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Figure 1.
Intercrural ligament.

Intercrural ligament.

Figure 2.
The purpose-built instrument (Beaty
Tensegrometer) that was used to measure nasal tip resistance to deformation
in 3 vectors.

The purpose-built instrument (Beaty Tensegrometer) that was used to measure nasal tip resistance to deformation in 3 vectors.

Figure 3.
Technique of cephalic strip resection.

Technique of cephalic strip resection.

Figure 4.
Technique of lateral crural truncation.

Technique of lateral crural truncation.

Figure 5.
Intercrural suture technique.

Intercrural suture technique.

Figure 6.
Diagram of dynamic adjustable
rotation tip-tensioning technique.

Diagram of dynamic adjustable rotation tip-tensioning technique.

Figure 7.
Preoperative (A, C, and E) and
postoperative (B, D, and F) photographs of a patient who underwent primary
rhinoplasty with intercrural fixation.

Preoperative (A, C, and E) and postoperative (B, D, and F) photographs of a patient who underwent primary rhinoplasty with intercrural fixation.

Figure 8.
Preoperative (A and C) and postoperative
(B and D) photographs of a patient who underwent dynamic adjustable rotation
tip-tensioning technique.

Preoperative (A and C) and postoperative (B and D) photographs of a patient who underwent dynamic adjustable rotation tip-tensioning technique.

Table 1 
Nasal Tip Support Mechanisms
Nasal Tip Support Mechanisms
Table 2. 
Compression Necessary (in Grams) to Deflect the Nasal Tip
in Each Vector
Compression Necessary (in Grams) to Deflect the Nasal Tip in Each Vector
Table 3 
Percentage Increase in Nasal Tip Support After Procedure*
Percentage Increase in Nasal Tip Support After Procedure*
Table 4 
Percentage Decrease in Nasal Tip Support After Procedure*
Percentage Decrease in Nasal Tip Support After Procedure*
1.
Tardy  MERhinoplasty: The Art and the Science. Philadelphia, Pa WB Saunders Co1997;
2.
Tardy  ME Rhinoplasty Cummings  CWed.Otolaryngology Head and Neck Surgery. St Louis, Mo Mosby–Year Book Inc1993;807- 856
3.
Anderson  JR The dynamics of rhinoplasty. Proceedings of the Ninth International Congress of Otolaryngology. Amsterdam, the Netherlands Excerpta Medica1969;708- 710Excerpta Medica: International Congress. Series, No. 206.
4.
Anderson  JR A reasoned approach to nasal base surgery. Arch Otolaryngol. 1984;110349- 358Article
5.
Anderson  JRRies  WRRhinoplasty: Emphasizing the External Approach. New York, NY Thieme-Stratton Inc1986;
6.
Johnson  CM  JrToriumi  DMOpen Structure Rhinoplasty. Philadelphia Pa WB Saunders Co1990;
7.
Kridel  RWHKonior  RJ Controlled nasal tip rotation via the lateral crural overlay technique. Arch Otolaryngol Head Neck Surg. 1991;117411- 415Article
8.
Kridel  RWHKonior  RJSchumrick  K  et al.  Advances in nasal tip surgery: The lateral crural steal. Arch Otolaryngol Head Neck Surg. 1989;1151206- 1212Article
9.
Kridel  RWHKonior  RJ Dome truncation for management of the overprojected nasal tip. Ann Plast Surg. 1990;24385- 396Article
10.
McCollough  EGEnglish  JL A new twist in nasal tip surgery: an alternative to the Goldman tip for the wide or bulbous lobule. Arch Otolaryngol. 1985;111524- 529Article
11.
Tebbetts  JBPrimary Rhinoplasty: A New Approach to the Logic and the Techniques. St Louis, Mo Mosby–Year Book Inc1998;
12.
Baker  SR Suture contouring of the nasal tip. Arch Facial Plast Surg. 2000;234- 42Article
13.
Perkins  SWHamilton  MMMcDonald  K A successful 15-year experience in double-dome tip surgery via endonasal approach: nuances and pitfalls. Arch Facial Plast Surg. 2001;3157- 164Article
14.
Dyer  WKBeaty  MMShawl  MS The nasal tip and its surgical modification. Facial Plast Surg Clin North Am. In press.
15.
Dyer  WK  IIYune  ME Structural grafting in rhinoplasty. Facial Plast Surg. 1997;13269- 277Article
Citations 0
Original Article
April 2002

The Quantification of Surgical Changes in Nasal Tip Support

Author Affiliations

From Milton Hall Plastic Surgery, Alpharetta, Ga (Dr Beaty), and Buckhead Facial Plastic Surgery (Drs Dyer and Shawl).

