Schematic of the classic procedure
described by Goldman.1 The primary goal is
to increase projection. Discontinuous lateral strips are seen. A, Lateral
view; B, base view.
Schematic of vertical lobule division,
with division between the dome and angle for decreased projection. Overlap
of the lateral segment on the medial segment in the shaded area with placement
of a columellar strut, an interdomal suture, scoring of the domes, and cephalic
resection of the lower lateral cartilages are seen. A, Lateral view; B, base
Sample questionnaire of patient
Preoperative (A and C) and postoperative
(B and D) photographs demonstrating deprojection after vertical lobule division.
A and B, Lateral view; C and D, base view.
Preoperative (A) and postoperative
(B) base view photographs demonstrating correction of a right tip bossae and
left knuckling after vertical lobule division.
Preoperative (A and C) and postoperative
(B and D) photographs demonstrating improvement in tip symmetry but formation
of knuckles after vertical lobule division. A and B, Oblique view; C and D,
Constantinides M, Liu ES, Miller PJ, Adamson PA. Vertical Lobule Division in RhinoplastyMaintaining an Intact Strip. Arch Facial Plast Surg. 2001;3(4):258-263. doi:
From the Division of Facial Plastic and Reconstructive Surgery, Department
of Otolaryngology, New York University School of Medicine, New York City (Drs
Constantinides, Liu, and Miller); and the Department of Otolaryngology, University
of Toronto, Toronto, Ontario (Dr Adamson).
Objective To review the indications for, surgical techniques of, and results of
vertical lobule division (VLD) of the alar cartilages.
Design Prospective study of patients assigned to undergo variations of VLD
of the lower lateral cartilages.
Setting Private facial plastic surgery practice in a major university teaching
Patients Twenty-four patients who underwent variations of VLD of the lower lateral
cartilages with re-creation of an intact strip, including 4 patients undergoing
Main Outcome Measures Postoperative photographs were reviewed for tip projection and rotation,
tip symmetry, bossae, knuckles, columellar position and length, and alar retraction.
Patients were polled about their overall satisfaction with nasal aesthetics
and degree of subjective nasal obstruction preoperatively and postoperatively.
Results Vertical lobule division decreased projection in 22 of 22 patients,
increased rotation in 12 of 12 patients, decreased rotation in 1 of 2 patients,
corrected tip asymmetry in 3 of 4 patients, and shortened a long infratip
lobule in 1 patient. Postoperatively, bossae and knuckling developed in 1
patient, and 2 patients demonstrated alar retraction that did not exist preoperatively.
One patient undergoing revision noted worsened nasal obstruction not related
Conclusions Vertical lobule division is a reliable, safe technique with predictable
outcomes in tip repositioning. It allows for preservation of a strong tip
complex while adding versatility to tip refinement.
VERTICAL DIVISION of the lobule (VLD) of the lower lateral cartilages
(LLCs) is a useful technique for nasal tip refinement. The division can occur
anywhere between the angle (the junction of the medial and lateral crus) and
the dome (the most anterior projecting point of the lateral crus). In 1957,
Goldman1 first described division of the LLC
just lateral to the dome, creating bilateral, symmetrical medial and lateral
strips. The medial strips were advanced anteriorly and sewn together to create
a strong medial unit, increasing projection and strengthening medial tip support.
The now discontinuous lateral strips were allowed to fall away posteriorly
(Figure 1). The primary indication
for the procedure was to increase projection and rotation. This converted
a weak, trapezoidal tip into a strong, pyramidal one. However, the classic
Goldman procedure created a discontinuous LLC. Tip irregularities, especially
in thin-skinned patients, ensued as wound healing and contracture progressed.
These included pinching of the lower third, knuckling, alar notching, and
a characteristic "tent-pole" tip. As a result of these potential postoperative
sequelae, many surgeons have avoided dividing the alar cartilages altogether.
Over the years, division of the alar cartilages has been expanded to
include a new technique, VLD, with different indications and results. The
source of potential unwanted sequelae in the Goldman technique lies in the
discontinuous LLC. To avoid these problems, VLD approximates the medial and
lateral strips to prevent the lateral strip from displacement or malposition.
Various manipulations can be made once the cartilage is transected. A portion
may be resected or not resected, and the medial and lateral segments may be
overlapped or only approximated.
