Nâng Mũi Thẩm Mỹ Nâng Cao: Nghệ Thuật, Khoa Học Và Các Kỹ Thuật Lâm Sàng Mới

870
R. Xavier
open approach is affording an enhanced surgical
exposure, facilitating nasal sculpturing by suturing
or by the introduction and fi xation of different kind
of grafts. Any modi fi cation of the cartilages can be
performed, and the result may be easily assessed.
The open approach allows maximal exposure of
the tip, improving diagnosis and facilitating cor-
rection of gross deformities [ 6, 9, 10 ] .
The extra time necessary for the approach and
for carefully closing the incisions cannot be con-
sidered a drawback of the open approach, and the
interference that the open approach causes to the
mechanisms of tip support [ 2, 5, 8 ] , although rel-
evant, may be overcome by using surgical tech-
niques that reinforce this support at some stage of
the procedure [ 5 ] .
The open approach, however, does leave an
extensive submucous wound area, leading to a
prolonged edema and to longer healing time [ 2 ] ;
there may be sensory disturbances at the tip area,
and there will be an external scar, which may be
of concern for some patients and that, eventually,
may not be completely undistinguishable.
Due to its maximal surgical exposure, improved
diagnosis, and facilitated correction of deformi-
ties, the open approach is particularly useful for
patients with marked asymmetry of the tip, patients
undergoing major reconstruction of the tip or of
the upper two-thirds of the nose and patients whose
complete diagnosis is still unclear after a careful
preoperative analysis of the nose [ 2, 4 ] .
The nondelivery approach, the delivery approach,
and the open approach are the three standard
approaches for rhinoplasty. Some surgeons always
perform rhinoplasty by using an open approach,
and others always use an endonasal approach; we
believe that every facial plastic surgeon should be
familiar with all approaches, as the choice of the
approach should not be dictated by the preferences
of the surgeon but, mainly, by the nasal deformities
of the patient and by the surgical techniques that
have been planned in order to achieve an improve-
ment in nasal functioning and aesthetics.
The simplest approach that allows the planned
surgical techniques to be performed without
dif fi culty should be selected, to cause the least
disturbance to the tip support [ 2, 8 ] . The surgeon
must always weigh the surgical trauma caused by
the approach against the surgical exposure
afforded by the approach. In other words, the
approach should be as invasive as necessary, but,
at the same time, as noninvasive as possible.
When performing surgery of the nasal tip, it is
often necessary to resect the cephalic margin of
the alar cartilages in order to improve tip
de fi nition, sometimes combining this procedure
with other techniques, such as domal or inter-
domal suturing, scoring, or morselization of the
cartilages [ 10 ] . The delivery approach is very
appropriate for this goal [ 2, 4 ] . It is usually not
dif fi cult to deliver the alar cartilages, to resect an
appropriated sized piece of cartilage and to con-
tinue with the other planned modi fi cations.
If the patient has long alar cartilages, it is par-
ticularly important to improve tip de fi nition by
performing cephalic resection of these cartilages.
In this kind of cartilages, however, it may be
dif fi cult to deliver the alar cartilages without
twisting or tearing the most lateral part of the lat-
eral crura and the intermediate crura or even the
dome area. The dome segment is usually the thin-
nest and most delicate portion of the entire alar
cartilage [ 11 ] , and any weakening of this portion
may endanger the resilience of the cartilage,
which could compromise the support of the nasal
tip. When planning surgery, the open approach
may be chosen to overcome this and to avoid
using an intercartilaginous incision, which may
interfere with the tip support; however, a modi fi ed
delivery approach may also be used, turning the
exposure of the tip cartilages easier and safer.
61.2
Surgical Technique
In the modi fi ed delivery approach, a transcarti-
laginous incision is fi rst used in each side of the
nose. The position of this incision must take into
account that the exact amount of cartilage to be
resected may be dif fi cult to assess at this stage, so
care must be taken to leave an appropriated sized
cartilage caudal to the incision (Fig. 61.1 ). The
cephalic piece of the alar cartilage is dissected
free in the vestibular and in the non-vestibular
sides and resected (Fig. 61.2 ). This procedure is
repeated in the opposite side of the nose.
Then, a marginal incision is made (Fig. 61.3 ),
and the remaining alar cartilage is dissected in the

871
61 A Modi fi ed Delivery Approach
non-vestibular
side
and
easily
delivered
(Fig. 61.4 ). After the same procedure is performed
in the opposite side, both alar cartilages are deliv-
ered and compared. At this stage of the procedure,
the size of the remaining alar cartilages is assessed;
if necessary, further resection is done again in
order to achieve perfect symmetry or to achieve
the desired size of the alar cartilages (Fig. 61.5 ).
The rhinoplasty may then proceed with other
surgical techniques to the alar cartilages, which
may be grafted, sutured, or modi fi ed as consid-
ered necessary to achieve a good functional and
aesthetic result (Fig. 61.6 ). After addressing the
upper two-thirds of the nose, at the end of surgery,
both the transcartilaginous and marginal incisions
are closed with an absorbable suture material.
Fig. 61.1 A transcartilaginous incision is fi rst used, taking
care to leave an appropriated sized cartilage caudal to the
incision
Fig. 61.2 The cephalic piece of the alar cartilage is dissected
and resected
Fig. 61.3 A marginal incision is made
Fig. 61.4 The remaining alar cartilage is dissected in the
non-vestibular side and delivered
Fig. 61.5 The remaining alar cartilages are delivered and
compared; if necessary, further resection is performed to
achieve perfect symmetry or the desired size

872
R. Xavier
61.3
Comments
A large proportion of patients seeking for rhino-
plasty will bene fi t from surgery of the nasal tip.
This may involve major reconstruction for correc-
tion of gross asymmetry or deformity of the tip
cartilages, usually achieved by using an open
approach. For most patients, however, the nose
will bene fi t from performing slight modi fi cations
in tip rotation or projection, from correcting a
bi fi d or boxy tip, or from improving tip de fi nition.
These modi fi cations can be achieved by using an
endonasal approach, usually a delivery approach.
In some cases, patients have long alar cartilages
or alar cartilages that are too cephalically posi-
tioned and these may be dif fi cult to deliver, some-
times even with medially and laterally extended
standard incisions. In these patients, we believe
that the delivery approach may be easier to per-
form by using a modi fi cation of the approach.
Another advantage of this modi fi ed approach
over the traditional delivery approach is avoid-
ing the intercartilaginous incisions, which may
jeopardize the attachments of the upper lateral
cartilages to the cephalic margin of the alar car-
tilages, a major support mechanism of the nasal
tip [ 2, 12 ] . Even though the cephalic margin of
the cartilages will be resected, the fi brous tissue
connections between the upper lateral and the
alar cartilages will not be broken by using a
transcartilaginous incision, thus preventing
weakening of the tip support.
The author has been using this modi fi cation of
the delivery approach for several years. In the ear-
lier cases, we used this modi fi ed delivery approach
only for patients with long alar cartilages and a
wide or bi fi d nasal tip. It was felt that this kind of
tip required performing cephalic resection of the
alar cartilages plus, if nothing else, interdomal
suturing. We felt that this modi fi cation could
make the delivery of long cartilages easier and
safer, as the cartilage would not be under tension
or under a twisting strength at any stage of the
procedure. In more recent cases, we have been
using this approach for most cases of re fi nement
of the nasal tip, as long as this involved more than
just cephalic resection of the alar cartilages. Thus,
we have been using the modi fi ed delivery
approach in almost every case that we would, oth-
erwise, be using the standard delivery approach.
The purpose of this modi fi cation is combining
the advantages of the nondelivery approach with
the advantages of the delivery approach in the same
procedure and avoiding an intercartilaginous inci-
sion. Thus, the delivery of each alar cartilage is
performed in two stages: at the fi rst stage, a cephalic
piece of the cartilage is resected; at the second
stage, the remaining alar cartilage is delivered.
The exact amount of cartilage to be resected
may be dif fi cult to assess at the fi rst stage, so it is
crucial to leave an appropriated sized cartilage
caudal to the transcartilaginous incision. At the
second stage, after the delivery of the remaining
alar cartilages on both sides, these are easily
assessed and compared. Further resection of the
alar cartilages may be performed at this stage of
the procedure, in order to achieve perfect symme-
try or to achieve the desired size of the cartilages.
By using fi rst a transcartilaginous incision and
then a marginal incision to deliver the alar carti-
lages, this modi fi ed approach combines the reli-
ability of the nondelivery approach with the
enhanced exposure of the more powerful delivery
approach. By using a transcartilaginous incision
instead of an intercartilaginous incision, this
modi fi ed delivery approach does not promote
weakening of one of the major tip support mecha-
nisms, the attachment of the upper lateral carti-
lages to the cephalic margin of the alar cartilages.
Fig. 61.6 The other planned maneuvers, such as domal
suturing, are performed

873
61 A Modi fi ed Delivery Approach
61.4
Clinical Cases
Some cases of patients operated on by using this
modi fi ed delivery approach are presented.
Case 1 (Fig. 61.7 )
A 27-year-old woman had a tension nose and a
septal deviation to the right side. Her nasal tip
was over projected and over rotated, boxy, and
bi fi d, with long alar cartilages. There was not a
distinct nasolabial angle, and the nasal dorsum is
convex.
A modi fi ed delivery approach was used, and
cephalic resection of both alar cartilages was per-
formed in two stages. A complete trans fi xion inci-
sion was also used, the septal deviation was
corrected and the anterior nasal spine was resected.
The nasal bony and cartilaginous dorsum was
lowered, and a piece of crushed cartilage was
introduced covering the bony dorsal framework.
Medial oblique and lateral intranasal osteotomies
were performed. Interdomal suturing was done
and an alar batten graft of autogenous septal carti-
lage was introduced on the left side.
After rhinoplasty, tip projection and rotation
have improved and the nasolabial angle has
gained better de fi nition. The tip lost its bi fi d and
boxy appearance, and an improvement in tip
de fi nition was achieved. The nasal dorsum was
lowered to be in balance with the tip. An improve-
ment in nasal aesthetics as well as in nasal func-
tioning was achieved by rhinoplasty.
a
b
Fig. 61.7 ( a ) Preoperative female with tension nose, over projected, and over rotated nasal tip, and long alar cartilages.
( b ) Postoperative