 

From Milton Hall Plastic Surgery, Alpharetta, Ga (Dr Beaty), and Buckhead Facial Plastic Surgery (Drs Dyer and Shawl).

Arch Facial Plast Surg. 2002;4(2):82-91. doi:
Abstract

Objectives  To quantify the changes in the strength of nasal tip support associated with various surgical modifications and to identify the procedures that best maintain or augment tip support.

Design  Case study in 2 phases. Phase 1 included 10 patients undergoing primary rhinoplasty, 5 undergoing secondary rhinoplasty, and 5 control patients. Fresh cadavers were used in phase 2. A purpose-built instrument (Beaty Tensegrometer; G. M. Tooling, Chamblee, Ga) was used to measure nasal tip support before and after surgical modifications.

Results  In the patients who underwent primary rhinoplasty, there was a 25% decrease in tip support when the ligamentous attachments between the lateral crura were divided. Reconstruction of these attachments increased tip support over baseline by 35%. With a columellar strut and ligament reconstruction, tip support was increased by 44%. In the secondary rhinoplasty group, reconstruction with the dynamic adjustable rotation tip-tensioning technique increased nasal tip support over baseline by 70%. In cadavers, intercartilaginous incisions and delivery of the lower lateral cartilages caused a loss of tip support, while raising the skin–soft tissue envelope with the open technique did not. Extensive resection of the lower lateral cartilages caused a loss of tip support.

Conclusions  This study demonstrates that nasal tip support can be reliably quantified in a reproducible manner. Use of the open approach, reconstruction of the attachments between the lateral crura, conservative resection of the lower lateral cartilages, and the dynamic adjustable rotation tip-tensioning technique for secondary rhinoplasty best preserve nasal tip support.

SURGICAL MODIFICATION of the complex architecture of the nasal tip is the most challenging aspect of rhinoplasty. Numerous clinical descriptions of nasal tip support and surgical methods for tip modification have been proposed. Surgical modifications that reshape the nasal tip affect the strength of its architecture. Maintenance or augmentation of the architectural strength of the nasal tip is necessary to achieve desired aesthetic and functional results.

Clinical evaluation of nasal tip support by finger palpation of its resistance to deformation is a routine part of the diagnostic workup for rhinoplasty. In Rhinoplasty: The Art and the Science, Tardy1 states that "pressure applied to the tip with the index finger will be helpful in determining the resistance to tip retrodisplacement and the degree of ‘recoil' and forward thrust of which that particular tip is capable." Surgeons may subjectively evaluate preoperative and postoperative nasal tip support with finger palpation. However, to our knowledge, objective changes in nasal tip support after surgical modification have never been quantified in the literature.

Our goal was to quantify changes in nasal tip support before and after common rhinoplasty modifications. Objective quantification of these changes will provide valuable information to guide modification of the nasal tip.

NASAL TIP SUPPORT

Tardy2 described nasal tip support mechanisms in major and minor groups (Table 1). These designations were determined by clinical experience and are currently accepted as the determinants of nasal tip support. Surgical alteration of these tip support mechanisms produces changes in the shape and function of the nasal tip. Selection of the appropriate surgical modification is determined by the desired effect, such as a change in tip rotation, projection, or width.

Anderson3 compared the nasal tip architecture to a tripod in 1969. According to his analogy, the medial crura of the lower lateral cartilages (LLCs) together form the central limb of the tripod. Each lateral crus independently forms a lateral limb. Anderson's4 description of nasal tip support mechanisms emphasizes the importance of the extensive ligamentous attachments between the crural cartilages. Tardy's description emphasizes the importance of the interdomal portion of these ligamentous attachments.

NASAL TIP MODIFICATION

Anderson and Ries5 described nasal tip modification by altering the components of the tripod: "Tip projection can be decreased by destroying the supports of the tripod or by shortening its legs. The main supports are destroyed by interrupting the ‘ligaments' connecting the medial ends of the lateral crura, by lowering the projection of the septal dorsum, and by excising cartilage from the region of the inferior septal angle." Anderson3 also believed that reconstitution of the ligamentous attachments between the lateral and intermediate crura was necessary to restore the strength of the nasal architecture.