In terms of nomenclature, vertical dome division
implies transection of the lateral crura at or lateral to the dome as described
by Goldman.1 As noted in an earlier article,
we prefer the term vertical lobule division, which
is more anatomically correct, as division may occur anywhere along the alar
Vertical lobule division may be used for accomplishing tip deprojection,
changing tip rotation, narrowing a wide domal arch, correcting tip asymmetries,
and improving infratip lobule abnormalities (eg, hanging or elongated infratip).
Skin thickness and Fitzpatrick skin type are not considerations. In distinction
to the Goldman procedure, VLD with cartilage overlap and resuturing will not
increase tip projection. We have found VLD to be most useful in the overprojected,
inferiorly rotated tip, as overlapping the cut segments results in deprojection,
rotation, or both. Vertical lobule division is not necessarily used as a first-line
technique if other, more conservative techniques that do not divide the cartilages
yield similar results.
The open approach to septorhinoplasty affords the best exposure to the
tip, and all of these manipulations are easily performed via an open approach.
However, VLD may also be performed using a closed approach with tip delivery.
The primary advantage of VLD lies in its versatility. Changing the location
of the division, the amount of cartilage resected, and the amount of overlap
results in precise contouring of the desired tip configuration. If projection
is desired, it can be restored using tip grafts, lateral crural advancement,
and/or scoring of the domes. Vertical lobule division is used in conjunction
with a columellar strut, interdomal suturing, and cartilage scoring. Tip asymmetries
tend to occur in regions of relative cartilage weakness; overlap techniques
strengthen these areas.
Critics of traditional LLC division cite tip asymmetries and collapsed
external valves. In thin-skinned patients, even slight asymmetries in the
final medial cartilage unit may lead to bossae. Cephalic rotation of lateral
segments may lead to notching and alar retraction. We believe that maintaining
an intact strip of cartilage reduces many of these problems.
Open rhinoplasty is performed for optimal exposure of the cartilaginous
complex, which helps to determine the exact nature of the underlying problem
and facilitates surgical manipulation. Unlike delivery approaches, the cartilages
remain in their native position and are not distorted in any way. Septoplasty,
if needed, is performed first. The vestibular skin is widely undermined from
the undersurface of the lobule and preserved. The cartilage of the lobule
is divided at the appropriate site; resection is rarely required. The lateral
segment is then overlapped over the medial segment and repositioned depending
on the desired effect. A 6-0 nylon horizontal mattress suture reconstitutes
the lobule. Placement of a columellar strut stabilizes the medial crura unit.
The cartilage is scored at the desired location of the new dome. An interdomal
simple 6-0 nylon suture stabilizes the tip structure (Figure 2).
Constantinides and Adamson2 previously
outlined the surgical technique and modifications used for specific indications.
For tip deprojection, the LLCs are transected between the dome and the angle.
If cephalic rotation is the goal, division is performed at the dome or just
lateral to it. Conversely, if caudal rotation is the desired goal, division
is performed at the angle, or the junction of the intermediate crus with the
medial crus. In either case, altering the amount of overlap will vary the
degree of desired rotation.
Twenty-four patients who underwent open septorhinoplasty performed by
one of us (M.C.) were included in the study from January 1, 1996, through
December 31, 1999. There were 16 women and 8 men (mean age, 30.8 years). Twenty
patients underwent primary rhinoplasties and 4 underwent revisions. Twenty
patients had bilateral division of the LLC, and 4 had unilateral procedures
performed. The reasons for VLD were to decrease projection (n = 22), increase
rotation (n = 12), decrease rotation (n = 2), correct tip asymmetries (n =
4), and decrease the length of the infratip lobule (n = 1) (Table 1). Vertical lobule division was used for more than 1 indication
in several patients.
All but 1 patient had a columellar strut placed. This was performed
after VLD to appreciate best any rotational effects due to the division. Another
of us (P.A.A.) prefers to place the columellar strut before VLD to effect
tip refinement on a strong medial unit. Twenty-three patients underwent excision
of the cephalic margin of the lateral crura, and 18 patients had an interdomal
suture placed. No tip grafts were placed in any of the patients. Two patients
received supratip grafts; 2 patients, bilateral batten alar grafts; and 2
patients, unilateral batten alar grafts.
Outcome measures consisted of blinded assessments of postoperative photographs
by 3 of us (M.C., E.S.L., and P.J.M.) (Table 2) and a patient questionnaire (Figure 3). Postoperative photographs were examined for specific
factors, including overall nasal projection and rotation, tip symmetry, columellar
position and length, the presence of bossae or knuckles, and alar retraction.