874
R. Xavier
Case 2 (Fig. 61.8 )
This 45-year-old woman had a bulbous under
rotated tip, long alar cartilages, and a dorsal hump.
A modi fi ed delivery approach was used, and
cephalic resection of the alar cartilages was per-
formed in two stages. Resection of the hump was
performed as well as medial oblique and lateral
intranasal osteotomies. In order to achieve a bet-
ter de fi ned tip with a triangular shape (on basal
view), interdomal suturing was performed.
A well-de fi ned nasal tip, with a slight increase
in rotation and a straight dorsum, proportioned to
the tip, were achieved by rhinoplasty.
a
b
Fig. 61.8 ( a ) Preoperative patient with bulbous under rotated nasal tip, long alar cartilages, and dorsal hump. ( b )
Postoperative

875
61 A Modi fi ed Delivery Approach
Case 3 (Fig. 61.9 )
This 43 year-old man has a crooked nose. The tip
is bulbous with long asymmetrical alar cartilages
and is deviating towards the right side on the
basal view. There is alar fl are on the left side.
There is also dorsal saddling with obstruction of
the left nasal cavity.
A modi fi ed delivery approach was used, and
asymmetrical resection of the alar cartilages was
performed in two stages. Medial oblique and lateral
intranasal osteotomies were performed, as well as
an intermediate osteotomy on the left side, to achieve
a symmetrical nose with a straight dorsum. Domal
and interdomal sutures were also performed as well
as alar base wedge resection on the left side.
After rhinoplasty, the nose looks straight,
symmetrical, and in the midline of the face. The
dorsum lost its saddling and achieved a stronger
appearance. The tip is better de fi ned, is balanced
to the upper two-thirds of the nose and, on basal
view, it presents no deviation.
a
b
Fig. 61.9 ( a ) Preoperative patient with crooked nose and long and asymmetrical alar cartilages. ( b ) Postoperative

876
R. Xavier
Conclusion
When performing tip rhinoplasty, it is often
necessary to perform cephalic resection of the
alar cartilages to improve tip de fi nition, some-
times combining this procedure with other sur-
gical techniques on the tip, such as domal or
interdomal suturing. This may be achieved by
using the standard delivery approach; however,
if the patient has long alar cartilages or alar car-
tilages that are too cephalically positioned,
these may be dif fi cult to deliver without twist-
ing or tearing the intermediate crura or the most
lateral part of the lateral crura, thus endanger-
ing the resilience of the alar cartilages.
A modi fi ed delivery approach may be a
way to overcome these dangers, facilitating
the exposure of the tip cartilages. This modi fi ed
approach, using a transcartilaginous and a
marginal incision, combines the reliability of
the nondelivery approach with the enhanced
exposure of the delivery approach.
The author has been using this modi fi ed
delivery approach for several years and found it
particularly useful for patients with long alar car-
tilages and a wide or bi fi d nasal tip. In this kind
of tip, this modi fi ed approach is easier to per-
form and safer to the tip support mechanisms.
The traditional delivery approach has some-
times been criticized due to the intercartilagi-
nous incision, as this incision may promote
weakening of a major support mechanism of
the nasal tip, the upper lateral cartilage attach-
ment to the cephalic margin of the alar carti-
lage. By using a transcartilaginous incision
instead of an intercartilaginous incision, this
modi fi ed delivery approach does not interfere
with the tip support.
References
1. Nolst-Trenité GJ (2005) Basic approaches and tech-
niques in nasal tip surgery. In: Nolst-Trenité GJ (ed)
Rhinoplasty, 3rd edn. Kugler Publications, The Hague,
pp 87–96
2. Tardy ME (2004) Contemporary rhinoplasty: princi-
ples and philosophy. In: Behrbohm H, Tardy ME (eds)
Essentials of septorhinoplasty. Thieme, Stuttgart,
pp 37–63
3. Tardy ME, Toriumi DM, Hecht DA (2009) Philosophy
and principles of rhinoplasty. In: Papel ID (ed) Facial
plastic and reconstructive surgery. Thieme, Stuttgart,
pp 507–528
4. Nolst-Trenité GJ (2009) Surgery of the nasal tip:
intranasal approach. In: Papel ID (ed) Facial plastic
and reconstructive surgery. Thieme, Stuttgart,
pp 563–576
5. Kim DW, Toriumi DM (2004) Open structure rhino-
plasty. In: Behrbohm H, Tardy ME (eds) Essentials of
septorhinoplasty. Thieme, Stuttgart, pp 117–135
6. Adamson PA, Litner JA (2009) Open rhinoplasty. In:
Papel ID (ed) Facial plastic and reconstructive sur-
gery. Thieme, Stuttgart, pp 529–546
7. Vuyk HD, Zijlker TD (2005) Open-tip rhinoplasty. In:
Nolst-Trenité GJ (ed) Rhinoplasty, 3rd edn. Kugler
Publications, The Hague, pp 115–123
8. Nolst-Trenité GJ, Vinayak BC (2005) External rhino-
plasty: the bene fi ts and pitfalls. In: Nolst-Trenité GJ
(ed) Rhinoplasty, 3rd edn. Kugler Publications, The
Hague, pp 125–141
9. Whitaker E, Johnson C Jr (2003) The evolution of
open structure rhinoplasty. Arch Facial Plast Surg
5(4):291–300
10. Farrior EH (1999) Dramatic re fi nement of the nasal
tip. Otolaryngol Clin North Am 32(4):621–636
11. Oneal R, Beil R Jr, Schlesinger J (1999) Surgical anat-
omy of the nose. Otolaryngol Clin North Am 32(1):
145–181
12. Gassner HG, Sherris DA, Friedman O (2009)
Rhinology in rhinoplasty. In: Papel ID (ed) Facial
plastic and reconstructive surgery. Thieme, Stuttgart,
pp 489–506

877
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_62, © AJCS/Allen Press 2010
62
62.1 Introduction
Tip reconstruction represents one of the more
dif fi cult challenges in rhinoplasty. The author has
always felt fortunate to have had the opportunity
to learn from and visit with many of the gurus of
rhinoplasty. House was the author’s fi rst chief
attending physician and was a direct descendent
of Cottle and his original courses on rhinoplasty.
You can imagine all the techniques we were
exposed to during my residency. The author fur-
ther had the opportunity to visit and observe leg-
ends such as Sheen and Parks and so many others.
McCollough advanced a technique that W.
Berman had originally described, and this served
as the basis for the modi fi cation the author even-
tually introduced.
There is no shortage of tip techniques described
in the literature [ 1– 21 ] . Some of the older, tradi-
tional techniques had sacri fi ced natural appear-
ance in order to attain an improved appearance.
Perhaps, for this reason, doctors and the public
may often perceive the results as “surgical,”
meaning arti fi cial and distracting. Most surgeons
today strive for natural-appearing noses with the
tip recognized as the most dif fi cult part to consis-
tently sculpt. When the tip has good projection
on its own with minimal width between the
domes, then most surgeons can achieve good
results. Dif fi culty in obtaining consistently repro-
ducible results is more common on wide tips, tips
with poor projection, or tips with poor medial or
middle crural support (Fig. 62.1 ). Many different
techniques have been discussed including sutur-
ing, Goldman-type procedures, shield tip grafts,
double-dome suturing techniques, premaxillary
bolsters, and indeed columellar struts. For these
more dif fi cult noses, combining the techniques of
the double-dome suturing, as described by
McCollough [ 2 ] , with the placement of a long
double columellar strut between the medial crura
and domes yields more consistent results without
sacri fi cing some aspect of natural appearance.
Having known about and used many of the
available tip techniques over the 28 years in prac-
tice, the author has been most impressed by the
utility of the technique espoused by McCollough
[ 2 ] (via W. Berman [ 22 ] ). Basically, he described
a technique where the cephalic sections of the
lower lateral cartilage were fi rst trimmed after
adequate exposure following the delivery tech-
nique. The dome was then narrowed by suturing
the lateral and medial parts (or middle parts as
described by Sheen [ 6 ] ) of the dome together.
The dome was incised and trimmed if necessary,
and then the right and left dome complexes were
The Double Columellar Strut:
An Adjunct to Improve the Nasal Tip
Mark Berman
M. Berman , M.D., FACS
University of Southern California,
120 S. Spalding Dr.,Suite 300,
Beverly Hills, CA 90212, USA
Facial Plastic Surgery , University of Southern
California , Los Angeles , CA , USA
e-mail: beautysurg@aol.com
Modi fi ed from © Berman, Mark: The double columellar strut:
an adjunct to nasal surgery. American Journal of Cosmetic
Surgery , 2010, 27(23), 119–124. With kind Permission of ©
AJCS/Allen Press 2010. All Rights Reserved.

878
M. Berman
sutured together. This procedure had the utility of
the dome splitting techniques without as much
risk for pinching. It is fairly effective in reducing
projection and even maintaining projection if
adequate medial crural support exists. However,
on thin skin individuals, it too can present with
pinching. If there is inadequate medial crura sup-
port, even with overcorrection, the tip may even-
tually drop. If the lower lateral crura are too long,
they may push the tip downward and cause a
drooping tip. This can be remedied by cutting the
lateral crura and setting them back, but medial tip
support is still critical to proper projection.
The columellar strut, placed or sutured between
the medial crura, is not a new concept. It has been
advocated as one possible method of adding sup-
port to the medial crura to aid in tip projection.
The single columellar strut may have certain dis-
advantages. When used as a long strut, commonly
septal cartilage, if slightly curved, it can leave the
tip twisted to the side. The single strut may pro-
trude, leaving a singularly pointy tip. Often, the
single strut is just too weak to support the medial
crura and domes in the new position. The colu-
mellar strut has also been described as a small
piece of cartilage used to bolster the medial crura
anteriorly. This is accomplished by suturing the
medial crura upon the strut (Fig. 62.2 ). This may
be a good procedure if the domes are in good
relative position and only lack projection. Daniel
described a signi fi cant columellar strut made
from rib cartilage, wedged at the base and secured
to the nasal spine via a suture passed through a
drill site [ 11 ] .
62.2
Technique
By using a double layer of cartilage for the colu-
mellar strut, one can gain signi fi cant advantages.
Simply, these would be increased projection that
is (1) straight, (2) strong, and (3) avoids pinching
of the tip. The columellar strut should be 3–4 mm
in width, or approximately the width of the medial
crura and the desired dome area. Typically, the
strut material is easily harvested from the septum,
although the auricular cartilage can be used as
well. A section of cartilage at least twice as wide
as needed is carefully harvested, trying to get as
long a segment as possible. Since the septal carti-
lage is rarely straight, by cutting it lengthwise in
half, it can then be sutured, or preferably glued,
Fig. 62.1 A tip with poor tip support (dependent tip) may look good at fi rst, but will ultimately fall back, resulting in
an under-projected or drooping tip