Many surgeons prudently believe that conservative surgery is essential to successful modification of the nasal tip. The open rhinoplasty approach, popularized by Anderson and Johnson and Toriumi,6 advocates wide exposure of the nasal tip architecture, with minimal violation of tip support mechanisms. This approach contrasts with the closed or delivery approach, in which exposure of the cartilage framework is limited and incisions violate significant tip support mechanisms.

Conservative methods of LLC modification using the open approach have been described. Kridel and Konior7 introduced the lateral crural overlay to achieve cephalic rotation of the tip without permanent division of the lateral crus. They also advocated conservative removal of cephalic strips to narrow and cephalically rotate the nasal tip. Kridel and Konior8-9 described the "lateral crural steal" for management of the underprojected nasal tip8 and the "domal truncation procedure" for management of the overprojected tip.9 Suture support of the domes has also been advocated by Tardy,1 McCollough and English,10 Tebbetts,11 Baker,12 and Perkins et al.13 The common thread of their techniques is conservation of nasal tip support.

Johnson and Toriumi6 emphasize both surgical conservation and augmentation of nasal tip support in Open Structure Rhinoplasty. They advocate placing a columellar strut between the medial crura for increased nasal tip projection and support. This strut is routinely fashioned from septal cartilage and is often combined with a shieldlike tip graft to project and refine the nasal tip.

We also advocate the concepts of conservatism and augmentation of support for tip rhinoplasty. In cases of primary rhinoplasty, we use the open approach to obtain maximal exposure and minimal interruption of tip support. Refinement of the nasal supratip is accomplished by excising conservative cephalic strips and reconstituting the ligamentous attachments between the medial and lateral crura (the intercrural ligament)14 (Figure 1). Reestablishment of the intercrural ligament significantly augments nasal tip support. If additional tip projection or support is necessary, a columellar strut is placed.

The cartilage and supportive ligaments of patients undergoing secondary rhinoplasty have often been severely weakened. The lateral crura and scrolls are frequently overresected or absent, and the domes are often malpositioned by scar contracture. This type of injury typically results in decreased tip projection, cephalic overrotation, and associated nasal valve collapse. This triad of findings has been termed a porcine deformity15 and presents a significant reconstructive challenge. Dyer and Yune15 describe the dynamic, adjustable, rotation tip-tensioning (DARTT) technique, a method of nasal reconstruction that reestablishes tensile support of the damaged nasal architecture. The DARTT technique allows precise selection of nasal tip projection, rotation, and correction of nasal valve collapse.

MATERIALS AND METHODS

One of us (M.M.B.) designed a device (Beaty Tensegrometer; G. M. Tooling, Chamblee, Ga) that is capable of measuring the resistance of the nasal tip to deformation in multiple vectors (Figure 2). This measure of resistance to deformity is a quantification of the subjective finger palpation that was advocated by Tardy.1 Instrument calibration was performed at 1-month intervals to ensure that no fatiguing of the springs had occurred. No significant changes in calibration were found during the study period. During calibration trials, each data point was independently measured 3 different times to evaluate the projected intertrial error of the device. Intertrial variation in these measurements was less than 3%.

Tightening of the thumbscrew at the crown of the gantry increased compression on a spring, applying pressure to the nasal tip along the chosen vector. Deflection of the tip was measured in millimeters along the attached scale at the side of the gantry. The compression necessary (in grams) to deflect the nasal tip by 1, 2, or 3 mm in each vector was recorded (Table 2). Compression of the tip beyond 3 mm resulted in the crural architecture pushing against the nasal septum, with further measurement reflecting resistance of the septal cartilage.

The device was stabilized on the upper lip and malar eminence, with the measurement gantry centered over the nasal tip. The measurement gantry was oriented along the vector to be evaluated. Three vectors were evaluated: (1) along the columella, (2) along the nasal dorsum, and (3) along the plane of the lateral crura. Measurements were taken before, during (directly on the cartilaginous tip framework), and immediately after surgery.

The study comprised 2 phases. In phase 1, tip support was measured in live patients; in phase 2, cadavers were studied. The results were statistically analyzed with a commercially available software package (Excel; Microsoft Corp, Redmond, Wash) by comparing group means using 1-way analysis of variance or paired t test, as appropriate.

