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A Variety of Surgical Techniques have been Employed for Reduction of NasalTip Width

 Reduction of lateral nasal tip width in order to optimize the shape while maintaining function presents a challenge in patients with wide middle and lower thirds of the nose. The nose is composed of seven primary anatomic components the paired nasal bones, upper lateral cartilages, lower lateral cartilages and the septum. Traditionally five of the seven primary anatomic components of the nose have been addressed to optimize nasal appearance. Techniques directed towards the nasal bones, septum, and lower lateral cartilages have included reduction of the height and width of the nasal bone, resection of the septum and modification of the lower lateral cartilages. The techniques that have been employed for reduction of nasal tip widths may be summarized as either resection of the lower lateral cartilages, plication techniques of the lower lateral cartilages or augmentation of the lower lateral cartilages.

While resection, plication, and/or medial augmentation of the lower lateral cartilages done separately or in combination can affect changes in the tip-lobular complex we identified a specific sub-set of our patients whose results were not altered to the extent we would have preferred. We have found that reduction of lateral nasal tip width in the specific sub-set of our patients with excess width at the junction of the lower third and upper two thirds present a significant challenge. In an effort to further enhance the shape of this region we have begun performing a reduction in the length and width in the lateral half of the upper lateral cartilages. Judicious removal of a portion of the upper lateral cartilages has effectively enhanced the nasal tip shape in the sub-set of our patients described above.


Materials and Methods

Between January 2003 and February 2005 we reviewed the records of 217 of our patients undergoing primary rhinoplasty. Of these, 43 patients underwent partial resection of the upper lateral cartilage to help control tip width. In this selected group of patients typically a 3 by 6 millimeter strip of the upper lateral cartilage inferior laterally was excised. The resection was performed under direct vision. All rhinoplasties were performed by a single surgeon using a closed approach with an inter-cartilaginous incision for exposure of the nasal dorsum including the septum, upper lateral cartilages and nasal bones. The lower lateral cartilages were delivered using an eversion technique and trimmed in all cases. The resection of the lower lateral cartilages varied from 2 to 8 millimeters at the cephalic end of cartilage. Following modification of the nasal bone and septum, a low to low osteotomy was performed in all cases, the upper lateral cartilages were trimmed medially and a nasal splint was applied. No patients noted a significant increase of difficulty breathing post-operatively. Nasal valve function was maintained in all cases. Reduction of the superior lateral tip width was noted in all patients. In retrospect, 42 of 217 patients, 20% of the total number of our patients having rhinoplasty, underwent the aforementioned technique.

Discussion:

Resection of various aspects of lower lateral cartilages have been advocated by a number of physicians performing rhinoplasty surgery in attempts to favorably alter the tip shape. Complete transection of the lower lateral cartilages has been combined with re-attachment of the lateral component to the medial component. In addition, a large number of suturing techniques have been proposed to plicate the lower lateral cartilages to decrease the tip width. In cases where resection and or plication have been unsuccessful numerous authors have advocated a variety of grafts to the tip of the nose in an effort to enhance projection and provide the appearance narrowing of the tip. The choices of graft materials for nasal tip augmentation include septum, ear, rib, ethmoid, vomer, or cranial bone to name a few. The aforementioned techniques focus on altering the lower lateral cartilages while not affecting a change in the width of the caudal portion of the upper lateral cartilages to refine the width of the nasal tip. We have felt that this is analogous to trying raising a central tent pole in a tent hoping to significantly change the shape of a square roof while two of the four corners of the roof of the tent are fixed. Some change will obviously be achieved with augmentation of the lower lateral cartilages particularly when the lateral aspect of the lower lateral cartilages are reduced, but we have found that the alteration may fall short of what we would have liked to obtain in a subset of patients. The subset of patients we have found refractive to “standard techniques” are those patients with increased nasal width at the junction of the middle and lower third of the nose.

Resection of the upper lateral cartilages obviously carries a risk of disruption of the internal nasal valve. Aggressive resection of the upper lateral cartilages coupled with prodigious resection of the lower lateral cartilages could impact the function of the external nasal valve as well. Courtiss has stated, “Unless the internal or external valves are adversely affected or unless a simultaneous septal operation results in septal perforation aesthetic rhinoplasty does not affect air flow.” This would tend to indicate that rather aggressive treatment of the nose during rhinoplasty may have a minimal affect. This approach is contrasted with that of Guyron who stated, “The length of the nasal bones, extent of the nasal bone repositioning, position of the inferior terminates and type of osteotomy are factors which all influence post-operative narrowing and air flow.” We would tend to agree with Guyron’s observation that basically any change in the structural integrity of the nose has a physiological sequelae. Smaller anatomic changes we feel exhibit minimal to marginal changes that do not adversely affect function. Constantian stated, “Rhinoplasty with resection of the cartilaginous dorsal roof, or alar cartilage, is undoubtedly the most common cause of acquired incompetence of the internal and external valves”, we would wholeheartedly agree. We, therefore, feel once a decision has been made to modify the upper lateral cartilages a small resection of the lateral and inferior component should be performed in order to minimize the risk of functional sequelae. To achieve these aims we prefer to resect the cartilages under direct vision. We utilize a closed approach in the majority of rhinoplasties which we perform, but excision of the lateral aspects of the inferior portion of the upper lateral cartilages can be easily accomplished with an open approach as well. We do note that prudent modification of the upper lateral cartilages in approximately 20% of our patients has provided us with a tool to achieve effective narrowing of the nasal tip and the illusion of increased nasal length which heretofore had proved elusive in our hands. Conservative surgical alteration of the lateral aspect of the upper lateral cartilage can enhance the final result in rhinoplasty in selective individuals. While clearly not applicable in the majority of patients, resection of the caudal lateral portion of the upper lateral cartilages represents a useful addition in the surgical algorithm we employ in aesthetic rhinoplasty when substantial reduction in width at the junction of the upper two thirds and lower third of the nose is desirable. Sapient use of the technique of modification of upper lateral cartilages in selected individuals has allowed us to enhance the final aesthetic results in a specific sub-set of patients who heretofore proved refractory to previously described techniques.

 

 


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