879
62 The Double Columellar Strut: An Adjunct to Improve the Nasal Tip
so that either both right sides or both left sides are
opposing each other. By doing that, one will
negate the curve of the septum and get a straight
strut. This can be done as well with auricular car-
tilage. Occasionally, there can be subtle advan-
tages to opposing convex or concave surfaces.
For example, opposition of convex surfaces will
tend to position the domes slightly wider in posi-
tion. By laminating the cartilages together (suture
or tissue glue), one also achieves a considerably
stronger material. If the tissues are especially
thin, three layers can be laminated to further
improve stability (Fig. 62.3 ).
After gathering and preparing the double colu-
mellar strut, the lateral crura are delivered through
marginal and intercartilaginous incisions. The
cephalic segment is trimmed as necessary. Then
the right and left domes are narrowed by suturing
the lateral and medial segments together with a
5-0 gut suture. The double columellar strut is
placed in a pocket between the medial crura. The
pocket needs to be between the medial crura, but
should not be overdissected nor extend down to
the nasal spine. An adequate base of soft tissue
under the strut supports the tip quite adequately.
Slight (1–2 mm) overcorrection, to make up for
intraoperative tissue edema, is recommended.
This can be done from open or closed technique.
It has been my preference, particularly in unoper-
ated noses, to use the closed technique as more
uniform stretching of the tip skin is possible.
With the open technique, there can be excessive
tension at the suture line. Once the double colu-
mellar strut is in place, a suture (e.g., 4-0
Monocryl) is passed through the right domal
complex, the strut, then the left domal complex
and back again. It is tied off on the side where it
started. Prior to securing the cartilages together
with the suture, the strut is trimmed and checked
for appearance by placing it into its pocket. The
top of the strut should be shaved and rounded off
to avoid sharp edges. If the skin is particularly
thick, one might leave extra projection from the
columellar strut to maximize tip projection and
narrowing. If the skin is thin, then the domes
should approximate the top of the strut to avoid a
tent pole protrusion. Once the position appears
adequate, the entire complex is secured together.
Ultimately, one is left with a cartilaginous tip that
is now 6–7 mm in width – wide enough to avoid
pinching, yet narrow enough to make a wide nose
look aesthetically pleasing. The internal incisions
are closed with running 5-0 gut starting on the
right marginal incision, passing through to the
McCollough
technique
With long double
columellar strut
Fig. 62.2 The tip technique described by McCollough (and originally W. Berman) brings both domes together. By adding
the double columellar strut, it further maintains tip support while also preventing over-narrowing (pinching) of the tip

880
M. Berman
left marginal incision, back by the left intercarti-
laginous incision, through to the right trans fi xion
incision, then back and forth through the septum
to close off the dead space, ultimately coming out
on the right and fi nishing by closing the right
intercartilaginous incision. No packing is used;
bacitracin ointment is applied as is a splint and a
moustache dressing (Fig. 62.4 ).
62.3
Results
All rhinoplasty cases employing the double colu-
mellar strut were evaluated over the last 20 years.
The technique was used in 245 patients. In fi ve
cases, the projection was not maintained as the strut
was either inadequate or the base was overdissected
and the strut descended too far. In the majority of
cases, there was temporary erythema and edema of
the columella. There were no incidences of infec-
tion or evidence of rejection reaction related to
using tissue glue between the cartilages. Revision
surgery was performed in 13 of the patients. Five
required additional tip grafting, two had to have the
strut reduced slightly, while the others were for
minor dorsal defects. The remaining patients main-
tained straight, adequate, non-pinched tip projec-
tion (Figs. 62.5 and 62.6 ).
62.4
Discussion
This procedure seems to work well with any tip
where there is concern about maintaining ade-
quate tip projection. Its biggest problem comes
when the septal cartilages are particularly short.
This can be dealt with by harvesting ear cartilage
or making a triple laminated strut. Harvesting a
septal cartilage strut with bone attached is possi-
ble but more dif fi cult.
It has been suggested that I have been losing
tip projection by virtue of complete trans fi xion
incisions made while performing a delivery
technique. The author has tried other techniques
NET RESULT
1
2
CUT
IN HALF
OR
HISTOCRYL
STRAIGHT LAMINATE
A
A
A’
A’
Fig. 62.3 Cartilage can be harvested from the septum or the auricle. Since cartilage is often naturally “warped,” cutting
it in half and securing the same side surface to each other “cancels out” the curves and yields a straight laminate

881
62 The Double Columellar Strut: An Adjunct to Improve the Nasal Tip
for securing adequate projection, but has found
them less reliable. Very often, prior to perform-
ing rhinoplasty, the author starts with a nose
simply wanting to maintain projection. In many
cases, however, the surgeon may not have ade-
quate support. Often the tip is being supported
by the septal cartilages and not the medial crura –
the dependent tip. Recessive premaxilla and
aging faces that lose fat in the upper lip are other
examples where there is loss of tip support.
These can be aided with premaxillary grafts or
sometimes fat grafts as well as double columel-
lar struts.
This technique for such dependent tips became
remarkably routine for the author. Its utility when
combined with the double-dome suture technique
(McCollough) is nearly universal. It provides a
straight, strong strut with enough combined
Fig. 62.4 ( a ) Patient demonstrating mild hump defor-
mity with dependent tip. ( b ) After lateral and medial
osteotomies and lowering dorsum. Tip is still dependent
and falls back. ( c ) Septal cartilage graft harvested from
inferior septum a few millimeters back from the caudal
area. ( d ) On the left , section of cartilage demonstrating
slight warp. This piece is actually fairly straight. On the
right , cartilage trimmed in half and sutured together (can
use tissue glue) provides a straight laminate that is 2–3
mm wide. ( e ) Long double columellar strut secured
between medial crura with 4-0 Monocryl suture. ( f ) Slight
over-projection seen immediately on the table. ( g ) ( Left )
Preoperative. ( Right ) Patient 1 year after operation
a
b
c
d
e
f

882
M. Berman
g
Fig. 62.4 (continued)

883
62 The Double Columellar Strut: An Adjunct to Improve the Nasal Tip
a
b
Fig. 62.5 ( Left ) Preoperative patient with wide nose –
both bony and cartilaginous. The tip shows poor projec-
tion and wide and laterally displaced domes. ( Right )
Rhinoplasty done by delivery technique: trim cephalic
lower lateral cartilages, place long double columellar
strut, and suture domes and strut together

884
M. Berman
thickness to prevent pinching of the tip. Its use
should be considered when confronted with poor
tip projection, poor medial crural strength,
drooped tips, dependent or tension tips, or any
case where there is a concern about maintaining
adequate tip projection.
References
1. Peck GC (1983) The onlay graft for nasal tip projec-
tion. Plast Reconstr Surg 71(1):27–39
2. McCollough EG, English JL (1985) A new twist in
nasal tip surgery: an alternative to the Goldman tip for
the wide or bulbous lobule. Arch Otolaryngol
111(8):524–529
3. Constantian MB (1985) Grafting the projecting nasal
tip. Ann Plast Surg 14(5):391–401
4. Parkes MH, Kanodia R, Kern EB (1988) The univer-
sal tip: a systematic approach to aesthetic problems of
the lower lateral cartilages. Plast Reconstr Surg
81(6):878–890
5. Petroff MA, McCollough EG, Hom D, Anderson JR
(1991) Nasal tip projection – quantitative changes fol-
lowing rhinoplasty. Arch Otolaryngol 117(7):783–788
6. Sheen JH (1991) Middle crus: the missing link in alar
cartilage anatomy. Perspect Plast Surg 5(1):31–53
7. Hugo NE, Mattson-Gates G, Sultan MR (1993)
Unhooking the hook: sculpting the nasal tip by
replanting the medial crura. Plast Reconstr Surg 91(7):
1344–1348
8. Mavili ME, Safak T (1993) Use of umbrella graft for
the nasal tip projection. Aesthetic Plast Surg 17(2):
163–166
9. Kridel RW, Konior RJ (1993) Irradiated cartilage
grafts in the nose. Arch Otolaryngol 119(1):24–30
10. Hoef fl in SM (1994) Geometric sculpting of the thick
nasal tip. Aesthetic Plast Surg 18(3):247–251
11. Daniel RK (1994) Rhinoplasty and rib grafts: evolv-
ing a fl exible operative technique. Plast Reconstr Surg
94(5):597–609
12. Berman M (1994) Gore-Tex e-PTFE in nasal surgery
and review of long-term results. Am J Cosmet Surg
11(3):179–182
13. Lawson W, Reino AJ, Seidman D (1996) The sili-
cone columellar strut. Plast Reconstr Surg 97(5):
938–943
14. Collawn SS, Fix RJ et al (1997) Nasal cartilage grafts:
more than a decade of experience. Plast Reconstr Surg
100(6):1547–1552
15. Peck GC, Michelson L et al (1998) An 18-year expe-
rience of the umbrella graft in rhinoplasty. Plast
Reconstr Surg 102(6):2158–2168
16. Garcia-Velasco J, Vida JT, Garcia-Casas S (1998)
Increasing the length of the middle crura for better tip
projection in primary rhinoplasty. Aesthetic Plast
Surg 22(4):253–258
Fig. 62.6 ( Left ) Preoperative patient with very wide tip and thick skin. ( Right ) Postoperative following double-dome
tip/double columellar strut technique to narrow and increase tip projection

885
62 The Double Columellar Strut: An Adjunct to Improve the Nasal Tip
17. Orak F, Yucel A, Aydin Y (1998) A new extrasup-
ported tip graft in the treatment of the bulbous nasal
tip. Aesthetic Plast Surg 22(4):259–266
18. De Carolis V (1998) The infradome graft: a new tech-
nique to improve dome reshaping in rhinoplasty. Plast
Reconstr Surg 102(3):864–871
19. Constantian MB (1999) Elaboration of an alternative,
segmental, cartilage-sparing tip graft technique: experi-
ence in 405 cases. Plast Reconstr Surg 103(1): 237–253
20. Sheen JH (2000) Rhinoplasty: personal evolution and
milestones. Plast Reconstr Surg 105(5):1820–1852
21. Daniel RK (1999) Rhinoplasty: a simpli fi ed, three-
stitch, open tip suture technique. Part I: primary rhi-
noplasty. Plast Reconstr Surg 103(5):1491–1512
22. Berman W (1975) Surgery of the nasal tip. Otolaryngol
Clin North Am 8(3):563–574