PHASE 1

The first phase of the study included 5 nonsurgical control patients and 15 surgical patients. Of the 15 surgical patients, 10 underwent primary nasal surgery and 5 underwent secondary rhinoplasty. All tip modifications were performed through an open approach.

During phase 1, measurements were taken before and after the following procedures: surgical incisions (marginal and transcolumellar), opening of the skin–soft tissue envelope (S-STE), placement of a columellar strut, reconstitution of the intercrural ligament, and performance of the DARTT technique. Preoperative and postoperative measurements were taken with the S-STE intact, and intraoperative measurements were taken directly on the cartilaginous framework.

PHASE 2

In the second phase of the investigation, 15 fresh cadavers were studied. Each cadaver was inspected to ensure that no significant nasal damage was present. They were divided into groups of 5 for evaluation of different surgical modifications. Cadavers were used for more than 1 evaluation when appropriate. For example, noses used to measure the effects of open technique exposure were also used to evaluate the effect of suture reconstitution of the intercrural ligament.

During phase 2, measurements were taken before and after the following procedures: surgical incisions (intercartilaginous, transfixion, marginal, and transcolumellar), opening of the S-STE, crural modifications, placement of a columellar strut, and reconstitution of the intercrural ligament.

Differences between the open and closed approaches to the nasal tip were analyzed for changes in support. Two different methods for lateral crural modification were evaluated. First, cephalic strips of crural cartilage were resected from medial to lateral (Figure 3). Second, cartilage was resected from lateral to medial, progressively truncating the crus (Figure 4). Twenty percent of the volume of the lateral crus was resected at a time before each measurement. Data were recorded on the effect of suture reconstitution of the midline intercrural ligament (Figure 5). Effects of each surgical modification were measured along the 3 vectors previously described.

RESULTS
PHASE 1

Fifteen patients who underwent rhinoplasty (10 primary, 5 secondary) were evaluated for nasal tip support before, during, and immediately after surgery. Each procedure was tailored to the needs of that specific patient and performed through an open approach. Three vectors were evaluated: (1) along the columella, (2) along the nasal dorsum, and (3) along the plane of the lateral crura. The vector along the plane of the lateral crura was chosen as the representative measure of tip support because it combines components of both projection and rotation. The following results are based on measurements that were taken along that vector, except where noted.

Preoperative Measurements

Measurements of nasal tip support in 5 control patients compared with preoperative patients undergoing primary or secondary rhinoplasty revealed no significant differences in any vector. In all groups, there was slightly greater tip support in the vector along the columella, compared with the other 2 vectors. This finding may indicate that there was slightly greater support along the vector of the paired medial crura. Mean values for each group are summarized in Table 2.

Elevating the S-STE

In all cases, elevating the S-STE reduced tip support. Paired t tests showed significant differences in nasal tip support before and after elevation of the S-STE in both primary and secondary rhinoplasty groups (P<.05).

In patients undergoing primary open rhinoplasty, the mean nasal tip support was reduced by 20%, 26%, and 20% at 1, 2, and 3 mm of deflection, respectively, by elevating the S-STE (P<.05). Patients undergoing secondary open rhinoplasty had even greater losses in tip support when the S-STE was opened, with mean reductions of 64%, 61%, and 52% at 1, 2, and 3 mm of deflection, respectively (P<.05).

Reconstructing the Intercrural Ligament

In primary open rhinoplasty, elevating the S-STE in a bloodless plane above the crural cartilages disrupted the intercrural ligament from the domes to the septal angle (25% loss of support). Reconstituting the intercrural ligament (Figure 5) provided an increase in tip support over baseline of 35%, 24%, and 24% at 1, 2, and 3 mm of deflection, respectively (P<.05).

Columellar Strut

Patients in the primary open rhinoplasty group were evaluated for changes in tip support after columellar strut placement. Placement of a columellar strut alone provided a 40% increase in nasal tip support in the vector along the columella (P<.05). In the vectors along the nasal dorsum and along the plane of the lateral crura, however, no significant difference was found (P = .15). Also, when intercrural fixation sutures were used in combination with a columellar strut (4 patients), the increase in support was even more pronounced (27%, 42%, and 44%, respectively) (P<.05).

