Plastic Surgery New Jersey

Although the dissatisfied patient can always define the deformity, the underlying etiology in a previously operated nose frequently is obscure, particularly in the nasal tip. For this reason, we use an external rhinoplasty approach in revision surgeries. This exposure allows an undistorted view of the structural relationships of the deformed tip. We can then reconstruct the nose with precise adjustments to the previous surgical deformities and position grafts accurately and securely.

The vertical dome division (Figs. 7A and 8) is an extremely useful maneuver in revision rhinoplasty, providing three major benefits.

Figure 7 (Continued).		Figure 8. Fixation of extended shield graft with vertical dome division and columella strut.

Tip narrowing is accomplished by bringing the domes closer to the midline. Tip projection is increased by forming a strong central cartilaginous structure. Tip projection and rotation are achieved by releasing the downward forces of the lateral limbs of the lower lateral cartilages. Our technique is performed by identifying and skeletonizing the dorsal surfaces of the lower lateral cartilages in an attempt to identify the dome and the angle of the lower lateral cartilages. The division must be symmetric and is performed at the angle or between the dome and the angle. The vestibular lining is separated from the under surface of the lower lateral cartilage at the site of division, and only the cartilage is incised. The medial crura are allowed to spring up by conservatively under-mining and releasing them from the vestibular lining. The medial crura then are bound in the midline with a 6-0 nylon suture about 3 mm from their tops. The lower lateral cartilage is allowed to abut or override the joined medial crura to form a new tip structure. When the dome and lower lateral cartilages are exces- and the angle. The vestibular lining is separated from the under surface of the lower lateral cartilage at the site of division, and only the cartilage is incised. The medial crura are allowed to spring up by conservatively under-mining and releasing them from the vestibular lining. The medial crura then are bound in the midline with a 6-0 nylon suture about 3 mm from their tops. The lower lateral cartilage is allowed to abut or override the joined medial crura to form a new tip structure. When the dome and lower lateral cartilages are excesively bulky and contribute to a poorly defined tip, appropriate trimming of the cephalic and medial aspects will debulk and narrow the tip.

Nasal tip grafts can be used if tip projection is inadequate following vertical dome division or if tip narrowing does not occur because the skin does not drape well. We use three types of tip grafts: the columella strut, the shield (lobule) graft, and the extended shield (columella-lobule) graft.

	Figure 9. Columella strut. A, Schematic representation showing force directions of columella strut, and the double break it produces at the columella-lobule angle. B, Columella strut placed between the medial crura. C, Preoperative and D, postoperative views showing the effects of the columella strut.

The columella strut sits between the medial crura, providing support for the tip structures (Fig. 9).

A pocket is created between the medial crura of the lower lateral cartilage extending toward the premaxilla by a blunt spreading motion of the scissors in the same plane as the medial crura. The graft is fixed in position between the medial crura with a 6-0 nonresorbable suture. The strut extends the length of the collumella, allowing the lobular portion of the medial crura to project above it and form the tip structure. It provides a foundation for the tip but does not create a tip structure, as this may produce an excessively pointing tip. A columella strut can be used to elongate the columella, change the nasolabial angle, maintain or increase tip projection, create cephalic rotation of the lobule, and shorten the nasal dorsum (Table 1).

The shield graft is a lobule graft primarily creating tip shape and tip projection (Fig. 10). It usually is placed after vertical dome division and a columella strut have been used to pro-vide a foundation for the tip. It is fixed in a precrural position with nonresorbable sutures. In our experience, we have found the exact placement and suturing of this graft to be difficult with the external approach, and we use it infrequently. The shield graft recontours the lobule, making it either wider or narrower de-pending on how it is fashioned. It elongates the lobule and increases the columella-lobule angle (termed the angle of rotation of the lower lateral cartilage by Sheens). It may increase tip projection, cause cephalic rotation of the lobule, and shorten the nasal dorsum. It does not alter the columella shape or change the nasolabial angle (Table 1).

	Figure 10. Shield graft. A, Schematic representation showing the placement of a shield graft. B, Shield graft placed in a precrural position. C, Preoperative and D, postoperative views showing the effects of the shield graft.

The extended shield graft is a precrural columella lobule graft that will provide structural support of the tip and create tip shape (See Fig. 7). It is shield-shaped in the lobule portion and tapers to a narrow base extending below the feet of the medial crura toward the premaxilla. The graft is placed in a pocket that is made caudal to the medial crura extending from the columella skin incision toward the premaxilla. If used in conjunction with a columella strut, the pocket for this graft is kept separate. The pocket is created with blunt dissection holding the scissors 90 degrees to the plane of the me-dial crura. The graft is placed in the pocket and extends above the tips of the medial crura to create the tip shape. It is fixed in position with one or two nonresorbable 6-0 sutures that go through the medial crura and loop around the graft. If stronger fixation is desired, particularly to provide projection with thick skin, the graft is sutured as shown in Figure 8. The extended shield graft recontours the lobule and can provide tip projection and cephalic rotation (Table 1). It elongates the lobule and the columella and alters the nasolabial and columella-lobule angles. The graft will increase the convexity of the columella (Figs. 7E and F). If increased nasal length is required, the graft may be buttressed with a second smaller graft placed behind it in the lobule (Fig. 11).

Alar grafts are used to replace over-resected lateral crura and are used in conjunction with tip grafts (Fig. 12). Their primary effect is to provide support and correct vestibular stenosis. They are also effective in recontouring the alar rim and correcting alar notching.

In comparing the three types of tip grafts, it is important to mention the relative ease of use of each graft. The ex tended shield graft is extremely easy to place. Seating it in the precrural pocket stabilizes it while simple suturing secures it in position. The shield graft can be difficult to position, particularly with an external approach. Fixation requires multiple precisely placed sutures and is facilitated by an assistant to hold it in position. Asymmetric placement can occur. The columella strut is easy to position, and, once oriented in the pocket, stabilization sutures are simple to place.

Each of the grafts has multiple effects on the appearance of the nasal tip and lower third of the nose (Table 1).

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