887
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_63, © Springer-Verlag Berlin Heidelberg 2013
63
63.1
Introduction
Rhinoplasty is the most dif fi cult facial plastic
surgery procedure. The complex anatomy of the
skeletal components of the nasal pyramid, sub-
jected to continuous gravitational force, negative
inspirational pressure, and postoperative scarring
process, often makes the long-term results of sur-
gery unpredictable.
The nasal tip is the cornerstone of rhinoplasty.
The patient seeks both an aesthetic natural-
looking nasal tip that will keep its shape over the
years, but also a nose that will allow normal
breathing and will fi t in with their face and eth-
nicity. Achieving long-lasting consistent good
results on tip surgery is the greatest challenge for
rhinoplasty surgeons.
The surgical techniques on the nasal tip were
over-resective in the past. Aggressive trimming of
the cartilage framework, dome division or soft-
tissue defatting were common maneuvers. Good
short-term results were followed by long-term
sequelae. Pinched noses, valve collapse, and
amputated or over-rotated tips are often found in
patients operated decades ago.
In order to obtain predictability along with
long-lasting results, in 1982, Pedroza described
the New Domes [ 1 ] and the Banner [ 2 ] tech-
niques. Both techniques are designed for the pri-
mary nose: the former for the Caucasian patient,
with strong cartilages and thin to normal skin,
and the latter for the mestizo nose, with weak car-
tilages and thick skin.
Preoperative aesthetic analysis, precise surgi-
cal maneuvers, cartilage preservation, respect for
the soft tissue envelope, and tip-support rein-
forcement are the key points of both techniques.
Almost 30 years of experience and thousands of
satis fi ed patients support the effectiveness of
New Domes and Banner techniques. The author
of this chapter has added small changes to these
techniques to adapt them to the open approach
and take into consideration the nostril-columella
relationship.
63.2
Aesthetic Analysis
Tip aesthetics can be explained through three
different parameters: projection, rotation, and
de fi nition. The projection of the nasal tip is the
Surgery on the Primary Nasal Tip:
New Domes Technique and Banner
Technique
Eduardo Morera Serna and Felipe Culaciati Tapia
E. M. Serna , M.D. (*)
Servicio de Otorrhinolaringologia , Hospital Universitario
Son Espases ,
Carretera de Valldemosa 79 , Palma de Mallorca, Islas
Baleares 07010 , Spain
e-mail: e_morera@hotmail.com
F. C. Tapia , M.D.
Servicio de Otorrhinolaringologia , Hospital Universitario
Son Espases ,
Carretera de Valldemosa 79 , Palma de Mallorca, Islas
Baleares 07010 , Spain
e-mail: felipeculaciati@yahoo.com

888
E.M. Serna and F.C. Tapia
distance from the alar-facial groove to the tip-
de fi ning point on the pro fi le view; normal projec-
tion is 28–30 mm. Nasolabial angle is the most
widely used parameter to de fi ne nasal tip rota-
tion; normal nasolabial angle ranges from 90° to
95° in men and 95° to 105° in women. Abnormal
upper lip position, as found in biprotrusive
patients or middle third hypoplasia, may distort
this angle; nasal length can be a more consistent
measure in those cases. Nasal length is the dis-
tance from the nasion to the nasal tip on the
pro fi le; normal nasal length is 45 mm in men and
40 mm in women; longer noses re fl ect under-
rotated tips, and shorter nasal length may be
found in patients with over-rotated tips. Nasal
length is a more reliable measure of tip rotation
when the nose starts at the supratarsal crease
(Figs. 63.1 and 63.2 ).
The de fi nition is the distance between the tip
domes in the frontal view; ideal interdomal dis-
tance is 10 mm, but it may range from 10 to
12 mm. Increased interdomal distance re fl ects a
wide tip, due to the absence of domal de fi nition
on the lower lateral cartilages, excessive diver-
gence of domes, thick soft tissue envelope over
the tip framework, or a combination of the afore-
mentioned. In secondary cases, lack of tip
de fi nition may also be due to scarring on the nasal
tip caused by overaggressive surgery (Fig. 63.3 ).
Columellar show on the pro fi le must have a
range from 2 to 4 mm. A lesser exposure corre-
sponds to a retracted columella and a bigger to a
hanging columella or a retracted alar rim or both
(Fig. 63.1 ). The surgeon must keep in mind that
incisions on the alar vestibule (marginal incision)
will create a vertical vector on scar contracture
that will lead to alar rim retraction on the long
term and that grafting on the medial crura will
tend to lengthen the columella. Adjusting the
columellar exposure in surgery is an art in itself.
Before surgery, tip aesthetics are discussed with
the patient taking into account height, ethnicity,
and the patient’s preferences. The authors normally
use computer morphing to optimize communica-
tion between patient and surgeon and also as an
educational tool, explaining to the patient the dif-
Fig. 63.1 Tip projection, tip rotation, and columellar show

889
63 Surgery on the Primary Nasal Tip: New Domes Technique and Banner Technique
ferent issues concerning their personal facial fea-
tures and the expected outcome. The natural and
modi fi ed pro fi le and frontal view photos of the
patient are taken to the operating room to be used
as a route map during the operation. We provide no
morphing copies to the patient and stress that the
software modi fi ed images are not a compromise of
result, but a target to pursue.
63.3
Pertinent Anatomy
The shape of the nasal tip is determined by the car-
tilaginous framework and the soft tissue envelope.
The paired symmetrical lower lateral cartilages,
with their almost in fi nite variations, give the struc-
tural support; their strength and their attachments
to the upper lateral cartilages and the caudal border
of the septum are the major tip-support elements.
Surgical approaches and tip-re fi nement maneu vers
do always damage most or all tip-support mecha-
nisms, so restoring and reinforcing tip support is
a mandatory step in every rhinoplasty.
Fig. 63.2 Tip rotation (male)
Fig. 63.3 Tip de fi nition

890
E.M. Serna and F.C. Tapia
The tip-de fi ning point is the place of the carti-
lage of maximum projection and corresponds to
the fold that divides the medial and lateral crura. As
Jack Anderson described 50 years ago [ 3 ] , the
lower lateral cartilages work as a tripod, with the
lateral crura acting as two lateral limbs and the con-
joined medial crura as the central limb (Fig. 63.4 ).
To change tip rotation and projection, we only have
to change the lateral/medial crura ratio by changing
the position of the dome or using overlapping
techniques.
The lateral crura must keep an angle of 45°
with the vertical axis of the nose, have a convex
shape, and be strong enough to avoid the collapse
of the nasal alae on inspiration. Malposition, con-
cavity, or weakness of the lateral crura will pro-
voke tip deformity and external valve collapse
which will have to be addressed during the opera-
tion (Fig. 63.5 ).
The skin over the nasal tip ranges from thin
and normal in Caucasian patients to thick in mes-
tizo, oriental, or patients of African descent
(Fig. 63.6 ). Thin skin will preclude the use of tip
grafts in order to avoid graft visibility through the
skin after soft tissue swelling has declined; most
normal skin cases would also fi t this statement.
On the contrary, thick-skin patients need tip grafts
to de fi ne their nasal tip [ 4 ] .
Irrigation of the nasal tip is carried through
paired columellar vessels, external branches of
the anterior ethmoidal arteries, and alar branches
of the angular arteries. A supraperichondrium
plane of dissection must be followed to preserve
blood supply; defatting of the soft tissue envelope
is strongly discouraged due to the uncontrolled
scarring induced by vascular damage on the sub-
dermal space.
63.4
New Domes Technique
1. External marking of the new domes: Using a
surgical pen and with the patient awake and
seated, the borders of the lower lateral carti-
lages are drawn, palpating them through the
skin. Regarding the vertical dimension, the
length, and the angle of the horizontal axis of
Fig. 63.4 Normal tip cartilages
Fig. 63.5 ( a ) Weakened lower lateral cartilages. ( b )
Malposition of the lateral crura. ( c ) Concave lateral crura

891
63 Surgery on the Primary Nasal Tip: New Domes Technique and Banner Technique
the lateral crus, we will decide whether or not
to mark a cephalic cartilage resection, lateral
crus repositioning, or lateral crus overlapping.
A re fl ex of the light appears on the external
domes; we mark them and we rotate the tip
with a gentle maneuver using the fi ngertips.
This will cause a redistribution of the cartilage
and a repositioning of the domes that will be
re fl ected by a lateralization of the light re fl ex
on the nasal tip; we make a second mark on
the new domes (Fig. 63.7 ).
2. In fi ltration: The nose is in fi ltrated with a mix-
ture of 5 mL of 1% lidocaine and 5 mL of
0.25% bupivacaine and 1/100,000 epineph-
rine. This combination provides a rapid onset
and a long-lasting effect. The authors wait for
10 min to make the incision, and this gives a
blood-free surgical fi eld.
3. Approach: The new domes technique was ini-
tially described using the closed approach. A
precartilaginous incision is made along the
lower border of the lower lateral cartilages,
and a postcartilaginous incision is made along
the upper border. Dissection proceeds in the
subperichondrial plane until the cartilage is
released and only remains attached to the nasal
vestibule by its ends; connective tissue attach-
ing the medial crura to the caudal border sep-
tum and the lateral crura to the upper lateral
cartilage is trimmed; interdomal ligaments
and dome-to-skin ligaments as well. A bipedi-
cle fl ap of cartilage and skin is then created on
each side of the nose.
An open approach is also suitable for this
procedure. A bilateral marginal incision and
an inverted-V-shape transcolumellar inci-
sion are performed [ 5 ] . Supraperichondrial
dissection and soft tissue fl ap rising provide
us with an excellent exposure of the nasal
tip framework that will facilitate precise
symmetrical maneuvers on the paired lower
lateral cartilages, while preserving the con-
nective attachments of the upper border of
this cartilages to the upper lateral cartilages.
The only drawback to this approach is the
prolonged swelling on the nasal tip due to
the columellar vessels injury caused by the
transcolumellar incision.
4. Internal marking of the domes and trans-
domal suture. After exposing the lower lateral
Fig. 63.6 ( a ) Thin skin. ( b ) Normal skin. ( c ) Thick skin