DARTT Technique

Reconstruction in patients undergoing secondary rhinoplasty was performed using the DARTT technique described by Dyer and Yune15 (Figure 6). These patients had a statistically significant increase in the strength of the cartilagenous nasal tip architecture after reconstruction (P<.01). Mean increases of 364%, 208%, and 213% were seen at 1, 2, and 3 mm of deflection, respectively. These measurements were taken intraoperatively, directly on the cartilaginous architecture before the S-STE was redraped.

Postoperative Measurements

Finally, all patients were evaluated for changes in tip support from the preoperative to the immediate postoperative state with the S-STE replaced. In the primary rhinoplasty group, nasal tip support was increased 30% over baseline in all 3 vectors. In the secondary rhinoplasty group, the tip support was increased 70% over baseline in all 3 vectors. All these changes were statistically significant (P<.05). A summary of preoperative vs postoperative tip support is provided in Table 3.

PHASE 2
Elevating the S-STE

The effect of the open rhinoplasty technique on tip support was measured on cadavers. Tip support was measured after marginal and transcolumellar incisions were made and the S-STE was elevated. During phase 2, care was taken to preserve the intercrural ligament as the S-STE was elevated. Support measurements were taken with the S-STE elevated and the intercrural ligament intact. Elevation of the S-STE caused no significant change in tip support (P = .11).

Closed Approach Incisions

The effect of the closed (transnostril) approach on tip support in cadavers was then evaluated. Placement of marginal and transfixion incisions had no effect on tip support. After intercartilaginous incisions, tip support decreased 25% in all 3 vectors. The LLCs were delivered and then replaced in their native position with no further modification. Delivery of the LLCs resulted in a 10% further loss of tip support (35% total) in vectors along the plane of the lateral crura and along the columella. A 42% loss of support was seen in the vector along the nasal dorsum. All these differences were statistically significant (P<.05) and are summarized in Table 4.

Intercrural Ligament Reconstruction

In 5 noses, after the closed technique with delivery of the LLCs was used (alone resulting in a 35% loss in tip support), a transcolumellar incision was made and the S-STE was elevated. This effectively converted the procedure into a "standard" open rhinoplasty approach. The intercrural ligament was then reconstructed with sutures, and tip support was measured. Tip support increased 25% in the vector along the plane of the lateral crura compared with preoperative measurements (P<.05). Tip support was equivalent to the preoperative levels in the vectors along the columella and nasal dorsum.

Crural Modifications

Cephalic strips were taken from medial to lateral in 5 noses through a closed approach. Serial measurements were taken after resection of increments of 20% from the total width of the lateral crus. Tip support did not change beyond that imposed by delivery of the crura (35% loss) until 80% of the lateral crural width was resected (Figure 3). With 80% of the LLC resected, a further 35% loss of tip support was seen in all 3 vectors.

Progressive resections of LLC were taken in 5 additional noses in a lateral to medial direction (Figure 4). In these specimens, an open approach was used, and the intercrural ligament was preserved. There was no significant change in nasal tip support until 80% of the width of the LLC was resected (P>.60). At 80% or greater resection, a 25% loss of tip support in all vectors was measured.

COMMENT

Most surgical procedures that alter nasal tip structure decrease tip support. An important goal of tip modification should be to maintain or augment nasal tip support. A nasal tip with adequate support can better withstand the compressive forces of the weight of the overlying S-STE and inevitable scar contracture. A purpose-built device (Beaty Tensegrometer) was designed to measure the changes in nasal tip support before and after common rhinoplasty procedures. Measurements were taken on live patients during phase 1 and on cadavers during phase 2.

PHASE 1

There was no difference between the preoperative measurements of tip support of the control patients and the preoperative measurements of the patients undergoing either primary or secondary rhinoplasty. The patients undergoing primary rhinoplasty were expected to have tip support measurements that were similar to those of the control patients. Those undergoing secondary procedures had deformed nasal tips manifest by deprojection, cephalic overrotation, and nasal valve collapse and were expected to have decreased tip support. This was not the case. The equivalent resistance to nasal tip deformation in these patients compared with controls is likely attributable to support from the nasal septum and scar tissue. Though having the same resistance to deformation as the noses of the control patients, their noses were collapsed and severely compromised both aesthetically and functionally.