They were initially interpreted irrespective of preoperative appearance. In
those patients in whom an unintended result occurred, the preoperative pictures
were examined for comparison. The mean clinical follow-up lasted 12.2 months,
and postoperative photography occurred at a mean of 10.1 months.
Six patients had overprojection after VLD. The surgical goal had been
to decrease projection in all of these patients. Projection was graded on
a scale of −3 (severe underprojection) to +3 (severe overprojection).
All 6 patients preoperatively received a rating of +2 to +3 and postoperatively
of +1, so some deprojection was accomplished. Four patients were found to
have postoperative overrotation. In 2 of these patients, no rotational changes
had been desired. In the third patient, the preoperative goal was to increase
rotation, which was accomplished. In the fourth patient, the goal was to decrease
rotation, which was not accomplished.
The columella was hanging in 4 patients. Three of these patients had
a hanging columellar position preoperatively. In 1 of these patients, columellar
position was improved, and in 2 it remained unchanged. In 11 patients, the
ratio of columellar to infratip lobule length was decreased; in 9, the decreased
ratio had existed preoperatively and was unchanged postoperatively.
One patient had an asymmetrical tip noted on base view, ie, one dome
was higher than the other. In this revision case, the same finding had existed
preoperatively and was improved but not corrected by surgery. Bossae and knuckling
developed in 1 patient, and 4 patients had mild alar retraction. In 2 of these
4 patients, the retraction was unchanged from the preoperative appearance.
The single patient who had VLD performed to correct a long infratip lobule
had adequate shortening postoperatively.
Fourteen of the 24 patients returned the survey. Patients were polled
about their overall satisfaction on a scale of 0 to 10 (with 10 indicating
the most satisfaction), whether they felt their tip was symmetrical or asymmetrical,
and about the degree of subjective nasal obstruction preoperatively and postoperatively.
Patients were also given a picture of the nose with the subunits appropriately
labeled and asked to circle any area with which they were dissatisfied (Figure 3).
The average rating of overall satisfaction was 7.6. Three patients noted
asymmetry of the tip on the questionnaire, but all were found to have symmetry
on analysis of postoperative pictures. Two patients circled the tip on the
diagram of the nose, but both were not found to have any tip irregularities
and in fact had normal projection and rotation. The mean preoperative score
for degree of nasal obstruction (0 indicated complete and 10, none) was 4.5,
and the mean postoperative score was 8.3. Only 1 patient undergoing revision
noted a decrease in subjective nasal obstruction. However, postoperative examination
failed to reveal any external valve collapse; breathing improved with support
of the upper lateral cartilages.
Vertical lobule division accomplished the presurgical goal in most instances.
The 2 major indications in our series were tip deprojection followed by increased
rotation. Vertical lobule division decreased projection in all cases (Figure 4), although 6 patients still had
some postoperative overprojection. Increased rotation was achieved in all
12 cases, and overrotation resulted in only 1 of these cases. Decreased rotation
was achieved in 1 of 2 patients, and a long infratip lobule was corrected
in the 1 patient.
According to the tripod concept of tip support, equal shortening of
all legs of the tripod should achieve tip deprojection without a change in
rotation. This can be accomplished by release of the medial crural feet from
their septal attachments and an equivalent release of the hinge region (the
lateral crural attachment to the lateral alar ligament). We use VLD when these
measures are inadequate to achieve the desired result. In those patients in
our study with remaining overprojection, more excision or more overlap of
the lateral and medial segments may have been needed. Increased rotation is
achieved by division of the LLC at the dome or just lateral to it. The amount
of rotation may be altered, depending on the amount of overlap.
Kridel and Konior3 proposed an alternative
method for decreasing projection while maintaining rotation. Via an external
approach, the vestibular skin is first undermined from the undersurface of
the domes. A blunt forceps elevates the overprojected alar complex, and a
transdomal suture is placed just posterior to the planned projection tip.
The overprojected dome region is then excised. Suturing, as in our technique,
provides stabilization and strength and prevents migration of the divided
To best summarize our postoperative analysis, we must look at the total
number of patients in whom a specific finding existed postoperatively and
the number of patients in whom the finding existed preoperatively. For example,
a patient may have had alar retraction before surgery that was not worsened
after surgery; thus, one cannot necessarily assume a relationship due to VLD.