892
E.M. Serna and F.C. Tapia
cartilages, we mark the domes and the new
domes with a surgical pen (Fig. 63.8 ). A cali-
per is used to do this maneuver with absolute
precision and to avoid postoperative twisting
of the nasal tip due to asymmetrical position-
ing of the new domes [ 6 ] .
A double trans fi xion transdomal suture is
passed starting on the medial side of the new
Fig. 63.7 ( a ) Marking of the tip de fi ning points. ( b )Frontal view of the tip de fi ning points. ( c ) Rotation of the tip and
marking of the new domes. ( d ) Frontal view of the fi nal markings

893
63 Surgery on the Primary Nasal Tip: New Domes Technique and Banner Technique
dome and taking care not to close the domal
angle too much with the knot, which would
produce a collapse of the nasal vestibule. The
needle is passed 2–3 mm from the new dome,
and the second pass is made 2–3 mm closer
to the cartilage border than the fi rst one
(Fig. 63.9 ).
We need to keep two things in mind when
doing this suture. First, even if no rotation of
the nasal tip is needed, at least 3 mm of dome
lateralization is done to avoid postoperative
loss of tip rotation due to injury to the tip-sup-
port mechanisms. Second, axis of folding of
the new domes must be symmetrical and per-
pendicular to the axis of the cartilage; improper
folding will cause asymmetries on the curve
of the nasal alae and the position of the alar
rim that will be visible on the frontal view.
5. Reinforcement of the tip support: Classic new
domes technique instructs tip-support rein-
forcement through columellar strut placing
between the middle crura [ 7 ] . Graft dimen-
sions are 18–20 mm long and 4 mm wide with
Fig. 63.8 Internal marking of the new domes
Fig. 63.9 ( a ) Marking of the left dome. ( b ) Three mm. lateralization of the domal point. ( c ) Folding of the new dome
and transdomal suture. ( d ) Final view of the new dome

894
E.M. Serna and F.C. Tapia
a slight curvature at the inferior border in order
to respect the double break on the contour of
the columella. The graft should be obtained
from the septal area close to the osteocartilagi-
nous junction, which corresponds to the thick-
est part of the quadrangular cartilage; avoidance
of graft contact with the anterior nasal spine is
recommended as well as the trimming of the
anterior part to allow shrinkage of the soft tis-
sue envelope between the new domes. Suture
of the columellar strut to the medial crura is
done with a 5-0 Vicryl or PDS stitch passing
the needle from the lower border of the medial
crura through the graft to the lower border
of the contralateral cartilage at three different
levels no closer than 6 mm from the new domes
(Fig. 63.10 ).
The downside of the columellar strut is the
loss of tip projection and the tendency to
develop a hanging columella in the long term
due to the lack of union between the graft
and the caudal septal border. To overcome
this problem, Fernando Pedroza included
columellar-septal fi xation with a 5-0 Prolene
suture in the original technique.
A more solid way to reinforce tip support is by
suturing the medial crura to the caudal septal
border as described by Russell Kridel in his
original paper on the “tongue-in-groove tech-
nique” [ 8 ] . This technique reduces the columel-
lar exposure, which is useful in hanging
columella patients while giving a strong tip sup-
port (Fig. 63.11 ). In patients with a normal colu-
mella or retracted columella (Fig. 63.12 ), a
caudal extension graft [ 9 ] will provide both con-
venient tip support and leave an adequate colu-
mellar exposure. The caudal extension graft is
obtained from the septal cartilage, and its size is
determined by the length of septal extension
needed plus 4–5 mm of graft area to overlay the
caudal septal border; fi xation between the graft
and the septal cartilage is done with several 5-0
PDS sutures, preventing any postoperative
movement of the graft (Fig. 63.13 ). A com-
pletely straight septum is mandatory to avoid
graft-provoked obstruction of the nose.
Fig. 63.10 Columellar strut
Fig. 63.11 Tongue-in-groove technique

895
63 Surgery on the Primary Nasal Tip: New Domes Technique and Banner Technique
6. Interdomal suture: Tip re fi nement is achieved
in thin and normal skin patients through the
interdomal suture [ 10 ] . This suture starts on the
upper border of the medial crura 2 mm from
the new domes, going from medial to lateral
in the right cartilage and from lateral to medial
in the left one and making the knot in the inter-
domal space (Fig. 63.14 ). 5-0 PDS is again the
preferred suture due to biocompatibility and
prolonged strength retention and absorption
pro fi le; permanent sutures have been aban-
doned by the author of this chapter after several
cases of foreign body reactions to 5-0 Prolene
found months to years after the surgery.
The combination of the interdomal suture, at the
upper border of the medial crura 2 mm from the
Fig. 63.12 ( a ) Hanging columella. ( b ) Normal columella. ( c ) Retracted columella
Fig. 63.13 Caudal extension graft

896
E.M. Serna and F.C. Tapia
new domes, and the tip-support reinforcement
suture, at the lower border of the medial crura 6 mm
from the new domes, creates a fl aring of the tip car-
tilages and a diamond-shape intercartilaginous
space that will produce a beautiful natural-looking
tip after soft tissue fl ap repositioning (Fig. 63.15 ).
63.5
Banner Technique
Achieving tip de fi nition using exclusively dome
re fi nement techniques and interdomal suture, as
in the New Domes technique, is an almost impos-
sible task in patients with thick skin and thin tip
Fig. 63.14 ( a ) Medial to lateral 2 mm. to dome, upper border
of the right lower lateral cartilage. ( b ) Lateral to medial 2 mm
to dome, upper border of the left lower lateral cartilage. ( c )
Tightening the knot. ( d ) Final view. Knot between the domes
Fig. 63.15 Final shape of the tip cartilages

897
63 Surgery on the Primary Nasal Tip: New Domes Technique and Banner Technique
cartilages. The Banner technique was speci fi cally
designed for this situation.
The fi rst steps are exactly the same as the New
Domes technique. After interdomal suture, a
Sheen-type tip graft [ 11 ] 18 mm long and 8 mm
wide at the anterior border is sculpted from the
septal cartilage; graft borders are beveled with a
cold knife to avoid graft show through the skin on
the long term. The graft is fi xed to the columella
and to the domes with 5-0 PDS, and depending
on the need for projection, the graft will be posi-
tioned at the dome level or above them
(Fig. 63.16 ). The shape and size of the graft allow
it to provide contour not just to the tip but to the
columella as well. When the tip of the graft is
fi xed above the dome’s level, some bending of
the graft will be expected after soft tissue redrap-
ing, and this will increase tip rotation. In case
this added tip rotation is not intended, cartilage
grafting should be done above the tip of the Sheen
graft to splint it. When using a Sheen graft, we
must always keep in mind that long-term loss of
rotation of the nasal tip is higher than in patients
where no tip grafts are used, so tip-support
maneuvers and hypercorrection of tip rotation are
strongly encouraged.
If the patient has a preoperative hanging colu-
mella or columellar show is adequate after inter-
domal suture, a large Sheen graft as described in
the original technique is not indicated. A small
Shield graft 6 mm long made from septal carti-
lage and carved in the same way as the large graft
can be fi xed to the medial crura and the new
domes (Fig. 63.17 ). This small graft must be
secured in place with several sutures, to prevent
postoperative displacement; postoperative tip
loss of rotation is less as the Shield graft is lighter
than the large Sheen graft.
Fig. 63.16 ( a ) Traversing the dome lateral to medial. ( b ) Traversing the Sheen graft 4 mm. to the upper border of the
graft. ( c ) Graf tinto position. ( d ) Tightening the knot. The suture hugs the graft to further stabilize it

898
E.M. Serna and F.C. Tapia
Fig. 63.17 Short Shield graft
Fig. 63.18 ( a ) Marking of the upper border of the crura lateralis on the left lower lateral cartilage. ( b ) Incision. ( c ) Trimming
of the excess of cartilage. ( d ) Final result. The preserved cartilage rim is at least 5 mm high at the dome and 7 mm. lateral to it

899
63 Surgery on the Primary Nasal Tip: New Domes Technique and Banner Technique
63.6
Complementary Maneuvers
1. Cephalic resection of the lower lateral carti-
lages: Fernando Pedroza advocated this
maneuver in his original paper. If cartilage
width is excessive at the new domes, a conser-
vative cartilage resection with vestibular skin
conservation is performed, leaving at least
5 mm width at the dome level and 7 mm width
10 mm lateral to the domes (Fig. 63.18 ).
This maneuver can be risky in some patients
with thin cartilages, leading to external nasal
valve collapse and nostril rim retraction in the
long term. Therefore, we advocate for lateral
crura conservation and only perform a limited
resection at the domal level in cases where bulky
lower lateral cartilages may cause a postopera-
tive pollybeak deformity; malposition of the lat-
eral crura should not be addressed by this
maneuver but by crura repositioning. Cephalic
resection will always provoke a vertical scarring
vector that can produce nostril retraction, so in
every case we do it, a rim alar graft is inserted at
the end of the surgery (Fig. 63.19 ). If there is any
doubt about alar strength after the resection, the
batten-type grafts should be used (Fig. 63.20 ).
2. Columellar-septal fi xation: This suture was
described by Fomon and Berman [ 12 ] and is
included in the original new domes technique.
A 5-0 polypropylene is passed through the
right medial crura exiting the columella skin
and reentering through the exiting hole and
Fig. 63.19 ( a ) Dissection of the pocket. ( b ) Introduction of the rim graft. ( c ) Closure of the marginal incisión. ( d ) Final result

900
E.M. Serna and F.C. Tapia
traversing the columella to the other side. The
needle reenters the exiting hole and traverses
the skin and the left medial crura; after this,
we have a fi rm grip on the columella, we
traverse the caudal septal border, and we make
the knot (Fig. 63.21 ). This suture has a double
effect. First, it sticks the columella to the cau-
dal septal border preventing a hanging colu-
mella in the long term, and second, if the
caudal septal border pass is done above the
columellar pass, a signi fi cant, although transi-
tory, gain in tip projection is achieved.
Columellar-septal fi xation is not necessary if
the caudal extension graft is used or tongue-
in-groove technique is done, as medial crura
are already sutured to the caudal septal border
in both cases.
3. Caudal septal shortening and vestibular skin
reduction: An excess of caudal septal border
pushing the columella downwards may be
found after tip-rotating maneuvers; this may
cause a hanging columella. Resection of cau-
dal septal border will be necessary to accom-
modate the quadrangular cartilage to the new
tip; the size and type of the resection will be
determined by the shape of the columella in
the pro fi le (Fig. 63.22 ).
Fig. 63.20 Batten graft
Fig. 63.21 Columellar-septal fi xation

