caudal nasal dorsum with scar tissue deposition,
  • insufficient removal of the dorsal cartilaginous septum,
  • inadequate resection of the cephalic portion of the lower lateral crura (LLC),
  • and inadequate tip projection.

Moreover, sometimes the surgeon focusing on a large dorsal hump or supratip deformity misses the concomitant underprojected nasal tip. It is therefore critical in correcting pollybeak deformity for the surgeon to make the aesthetic decision as to whether there is adequate tip projection. All too often patients are still misdiagnosed and consequently undergo the inappropriate treatment. Excessive attention to the dorsal hump results in overreduction of the dorsum with resultant long term resultant pollybeak deformity as the skin soft tissue envelope is unable to contract to the newly reduced skeletal framework.

To make this determination we evaluate certain characteristics which can serve as signs for underprojected nasal tip: shortened columella, acute nasolabial angle, maxillary retrusion, and small, weak alar cartilages. The use of tip grafts, particularly in revision surgery, for the treatment of supratip deformity often is the only means of correction available. Suture techniques, such as the lateral crural steal, which increase projection in patients, are often simply not sufficient to project the tip to the desired level. These patients have often undergone overresection of the alar cartilages and have resultant weakened tip support. In addressing these patients tip grafts provide the needed cartilaginous skeletal framework needed to support the weakened alar cartilages.

Overresected Nasal Tip

When the nasal tip has been overly resected, in revision surgery we are often faced with excessive tip narrowing, bossae formation, asymmetric and occasionally external valve collapse. In the over- resected nasal tip, bossae are generally thought to result from the dynamic forces of scar contracture. In general terms, the surgical maneuvers that contribute to bossae formation are those that fail to secure symmetric dome cartilages, those that promote separation of the domes, and those that weaken the cephalic margin of the LLCs. While it would be nice if all surgeons prevented bossae by reconstituting the domes, reinforcing weak cartilage and avoiding sharp edges, nasal tip bossae continue to constitute one of the major causes of revision rhinoplasty for our practice.

In those patients with an asymmetric nasal tip, the asymmetry is often the result of unequal LLC removal or distorting forces on the medial or lateral crura that twist the tip. If adequate tip projection and tip strength are present, correction requires separation of the medial and lateral components followed by repositioning and trimming. Very commonly, unfortunately, overresection has occurred concomitantly and necessitates grafting in order to camouflage and support. In some of our revision cases the tip graft is often the only means of correction when overresection of the ala has resulted in bossae formation, excessive tip narrowing, asymmetry, or external valve collapse.

Poor Tip Definition

Poor tip definition continues to represent the most difficult challenge for the rhinoplasty surgeon operating on ethnic rhinoplasty patients. While wide variability exists in the ethnic patient population as a whole, generalizations can be made which can be used as a guide when planning rhinoplasty in this patient population. Specifically, when compared to the Caucasian standard, numerous studies have shown that African American and Hispanic patients tend to have combinations of:

Thick, sebaceous, relatively inelastic skin
Weak lower lateral cartilages
Wide bulbous tip
Excess fibrofatty tissue in the nasal tip
Acute nasolabial angle
Short medial crura
Thin weak septal cartilage

In this type of nose it is important to implement structured augmentation in order to not only provide adequate support but also to give meaningful definition and refinement.The shield graft is useful in ethnic patients when additional tip defining techniques are needed because the standard suturing tip procedures often do not give an entirely satisfactory result. Over the years we have found that the most challenging assignment in ethnic rhinoplasty is correcting the deficiency in tip projection in the face of a bulbous, amorphic tip with thick skin.  In particular, as many of these patients prefer thinner, more refined nasal tips it is important not to build up too much. As a result a balance must be delineated between appropriate refinement without excessive projection.

Overshortened Nose

The aesthetically short nose appears when excessive upward tilt of the nasal tip results in a foreshortened appearance. In the revision patient, the overshortened nose generally occurs after excessive shortening of the caudal septum. Over time, the result is an increased nasolabial angle with increased nostril show. When we are faced with these challenging patients, correction generally entails the use of a caudal septal graft in order to lengthen the nose as well as a tip graft to restructure and reproject the tip.

False Tip Projection or Loss of Tip Support Mechanisms

Many routine techniques in rhinoplasty result in false tip projection at the time of surgery or result in loss of tip projection in the long term. If the primary surgeon is cognizant of these considerations at the primary setting, the revision surgeon would not find indication for the need of increased projection. Unfortunately, while occasionally these patients can have correction with more conservative techniques such as the lateral crural steal, we have found occasion for the use of tip grafts in these patients in order to achieve adequate projection.

Moreover, many surgeons continue to find that an initially satisfactory result ultimately becomes an underprojected tip with the illusion of supratip deformity. The reason is often secondary to the utilization of techniques that weaken major and or minor tip support mechanisms which then in time result in loss of projection. Specifically, the cartilage splitting, cartilage delivery techniques and cephalic trimming of LLCs all result in disruption of the major supportive attachment of the ULCs to the LLCs in the scroll area. Full transfixion incisions interrupt the attachments between the LLC and the anterior septal angle and, if carried low enough, will disrupt the attachment of the medial crus feet to the posterior septal angle. And lowering the cartilaginous dorsum and shortening the caudal septum contribute to loss of minor tip support mechanisms. Finally, it is imperative for the surgeon in the primary setting to consider operative tip swelling secondary to infiltration of local anesthetics, the edema of surgical trauma, and repeated stretching of the nostrils with the nasal speculum. The increased tip projection  is transient and it subsides early in the healing phase as the extra interstitial fluids are mobilized back into the intravascular space.

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