Vertical lobule division created tip symmetry in 3 of the 4 patients
with asymmetrical domes preoperatively (Figure
5) and was unsuccessful in 1 patient undergoing revision. No patient
who had symmetrical domes preoperatively ended up with asymmetry postoperatively.
Mild alar retraction developed in 2 patients who did not have preoperative
alar retraction. A hanging columella developed postoperatively in 1 patient.
Most patients also had a columellar strut and an interdomal suture placed.
No patient required a tip graft. Therefore, no underlying irregularity was
masked, nor was it necessary to compensate for too much deprojection using
a tip graft. We did not compare primary and revision cases because of the
small number of cases.
The single patient in whom bossae and knuckling developed had thin skin.
Skin type, however, should not enter the decision to perform VLD. Indeed,
the new highlights formed in the tip cartilages by VLD are typically seen
better in thin-skinned patients. This same patient had an overprojected, narrow
tip preoperatively (Figure 6). Vertical
lobule division typically converts a wide trapezoidal tip into a more narrow
and refined one. Although deprojection was achieved in this patient, the narrow,
pointed tip was not altered.
The normal ratio of the columellar length to infratip lobule length
is 2:1. This ratio was reduced in 11 patients based on review of their postoperative
photographs, but had been reduced preoperatively in 9 of these. In the other
2 patients, this probably occurred because of division at the angle for enhanced
Simons4 proposed that vertical division
of the LLC is a conservative approach rather than a radical one. He argued
that it is an incisional technique rather than an excisional one (like cephalic
trims), the latter being more susceptible to postoperative fibrosis and irregularities.
He used a delivery approach after marginal incisions.4
Brennan5 similarly reported good results using
a closed approach to perform dome-splitting techniques. After delivery, the
LLC is transected and the lateral segment sculpted. After undermining of the
vestibular skin, the lateral segment is advanced medially into a pocket created
above the medial segment. Closure of the marginal incision holds the lateral
segment in place.
We prefer an open approach, which enables us to visualize both domes
simultaneously in their native positions. Of even more importance is that
Brennan5 and Simons4
describe techniques that increase projection and leave the LLCs discontinuous.
Vertical lobule division, in our experience, always reduces projection and
leaves a continuous LLC, which is stronger in the lobule region than preoperatively
from the double layer of overlapped cartilage.
Before 1987, Adamson et al6 performed
a cartilage resection and did not overlap the medial and lateral segments
after division. After 1987, they changed to an overlap technique before resuturing
the lateral and medial segments and found fewer postoperative tip irregularities.
The cartilage overlap technique reduced the number of postoperative tip irregularities
and the need for revision.
Muti7 described his reasoning for performing
dome division. Contraindications included well-balanced length and positioning
of the lateral and medial crura, satisfactory dome curvature, and well-positioned
domes in relation to the planned correction, thereby necessitating cephalic
trims only. Indications included long lateral crura in relation to the medial
crura, giving a hooked-nose effect; wide domes (bulbous nose); dome diastases;
asymmetrical right and left lateral crura; and extensive surgical correction.
Use of the patient survey in postoperative analysis is helpful for the
surgeon to understand how the patient interprets his or her results. The 3
patients who noted tip asymmetries on the questionnaire were found to have
symmetrical tips on examination of postoperative photographs. Similarly, the
2 patients who circled the tip on the questionnaire diagram were not found
to have any tip irregularities. This underscores the fact that patients and
surgeons may see different things when evaluating surgical results. The 2
patients with tip asymmetries on the photographs failed to respond to the
questionnaire; therefore, an inverse statement cannot be made. Only 1 patient
undergoing revision noted worsening nasal obstruction, likely from internal
nasal valve collapse and unrelated to VLD. Overlapping and resuturing increase
the strength of the lateral crura, so external nasal valve collapse should
Vertical lobule division remains a powerful technique when more conservative
methods are inadequate. Maintaining intact lateral crura by means of an overlap
method maintains the lateral segment in a strengthened position that is less
subject to the ensuing forces of scarring and wound contracture. Careful attention
must be maintained when reapproximating the lateral and medial segments to
accomplish the presurgical goals. With attention, these goals are accomplished
with precision and great predictability while minimizing postoperative malformations.
Accepted for publication March 21, 2001.
Presented in part at the American Academy of Facial Plastic and Reconstructive
Surgery Spring Meeting, Orlando, Fla, May 14, 2000.
Corresponding author and reprints: Minas Constantinides, MD, 530
First Ave, Suite 7-U, New York University Medical Center, New York, NY 10016