901
63 Surgery on the Primary Nasal Tip: New Domes Technique and Banner Technique
Tongue-in-groove technique may also address
excessive columellar show; in some cases, both
caudal septal shortening and suturing of the
medial crura to the caudal septum will be neces-
sary to achieve an adequate columellar show.
A triangular portion of vestibular skin should
also be excised in order to avoid vestibular
obstruction due to skin bulging when the colu-
mella is pushed upwards and the caudal septal
border is shortened (Fig. 63.23 ).
Fig. 63.22 Caudal septal shortening
Fig. 63.23 Vestibular skin reduction

902
E.M. Serna and F.C. Tapia
Fig. 63.24 New Domes technique

903
63 Surgery on the Primary Nasal Tip: New Domes Technique and Banner Technique
63.7
Discussion
The New Domes technique and the Banner tech-
nique have been used in hundreds of patients in
the last 7 years by the author of this chapter. A
low revision rate and almost 100% patient satis-
faction support the ef fi cacy of this comprehen-
sive approach to the nasal tip.
A review of long-term results of the technique
was done on 182 patients operated by Fernando
Pedroza [ 2 ] . The effectiveness of each of the surgi-
cal maneuvers was studied, using tip rotation, tip
projection, and tip de fi nition as outcome parame-
ters. The results of the analysis supported the
aforementioned observations; only columellar-
septal fi xation failed to show any ef fi cacy in the
long-term with regard to the tip projection. The
columellar show was not assessed in this study.
Modi fi cations to the original technique were
done in order to adapt it to the open approach and
to address the nostril-columella relation on the
pro fi le more ef fi ciently. Open approach provides
a better exposure of the tip framework and facili-
tates the surgical maneuvers, especially tip graft-
ing. The drawback of open approach is the
prolonged swelling of the tip compared to the
close approach; columellar scar is inconspicuous
when the incision and the closure are correctly
performed. Permanent sutures were abandoned
after two patients presented with foreign body
reaction months after the procedure.
Reinforcing tip support and maintaining the
strength of the framework are the key points to
achieving long-lasting good results. Even in
patients with normal preoperative tip support,
reinforcement maneuvers are done to counteract
the loss of tip support due to the surgical approach,
and this is especially true in patients with thick
skin and thin cartilages. A slight overcorrection
on tip projection and tip rotation is desirable on
the surgical table, as some de-rotation and de-
projection will appear in the fi rst months as swell-
ing disappears.
Patients are instructed about swelling and post-
operative care; we inform them what they should
expect at 1 month, 2 months, and 1 year after the
rhinoplasty. We encourage every patient to come
back once a year for a free control and to take
photographs. Just a few cases of revision surgery
have been done so far, and all of them were minor
procedures done under local anesthesia. Safety,
versatility, and patient satisfaction have made the
New Domes technique and the Banner technique
two of the most widely used rhinoplasty tech-
niques around the world (Figs. 63.24 , 63.25 ,
63.26 , 63.27 , 63.28 , and 63.29 ).

904
E.M. Serna and F.C. Tapia
Fig. 63.25 New Domes technique

905
63 Surgery on the Primary Nasal Tip: New Domes Technique and Banner Technique
Fig. 63.26 New Domes technique

906
E.M. Serna and F.C. Tapia
Fig. 63.27 Banner technique

907
63 Surgery on the Primary Nasal Tip: New Domes Technique and Banner Technique
Fig. 63.28 Banner technique

908
E.M. Serna and F.C. Tapia
Fig. 63.29 Banner technique

909
63 Surgery on the Primary Nasal Tip: New Domes Technique and Banner Technique
References
1. Pedroza F (2002) A 20-year review of the “new
domes” technique for re fi ning the drooping nasal tip.
Arch Facial Plast Surg 4(3):157–163
2. Morera E, Escobar C, Pedroza F, Frontera G (2008)
Long-term changes on nasal tip in rhinoplasty patients
operated with the New Domes technique and the
Banner technique. Acta Otorrinolaringol Esp 59(8):
390–398
3. Anderson JR (1971) New approach to rhinoplasty.
Arch Otolaryngol 93(3):284–291
4. Cobo R (2003) Mestizo rhinoplasty. Facial Plast Surg
19(3):257–268
5. Stone JV (1980) External rhinoplasty. Laryngoscope
90(10 Pt 1):1626–1630
6. Tardy ME Jr, Patt BS, Walter MA (1993) Transdomal
suture re fi nement of the nasal tip: long-term out-
comes. Facial Plast Surg 9(4):275–284
7. Fomon S (1960) Cosmetic surgery: principles and
practice. JB Lippincott, Philadelphia
8. Kridel RW, Scott BA, Foda HM (1999) The tongue-
in-groove technique in septorhinoplasty. A 10-year
experience. Arch Facial Plast Surg 1(4):246–258
9. Byrd HS, Andochick S, Copit S, Walton KG (1997)
Septal extension grafts: a method of controlling tip pro-
jection shape. Plast Reconstr Surg 100(4):999–1010
10. Vuyk HD (1995) Suture tip plasty. Rhinology 33(1):
30–38
11. Sheen JH (1993) Tip graft. A 20-year retrospective.
Plast Reconstr Surg 91(1):48–63
12. Berman WE (1975) Surgery of the nasal tip.
Otolaryngol Clin North Am 8:563–574

911
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_64, © Springer-Verlag Berlin Heidelberg 2013
64
64.1
Evolution of Nasal Tip Sutures
Joseph, thought by many as the father of modern
rhinoplasty, published his operative techniques in
1931 [ 1 ] and included one of the fi rst descriptions
of suture use in tip rhinoplasty. He described a
columellar-septal suture that served to rotate the
nasal tip, providing increased projection while sta-
bilizing the tip lobule complex. This suture was
used after transecting the lateral crural cartilages
adjacent to the domes and excising a full thickness
triangular alar section. Joseph also described what
is now known as the interdomal suture which pro-
vides stabilization, tip rotation, and narrowing.
The early suturing techniques focused on
securing repositioned alar cartilage remnants after
the supporting structures of the nasal tip had
undergone signi fi cant disruption and resection.
Although many of these techniques were effective
in achieving tip projection and cephalic rotation,
such techniques could potentially result in unde-
sired postoperative sequelae. Over time through
the understanding of the underlying cartilaginous
supporting structures of the nose, techniques of
altering the nasal tip would focus more on preser-
vation and alteration of structures instead of resec-
tion and disruption of the underlying cartilage.
In 1954, Goldman [ 2 ] described the “Goldman
technique” where he utilized a segment of lateral
crura to augment medial crural height through
the creation of a single midline strut. In this endo-
nasal procedure, marginal and intercartilaginous
incisions were employed to deliver and com-
pletely transect the lower lateral cartilages at a
position lateral to the dome. A medial crural
suture was then placed in the area of the domes,
thus increasing tip projection while narrowing
the tip. Long-term results of this procedure could
potentially result in visible tip asymmetries and
alar rim collapse with nasal tip pinching [ 3 ] .
Goldman’s technique may have fallen out of pop-
ularity, but it is important historically as it stressed
the importance of the medial crura in tip surgery.
64.2
The Popularity of Nasal Tip
Suture Techniques
The progression of cartilage disrupting rhino-
plasty techniques to preservation techniques can
be attributed to the work of Janeke and Wright
The Medial Crural Suture Technique:
Long-Term Columellar Narrowing
Resulting in Increased Tip
Projection and Rotation
Helen Perakis and Achih H. Chen
H. Perakis , M.D. (*)
Department of Otolaryngology – Head and Neck
Surgery , Georgia Health Sciences University ,
1120 15th Street , BP-4109 , Augusta , GA 30912 , USA
Department of Plastic and Reconstructive Surgery ,
University of Minnesota , Minneapolis , MN , USA
e-mail: hperakis@gmail.com
A. H. Chen , M.D.
The Georgia Center for Facial Plastic Surgery ,
613 Ponder Place , Evans , GA 30809 , USA
Division of Facial Plastic and Reconstructive Surgery,
Department of Otolaryngology – Head and Neck
Surgery , Georgia Health Sciences University ,
Augusta , GA , USA
e-mail: achen@thegeorgiacenter.net

912
H. Perakis and A.H. Chen
[ 4 ] . In their studies of the supportive structures of
the nasal tip, they discussed the preservation of
the ligamentous connections between the medial
crural footplates and the posterior caudal septum,
the dense fi brous tissue joining the lateral crura to
the sesamoid cartilages, the fi brous attachments
between the upper and lower lateral cartilages,
and the interdomal ligament. Their work pro-
vided an understanding of these underlying struc-
tures and stressed the fact that manipulation of
one structure could alter the entire nasal tip. Their
work indirectly emphasized the use of sutures for
controlling and altering these tip-supporting
structures [ 5 ] .
Cartilage preservation techniques were also
utilized by cleft rhinoplasty surgeons. In 1959,
McIndoe and Rees [ 6 ] would remodel the cleft
nasal tip by repositioning and realigning the car-
tilages and fi xing them in place through the use
of multiple medial crural sutures, columellar-
septal sutures, and interdomal sutures. Tajima
and Maruyama in 1977 [ 7 ] also used sutures to
adjust cleft nostril deformities by placing medial
crural suture, interdomal suture, and lateral crura
sutures in the alar cartilages. The experience and
knowledge obtained from correcting nasal cleft
deformities would eventually be applied to aes-
thetic rhinoplasty.
There is much variability when attempting to
reshape the nasal tip with the use of cartilage
grafts. Cartilage grafts are often dif fi cult to control,
making their fi nal position variable. Malposition,
displacement, warping, resorption, visible irregu-
larities, extrusion, infection, soft tissue deforma-
tion, and atrophy are all common problems cited.
This is especially true when grafts are placed
subcutaneously [ 5 ] . Beginning in the 1980s, there
was a trend from cartilage disrupting surgery
with placement of cartilage grafts to more utiliza-
tion of suture techniques to change nasal tip rota-
tion and projection.
64.3
Anderson’s Tripod Model
Aesthetic rhinoplasty requires an understanding
of the anatomic support mechanisms of the nasal
tip. In the tripod model described by Anderson in
1969 [ 8 ] , the lateral crura of the alar cartilages
form two legs of the tripod, while the two fused
medial crural form the third leg of the tripod. The
apex of the tripod, where the domes are located,
forms the nasal tip. Lengthening or shortening
any limb of the tripod will alter both tip projec-
tion and tip rotation. Anderson warned surgeons
in his later works that the basal tripod had several
important structures, some or all which could be
weakened or destroyed during rhinoplasty. He
cautioned that failure to compensate for this dam-
age could adversely affect the results of the oper-
ation. He spoke of a ligamentous structure
overlapping the feet of the medial crura with the
caudal edge of the septal cartilage. He empha-
sized that excision of septal cartilage from the
area of overlap would dramatically lessen tip
support, causing loss of tip projection [ 9 ] .
Several years later, Song [ 10 ] would describe
a small rod of soft tissue that is always found
between the medial crura of the alar cartilages
that appeared to be part of a pair of muscles.
Given the well-described depressor septi nasi
muscle, this newly discovered muscle was given
the antagonist muscle name of levator septi nasi
muscle. In the tripod model, the medial crura
were considered fused. In reality, they are ana-
tomically separated by the levator septi nasi mus-
cle. As a result, the medial crura may be widely
separated, forming a triangle with the apex near
the nasal tip and the base near the nasal spine.
64.4
Trigonometry to Analyze
the Nasal Base
Individuals with widely separated medial crura
present preoperatively with a widened columella
on basal view. In these individuals, permanently
narrowing the distance between the medial crura
will not only result in narrowing of the columella,
but according to the Pythagorean theorem in
which the sum of the square of the legs of a right
triangle equals the square of the length of the
hypotenuse, narrowing of the distance between
the medial crura will also result in increased tip
projection (Fig. 64.1 ). Utilizing the Pythagorean
theorem, the triangle formed by widely separated

