| PATIENTS AND METHODS
PATIENTS
Our study is a consecutive sample of 10 patients (O women and 4 men) who were seen for treatment at the private practice of one of us (A.I.G.) in Highland Park. NJ, from August 1, 1998. to January 31, 1999. The patients Were aged from 27 to 52 years, with a mean age of 32 years (Table). The primary cause in each of these patients was excessive columellar show that was due to columellar hang and not alar retraction. Measurement of the alar-columellar complex was facilitated using computer-assisted photography (Mirror fmage Co). Photographs in the Frankfort horizontal position excluded patients with alar retraction. Photographic measurements were obtained 3 months postoperatively from images superimposed on the preoperative pictures. This ensured identical sizing and position of anatomical structures to accurately measure the correction of the columellar deformity. Age, sex, previous nasal surgery. and the patients awareness of the condition were noted. Intraoperative findings such as the use of columellar struts. septal shortening, or medial crural tailoring were recorded. All surgery was per-formed through an external approach. Permission for preoperative, Intraoperative and postoperative photography was obtained.
OPERATIVE
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Figure 3. The caudal septum is set well back from the medial crura and not contributing to the hanging columella. |
A transcolumellar incision was carried into marginal incisions, followed by sharp dissect ion of the soft tissues over-lying the nasal skeleton in the subperichondrial and subperiosteal planes. The medial Crural curvature and width were assessed as well as their relation to the caudal septum. While retracting the soft tissue flap superiorly, the medial crura were separated, and mucosal flaps were elevated over the length of the septum to allow for repositioning of the medial crura without bunching or resection of the membranous septum. If septoplasty or septal shortening was indicated, it was performed at this time. (Figure 3).
The angle between the medial and the lateral crura was identified by the internal soft tissue triangle" The vestibular lining was dissected from the overlying cartilage Transection of the angles, not the domes. resulted in straightening of the medial crura that were then sutured together using a 6-0 nylon suture approximately mm caudal to the cut edges.
When necessary, minimal septal shortening was per-formed. Sutures (4-0 chromic) were used to fix the caudal end of the septum to the cephalic margin of the medial crura.
When indicated, columellar struts were placed in a pocket between the medial crura extending inferior to the nasal spine and fastened with 6-0 nylon. columellar strut dimensions were typically 2.0 to 2.5 cm long, and 2.0 to 3.0 mm wide. "the width was always less than that of the medial crura and was carefully evaluated to ensure that it did not hinder adequate columellar repositioning.
The 30-year experience of one of us (A.I.G.) as a rhinoplasty surgeon represents an endonasal approach until 1988 and a transition to an external approach for the past 12 years. Until converting to the external approach. the importance of the C-shaped curvature ol the medial crura was not as apparent, and traditional techniques of columellar hang correction were used. Over the past 12 years using an external approach, the importance of the curvature of the medial crura and excessive lobule protrusion has be-come apparent. This study was undertaken to document these findings.
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Aesthetics and Aging A New Paradigm