In live patients, opening the S-STE reduced tip support. During primary rhinoplasty, the S-STE is usually opened directly over the LLCs in a "bloodless" tissue plane. During this procedure, the intercrural ligament is routinely divided from the dome to the anterior septal angle. Separation of this ligamentous support between the 2 lateral crura, from the anterior septal angle to the domes, resulted in a 25% loss of tip support. Intercrural fixation sutures that are placed to reconstruct the ligament achieved a 35% increase (over baseline) in nasal tip support.

In the primary rhinoplasty group, measurements of changes in tip support for several surgical modifications were recorded. Placement of a columellar strut provided a statistically significant increase in tip support of 40% along the vector of the columella. There was no significant increase in support along the other vectors. A columellar strut alone is only capable of providing substantial tip support along its long axis. Because a columellar strut does not prevent tip rotation, loss of support of the lateral crura can cause cephalic rotation of the nasal tip.

After cephalic strip resection, the medial edges of the lateral crura were reapproximated from the anterior septal angle to the domes, eliminating dead space and increasing tip support. These sutures alone produced a 35% net increase in nasal tip support over baseline when measured directly on the cartilaginous framework during surgery. The intercrural ligament is essential to support of the nasal tip and should be considered a major tip support mechanism. Also, when intercrural fixation sutures are used along with a columellar strut, the increase in support is even greater, measuring a mean increase of 44%.

All patients undergoing secondary rhinoplasty had significant compromise of the cartilaginous architecture of the nasal tip. Three patients had near total resection of the lateral crura. One patient had multiple vertical divisions of the lateral crura, and one had a crushed nasal septum that appeared to have been morselized.

Despite similar preoperative values in resistance to deformation, the patients undergoing secondary rhinoplasty lost more tip support than those undergoing primary rhinoplasty on elevation of the S-STE (60% vs 25%). In the secondary rhinoplasty group, the S-STE was opened and the supportive scar tissue was separated from the remnants of the weakened LLC. This separation resulted in a decompression that caused the larger measured loss of tip support.

Patients in the secondary rhinoplasty group underwent the DARTT reconstruction as described by Dyer and Yune.15 A columellar strut affixed to the medial crura is joined as an integrated structure with septocolumellar interposition grafts. The entire structure is then placed on tension using a double-pronged hook beneath the domes. The nasal tip is held in the desired position (rotation and projection) while the torsionally stable septocolumellar interposition grafts are sutured to the nasal septum. Nasal tip support measured directly on the cartilaginous framework is approximately tripled after the DARTT technique is used.

After closure of the S-STE in patients undergoing a DARTT technique, a mean increase of 70% over baseline in nasal tip support was seen. The technique provides renewed support and allows adjustability and precision in placement of the nasal tip.

PHASE 2

Cadavers were used to evaluate surgical techniques that are not generally used in our practice, many of which are associated with the closed approach to the nasal tip. Marginal and transfixion incisions had no significant effect on nasal tip support. These findings are in agreement with the conclusion of Tebbetts11 that "soft tissue incisions were the scapegoat for the real culprit—destructive tip shaping techniques." Placement of intercartilaginous incisions produced a 25% loss in tip support in all vectors. These incisions divide the scrolled attachment of the lower lateral and upper lateral cartilages as well as transecting the intercrural ligament from the septal angle to the dome. Delivery of the LLCs completes the division of the ligamentous binding between the domes and medial crura and further weakens the nasal tip (total, 35%).

In contrast to the outcome in live surgical patients, in cadavers the ligamentous attachments between the LLCs were preserved when the S-STE was elevated. Freeing the S-STE, while preserving the intercrural ligament, was shown to have no significant effect on support of the nasal tip. The intercrural ligament is a major tip support mechanism, and its division significantly weakens tip support. When the intercrural ligament is reconstructed, nasal tip support returns to preoperative levels or greater.

Resection of portions of the LLCs had no significant effect on nasal tip support until 80% of the cartilage had been excised. This held true whether cephalic strips were taken from medial to lateral or whether crural truncation was performed from lateral to medial. These surprising findings suggest that the maintenance of the intercrural ligament may be more critical to nasal tip support than the bulk of the lateral crural cartilage itself. Although the intercrural ligament is a major tip support mechanism, large resections of the LLC can still produce significant nasal tip deformities and functional compromise owing to the inevitability of scar contracture.