913
64 The Medial Crural Suture Technique: Long-Term Columellar Narrowing Resulting
medial crura may be divided into two right trian-
gles by bisecting the medial crural triangle. As
the length of the hypotenuse, which is the length
of the medial crura, remains constant, perma-
nently decreasing the distance between the medial
crura will result in permanently decreasing the
length of one of the legs of the right triangle.
Consequently, the other leg of the right triangle
must permanently increase in length to accom-
modate the unaltered length of the medial crura.
In other words, permanently decreasing distance
between the medial crura, given a constant length
of the medial crura (no surgical alteration of the
length), must permanently increase the distance
from the feet of the medial crura to the nasal tip,
permanently increasing tip projection.
In formula format, where the length of the
medial crura is c , which is constant; the length of
the half of the distance between the medial crura is
a , which is permanently decreased from columel-
lar narrowing; and b is the distance from the feet of
the medial crura to the tip, c 2 = a 2 + b 2 , the length of
the columella, b , must permanently be increased in
length if the distance between the medial crura, a
(2 × a is actually the distance between the medial
crura as the right triangle is a bisection of the tri-
angle formed by the medial crura), is permanently
decreased, while c remains constant.
As aesthetic rhinoplasty may include many
maneuvers, all of which may affect nasal tip pro-
jection and rotation, it becomes very dif fi cult, if
not impossible, to assess the results of a single
surgical maneuver. Utilization of the Pythagorean
theorem allows conclusions made of the effect of
the medial crural suture technique on the dis-
tance between the medial crura. This is a mea-
surable variable which can be extrapolated to
make conclusions about nasal tip projection and
rotation, irrespective of the other surgical maneu-
vers performed.
64.5
Pythagorean Theorem
Demonstrates Increased
Tip Projection
A series of 12 consecutive primary rhinoplasty
patients undergoing aesthetic endonasal rhino-
plasty who presented with widened columella due
to widely separated medial crura preoperatively
was previously published by Chen et al. [ 11 ]
(Fig. 64.2 ). Long-term follow-up subsequent to
removal of a portion of the levator septi nasi mus-
cle and suture approximation of the medial crura
was examined. Nasal tip projection, columellar
width, and nasolabial angle were measured by
National Institutes of Health (Bethesda, MD)
Image J software (V1.34j) using pre- and postop-
erative photographs for each patient [ 12 ] . Nasal
tip projection was quanti fi ed using the method of
Crumley and Lanser [ 13 ] on right pro fi le view
photographs (Fig. 64.3 ). A line from the vertex of
the nasofrontal angle to the vermilion-cutaneous
junction of the upper lip was compared to a per-
pendicular line, extending to the tip-de fi ning
point. Columellar width was quanti fi ed on basal
view photographs, using a ratio of columellar to
nasal base width (Fig. 64.4 ). The columellar width
was measured halfway between the anterior and
posterior portion of the naris. The nasolabial angle
c
a
b
Fig. 64.1 The paired columella join near the nasal tip
and diverge near the nasal spine forming a triangle.
Bisection of this triangle creates two mirror-image right
triangles . The hypotenuse, c , remains constant as it is
surgically unaltered. The distance between the medial
crura is 2 × a , where a is the length of one of the legs of the
right triangle. The length of a is decreased as the colu-
mella is narrowed. Since the length of the medial crura,
c , remains constant, b , the length of the medial leg of the
Anderson [ 8 ] tripod must increase where according to the
Pythagorean theorem, c 2 = a 2 + b 2

914
H. Perakis and A.H. Chen
was measured using the angle tool on the Image J
software (Fig. 64.5 ).
The ratio of columellar width to nasal base
width, the nasolabial angle, the ratio of the dis-
tance from the nasofrontal angle to the vermilion-
cutaneous junction of the upper lip compared to a
a
b
Fig. 64.2 ( a ) Preoperative widely separated medial crura. ( b ) Postoperative following medial crural suture technique
with narrowing of the columella
Fig. 64.3 Nasal tip projection was quanti fi ed using the
method of Crumley and Lanser [ 13 ] . A line from the ver-
tex of the nasofrontal angle to the vermilion-cutaneous
junction of the upper lip was compared to a perpendicular
line , extending to the tip-de fi ning point
Fig. 64.4 Columellar width was quanti fi ed, using a ratio
of columellar to nasal base width. The columellar width
was measured halfway between the most anterior border
of the naris and the most posterior

915
64 The Medial Crural Suture Technique: Long-Term Columellar Narrowing Resulting
perpendicular line, extending to the tip-de fi ning
point, were analyzed. The ratio of columellar
width to nasal base width on basal view photo-
graphs decreased from a mean of 0.24 ± 0.01 (95%
con fi dence interval, 0.22–0.26) to 0.20 ± 0.008
(95% con fi dence interval, 0.18–0.22), represent-
ing a statistically signi fi cant reduction in columel-
lar width ( p = 0.0001). There was no signi fi cant
difference between the preoperative nasolabial
angle, 92.0 ± 3.6 (95% con fi dence interval, 84.0–
100.0), and postoperative nasolabial angle,
94.0 ± 4.1 (95% con fi dence interval, 85.0–103.0),
( p = 0.56). Based on the method of Crumley and
Lanser, the calculation of nasal tip projection
decreased signi fi cantly from 0.30 ± 0.02 (95%
con fi dence interval, 0.29–0.32) to 0.28 ± 0.02
(95% con fi dence interval, 0.26–0.29), ( p = 0.006)
[ 13 ] . According to the Anderson tripod model,
increasing the length of the leg of the tripod
formed by the medial crura should result in both
increased tip rotation and projection, but aesthetic
rhinoplasty often utilizes multiple techniques, all
of which affect tip projection and rotation. The
use of multiple simultaneous techniques during
aesthetic rhinoplasty confounds almost any post-
operative data involving tip projection and rota-
tion as demonstrated by the fi nding of the lack of
increased tip rotation and even the loss of tip
projection by Chen et al.; however, they were
able to demonstrate increased tip projection with
data extrapolated from use of Pythagorean
theorem.
64.6
Medial Crural Suture
Technique
The technique of columellar narrowing in indi-
viduals with widely separated medial crura
(Fig. 64.6 ) begins with local in fi ltration of 1%
lidocaine with 1:100,000 epinephrine. Following
adequate vasoconstriction, a hemi-trans fi xion
incision is completed. Blunt dissection with a
curved iris scissor is carried into the area between
the medial crura. The intervening soft tissue,
made up of the levator septi nasi, is sharply
excised. Following adequate hemostasis, transcu-
taneous sutures using 4-0 chromic are completed
to approximate the medial crura. The end result is
narrowing of the distance separating the medial
crura.
A variation of this above-described technique
was described by Lawson and Reino [ 14 ] who
referred to it as reduction columelloplasty. In
their technique, a diamond-shaped area was
marked on the lower columellar skin surface,
with its superior apex located between the feet of
the medial crura and the inferior apex extending
slightly onto the philtrum. The skin incision was
carried through and through with a no. 11 blade,
removing skin, levator septi nasi muscle, and sur-
rounding soft tissue en bloc. The feet of the
medial crura were then identi fi ed and approxi-
mated with a 4-0 clear nylon mattress suture. The
residual defect was closed in a vertical orienta-
tion with a single deep 4-0 chromic catgut suture
placed at the midpoint of the diamond. The skin
was apposed with 6-0 nylon sutures. Although
effective, this technique involves a more visible
external incision.
Fig. 64.5 Nasolabial angle measured as the angle between
the columella and the upper lip

916
H. Perakis and A.H. Chen
64.7
The Lasting Effects
of the Medial Crural
Suture Technique
In the tripod model described by Anderson [ 8 ] ,
the two fused medial crura form the third leg of
the tripod. Lengthening this leg will result in
increased tip rotation and projection, while short-
ening will result in the opposite. In Anderson’s
model, the medial crura are fused. In reality, they
are separated by the levator septi nasi muscle,
forming a triangle with the apex near the nasal tip
and the base near the nasal spine. The medial cru-
ral suture technique, in combination with partial
excision of the levator septi nasi muscle, can be
used to increase tip projection. Partial removal
of the levator septi nasi muscle serves two pur-
poses. First, it decreased the bulk of the soft
tissues intervening between the medial crura.
Second, it allows for scarring of the medial crura
together. The resulting columellar narrowing is
lasting. Consequently, the angle formed by the
two medial crura decreases, resulting in increased
tip projection.
Using the Pythagorean theorem, c 2 = a 2 + b 2 ,
where c , the length of the medial crura, is con-
stant because it is surgically unaltered, and a , the
length of half of the distance separating the
a
c
b
d
Fig. 64.6 ( a ) Preoperative widely separated medial crura.
( b ) Partial removal of the levator septi nasi muscle follow-
ing hemi-trans fi xion incision. ( c ) Transcutaneous suture
approximation of the medial crura. ( d ) Narrowed colu-
mella immediately postmedial crural suture technique

917
64 The Medial Crural Suture Technique: Long-Term Columellar Narrowing Resulting
medial crura, has been shown to be decreased in
length over the long term by the medial crural
suture technique. As a result, b , the length of the
distance from the apex of the nasolabial angle to
the nasal tip and the length of the third leg of the
Anderson tripod, must be permanently increased.
Increasing the length of the medial leg of the tri-
pod increases both tip projection and tip
rotation.
64.8
The Role of the Medial
Crural Suture
Aesthetic rhinoplasty requires an individualized
approach for each patient. Consequently, multi-
ple surgical maneuvers and techniques may be
utilized during a single setting to achieve the
desired cosmetic outcome. All of the utilized sur-
gical techniques may potentially affect nasal tip
projection and rotation. As a result, it is very
dif fi cult to assess the rami fi cations of a single
surgical maneuver on tip projection and tip rota-
tion. The medial crural suture technique is a pro-
cedure that can be performed in addition to other
techniques utilized during aesthetic rhinoplasty
to address undesirable characteristics. Other
techniques such as the lateral crural fl ap tech-
nique can be used concurrently to increase nasal
tip rotation while simultaneously decreasing tip
projection [ 15 ] . Trimming the cephalic margin of
the lower lateral cartilages without vertical dome
division has also been shown to decrease tip pro-
jection [ 16 ] . Reducing the anterior septal angle
also reduced tip projection while increasing tip
rotation. Consequently, any increases in nasal tip
projection that may result from the medial crural
suture technique will be negated by the other rhi-
noplasty techniques performed in conjunction.
The effect of several combined rhinoplasty
techniques on tip projection and rotation makes it
very dif fi cult, if not impossible, to make conclu-
sions about the medial suturing technique on tip
projection and rotation based on direct measure-
ments. However, the Pythagorean theorem allows
extrapolation of a measurable variable, columel-
lar width, on tip projection and rotation. The ratio
of columellar width to nasal base width has been
shown to be decreased, representing a statistically
signi fi cant reduction in columellar width. The
Pythagorean theorem allows extrapolation of this
statistically signi fi cant fi nding in concluding that
the medial crural suture technique provides last-
ing increases in tip projection and tip rotation.
Medial crural suturing techniques have indicated
a resultant strengthening of the nasal tip [ 17 ] .
Conclusions
In the rhinoplasty patient presenting with a wid-
ened columella due to widely separated medial
crura, partial removal of the levator septi nasi
muscle with absorbable transcutaneous suture
approximation of the medial crura maintains
lasting narrowing of the preoperatively wid-
ened columella. During aesthetic rhinoplasty,
several surgical maneuvers are often performed,
each affecting nasal tip projection and rotation.
Using Anderson’s tripod model, narrowing of
the columella augments the medial limb of the
nasal tip tripod and therefore produces lasting
improvement in tip projection and tip rotation.
This technique can be used in combination with
other techniques to provide lasting results affect-
ing tip projection and rotation.
References
1. Joseph J (1931) Nasenplastick und Sonstige Gesichts-
plastik nebst einen Anhang ueber Mammaplastik.
Verlag von Curt Kabitzsch, Leipzig
2. Goldman IB (1954) Surgical tips on the nasal tip. Eye
Ear Nose Throat Mon 33(10):583–586
3. Goldman IB (1957) The importance of the mesial
crura in nasal-tip reconstruction. AMA Arch
Otolaryngol 65(2):143–147
4. Janeke JB, Wright WK (1971) Studies on the support
of the nasal tip. Arch Otolaryngol 93(5):458–464
5. Behmand RA, Ghavami A, Guyuron B (2003) Nasal
tip sutures part I: the evolution. Plast Reconstr Surg
112(4):1125–1129
6. McIndoe A, Rees TD (1959) Synchronous repair of
secondary deformities in cleft lip and nose. Plast
Reconstr Surg 24:150
7. Tajima S, Maruyama M (1977) Reverse-U incision
for secondary repair of cleft lip nose. Ann Plast Surg
60(2):256–261
8. Anderson JR (1970) The dynamics of rhinoplasty.
In: Busta ment GA (ed) Proceedings of the ninth

918
H. Perakis and A.H. Chen
international congress of otorhinolaryngology, Mexico
City, 10–14 Aug 1969. Excerpta Medica, Amsterdam
9. Anderson JR (1984) A reasoned approach to nasal
base surgery. Arch Otolaryngol 110(6):349–358
10. Song R, Ma H, Pan F (2002) The “levator septi nasi
muscle” and its clinical signi fi cance. Plast Reconstr
Surg 109(5):1707
11. Chen AH, Moretz WH, Perakis H, Champagne JP,
Markarian A, Kamer FM (2010) Medial crura suture
technique: long term columellar narrowing and
extrapolated effect on tip projection and rotation. Am
J Cosmet Surg 27(3):107–114
12. Rasband WS, Image J (1997–2011) U. S. National
Institutes of Health, Bethesda, Maryland, USA. http://
imagej.nih.gov/ij/ . Accessed May 15, 2012
13. Crumley RL, Lanser M (1988) Quantitative analysis
of nasal tip projection. Laryngoscope 98(2):202–208
14. Lawson W, Reino AJ (1995) Reduction columelloplasty:
a new method in the management of the nasal base. Arch
Otolaryngol Head Neck Surg 121(10):1086–1088
15. Durante BJ, Porubsky ES (1988) Stabilizing the lateral
crural fl ap in septorhinoplasty. Laryngoscope 98(1):
117–119
16. Rich JS, Friedman WH, Pearlman SJ (1991) The
effects of lower lateral cartilage excision on nasal tip
projection. Arch Otolaryngol Head Neck Surg 117(1):
56–59
17. Guyuron B, Behmand RA (2003) Nasal tip sutures
part II: the interplays. Plast Reconstr Surg 112(4):
1130–1145

919
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_65, © Springer-Verlag Berlin Heidelberg 2013
65
65.1
Introduction
One of the most dif fi cult problems confronting
the rhinoplasty surgeon is a lack of nasal tip pro-
jection. Many procedures have been developed to
solve this problem.
Certain teams use the transdomal suture [ 1 ] or
alar cartilage scoring [ 2 ] . Others use columellar
struts to gain and maintain tip projection [ 3, 4 ] .
The auricular and septal cartilages are most com-
monly used as onlay grafts for accentuating the
nasal tip [ 5 ] . Autologous inferior turbinate bone
can be used for the same purpose [ 6 ] . Silicone
implants are also proposed for maintaining tip
projection [ 7 ] .
The onlay folded fl ap (OFF) [ 8 ] is a new tech-
nique, used for reshaping, re fi ning, supporting,
and projecting the nasal tip without either carti-
lage resection or cartilage grafting. This method
uses and remodels the cephalic portions of the
lateral crura, which are usually discarded during
the reduction of the alar cartilages.
OFF surgical technique (Fig. 65.1 ):
The procedure is performed under general
•
anaesthesia using an open approach.
The skin is in fi ltrated with 1% xylocaine with
•
epinephrine to facilitate dissection.
The two alar cartilages are undermined from
•
the overlying tissue.
The cephalic portions of the lateral crura are
•
carefully dissected.
Two symmetric lateral fl aps are taken from the
•
cephalic portions of the lateral crura, leaving
the caudal portions intact (there must be at
least 5 mm of the total width of each lateral
crus remaining). These fl aps are anteriorly
vascularized and attached to the domal seg-
ments of the middle crura.
The fl aps’ internal edges are carefully sutured
•
together to form a single, large fl ap.
The new fl ap wraps the domes and is folded into
•
two layers. Firstly, it is rotated anteriorly over the
original domes and fi xed with them with 2 U
sutures using polydioxanon (5-0), before its distal
portion is turned posteriorly over the fi rst layer.
The fl ap’s two layers are fi xed together with
•
the domes with 2 U sutures using polydiox-
anon (5-0), creating an onlay folded fl ap (OFF)
to form new, increased, and projected domal
segments. If necessary, 1–2 mm is excised
from each onlay folded fl ap’s external edge to
decrease the width of the OFF, depending on
the new domes desired.
The incisions are sutured using polyglactin
•
910 (5-0) for the alar margins and polypropyl-
ene (6-0) for the columella.
OFF surgical technique steps (Fig. 65.1 ):
(a) The two alar cartilages are undermined
from the overlying tissue. (b, c, d) Two symmetric
The Onlay Folded Flap (OFF)
for Nasal Tip Surgery
Hani Abou Mayaleh
H. A. Mayaleh , M.D.
French Hospital , Kassaa , Damascus ,
B.P. 2004 , Syria
Italian Hospital ,
Salhia Street , Damascus , Syria
e-mail: h.a.mayaleh@hotmail.fr,
info@hani-abou-mayaleh.net

920
H.A. Mayaleh
lateral fl aps are taken from the cephalic por-
tions of the lateral crura, leaving the caudal
portions intact (at least 5 mm of the total width
of each lateral crus). (e) The fl aps’ internal
edges are sutured together to form one large
fl ap. (f) The fl ap is rotated anteriorly over the
original domes, fi xed with them using 2 U
sutures. (g) The fl ap’s distal portion is turned
posteriorly over the fi rst layer. (h, i) The fl ap’s
two layers are fi xed together with the domes
using 2 U sutures creating a onlay folded fl ap
(OFF).
Calculate the distance between the a lar crease
and the nasal tip ‘DAT’ (Fig. 65.2 ) (Table 65.1 ).
The nasal tip projection can be calculated
using DAT method, with two identical pro fi le
a
b
c
d
e
f
g
h
i
Fig. 65.1 Onlay folded fl ap (OFF) surgical technique.
( a ) The two alar cartilages are undermined from the over-
lying tissue. ( b – d ) Two symmetric lateral fl aps are taken
from the cephalic portions of the lateral crura, leaving the
caudal portions intact (at least 5 mm of the total width of
each lateral crus). ( e ) The fl aps’ internal edges are sutured
together to form one large fl ap. ( f ) The fl ap is rotated ante-
riorly over the original domes, fi xed with them using 2 U
sutures. ( g ) The fl ap’s distal portion is turned posteriorly
over the fi rst layer. ( h , i ) The fl ap’s two layers are fi xed
together with the domes using 2 U sutures creating an
onlay folded fl ap (OFF)