CONCLUSIONS

This study demonstrates that nasal tip support can be reliably quantified in a reproducible manner. Based on the findings of this study, the intercrural ligament (ligamentous attachments between the lateral, domal, and medial crura) is a major tip support mechanism. When the intercrural ligament alone is completely divided, nasal tip support decreases by 35%. Therefore, a full one third of the support of the nasal tip is attributable to the midline binding of the intercrural ligament. During rhinoplasty, suture reconstitution of the intercrural ligament increases tip support by 35% over peroperative measurements. The open approach to rhinoplasty is less damaging to nasal tip support than the closed approach. This observation was confirmed by measuring tip support before and after each approach.

We advocate the concepts of surgical conservatism and augmentation of nasal tip support during rhinoplasty. After nasal tip rhinoplasty, a well-supported nasal tip is better able to withstand the compressive forces of the inherent weight of the S-STE and the inevitability of scar contracture.

In primary rhinoplasty, we use the open approach to obtain maximal exposure and minimal interruption of tip support. Refinement of the nasal supratip is accomplished by excising conservative cephalic strips and reconstituting the intercrural ligament. If additional tip projection or support is necessary, a columellar strut is placed. Using these guidelines, nasal tip support will increase between 35% and 44% over baseline (Figure 7). In secondary rhinoplasty, we advocate an open approach and the DARTT technique, which increases tip support by an average of 70% (Figure 8).

Although the quantification of nasal tip support is in its infancy, it has great potential to guide facial plastic surgeons toward predictable and structurally stable results. Selecting the methods of tip modification that best preserve or augment the architectural integrity of the nasal tip will ultimately benefit all our patients.

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Article Information

Accepted for publication August 15, 2001.

Corresponding author and reprints: Mark M. Beaty, MD, Milton Hall Plastic Surgery, 2365 Old Milton Pkwy, Alpharetta, GA 30004 (e-mail: mmbeaty@earthlink.net).

References
1.
Tardy  MERhinoplasty: The Art and the Science. Philadelphia, Pa WB Saunders Co1997;
2.
Tardy  ME Rhinoplasty Cummings  CWed.Otolaryngology Head and Neck Surgery. St Louis, Mo Mosby–Year Book Inc1993;807- 856
3.
Anderson  JR The dynamics of rhinoplasty. Proceedings of the Ninth International Congress of Otolaryngology. Amsterdam, the Netherlands Excerpta Medica1969;708- 710Excerpta Medica: International Congress. Series, No. 206.
4.
Anderson  JR A reasoned approach to nasal base surgery. Arch Otolaryngol. 1984;110349- 358Article
5.
Anderson  JRRies  WRRhinoplasty: Emphasizing the External Approach. New York, NY Thieme-Stratton Inc1986;
6.
Johnson  CM  JrToriumi  DMOpen Structure Rhinoplasty. Philadelphia Pa WB Saunders Co1990;
7.
Kridel  RWHKonior  RJ Controlled nasal tip rotation via the lateral crural overlay technique. Arch Otolaryngol Head Neck Surg. 1991;117411- 415Article
8.
Kridel  RWHKonior  RJSchumrick  K  et al.  Advances in nasal tip surgery: The lateral crural steal. Arch Otolaryngol Head Neck Surg. 1989;1151206- 1212Article
9.
Kridel  RWHKonior  RJ Dome truncation for management of the overprojected nasal tip. Ann Plast Surg. 1990;24385- 396Article
10.
McCollough  EGEnglish  JL A new twist in nasal tip surgery: an alternative to the Goldman tip for the wide or bulbous lobule. Arch Otolaryngol. 1985;111524- 529Article
11.
Tebbetts  JBPrimary Rhinoplasty: A New Approach to the Logic and the Techniques. St Louis, Mo Mosby–Year Book Inc1998;
12.
Baker  SR Suture contouring of the nasal tip. Arch Facial Plast Surg. 2000;234- 42Article
13.
Perkins  SWHamilton  MMMcDonald  K A successful 15-year experience in double-dome tip surgery via endonasal approach: nuances and pitfalls. Arch Facial Plast Surg. 2001;3157- 164Article
14.
Dyer  WKBeaty  MMShawl  MS The nasal tip and its surgical modification. Facial Plast Surg Clin North Am. In press.
15.
Dyer  WK  IIYune  ME Structural grafting in rhinoplasty. Facial Plast Surg. 1997;13269- 277Article
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