Ideas and Innovations A New Concept in the Tip Plasty of Asian Rhinoplasty: The Flag Technique by Use of Only a Septal Cartilage Cheol Hwan Kim, M.D. Seoul, Republic of Korea
Background: To achieve the desired refinements in Asian patients, sufficient septal cartilage is needed for ideal tip projection and lengthening of the nose by the septal extension supported by the stable septum. There are many cases of insufficient septal cartilage in Asian patients. For optimal outcome, the author proposes a new technique, the so-called flag technique, which uses a tipstrut complex in a flag-like shape. Methods: Using the open approach in 161 patients, an elongated columellar septal strut graft was sutured to the medial crura, and bilateral mini-spreader grafts in triangular or trapezoidal and flag-like shapes were attached bilaterally on both sides of the upper part of the strut graft, with a shield-shaped graft on the caudal edge of the upper part of the strut graft. Results: There were significant improvements in three parameters for evaluating tip projection preoperatively and postoperatively. When compared with the ideal figure, the results are very effective in the ratio of tip projection to the distance from the tip to the vertical line of the upper lip, but there were significant differences in the ratio of nasal length (radix to tip) to tip projection and the ratio of alar base width to the width between each side of the tip-defining points. Conclusion: The flag technique of using a tip-strut complex in a flag-like shape is an alternative method of tip-plasty in Asian rhinoplasty with insufficient septal cartilage. (Plast. Reconstr. Surg. 135: 1033, 2015.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
A
sian patients typically have a smaller amount of cartilaginous septum compared with white patients.1 For achieving the desired refinements in Asian patients, sufficient septal cartilage is needed for ideal tip projection and lengthening of the nose by the septal extension graft2 or extended spreader grafts, columellar septal strut graft,3,4 onlay tip graft,5 and shield graft.6 Actually, there are many Asian rhinoplasty patients with insufficient septal cartilage, if needed, at the same time using auricular and/or costal cartilages. Asian patients dislike the additional scars on the auricular and/or costal areas. I would like to propose a new technique, the “flag technique,” which uses a tip-strut complex in a flag-like shape, using only the septal cartilage as an elongated columellar septal strut graft, a shield graft, and From the Department of Plastic Surgery, Winners Clinic. Received for publication September 12, 2014; accepted October 21, 2014. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000001107
bilateral mini-spreader grafts of the upper part of the elongated columellar septal strut graft without the septal extension grafts or extended spreader grafts (Fig. 1).
PATIENTS AND METHODS Retrospective analysis was performed of 161 patients who underwent open rhinoplasty consisting of dorsal augmentation using Silastic implants, Disclosure: The author did not receive any financial benefit from any commercial entity in support of this article. Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s Web site (www.PRSJournal.com).
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Plastic and Reconstructive Surgery • April 2015
Fig. 1. Illustration of a tip-strut complex. It has (1) an elongated columellar septal strut graft, (2) two mini-spreader grafts, and (3) a shield graft. (Left) Oblique view. (Right) Oblique view of the postoperative state.
and tip shaping using only septal cartilages between January of 2008 and January of 2014. These included 137 patients who underwent primary rhinoplasty and 24 patients who underwent secondary rhinoplasty. Patients’ photographs and charts were reviewed for the increasing tip projection and lengthening of the nose postoperatively. The follow-up period ranged from 7 months to 6 years postoperatively, with a mean of 357.3 days. Operative Technique With the patient under sedative anesthesia, harvest of a septal cartilage is performed through a right hemitransfixion incision. The open approach is used exclusively in performing this technique. Retraction of the undermined area exposes the entire
osseocartilaginous framework. When an elongated columellar septal strut graft (approximately 17 mm long, 4 mm wide, and 1.5 mm thick) is sutured with 5-0 polydioxanone to the medial crura at a 95-degree columellar-labial angle, the middle and lower parts of the strut graft provide stabilization of the tip, but the upper part provides the new tip projection, definition, and support because the elongated columellar septal strut graft is approximately 5 mm longer than a conventional columellar strut. Interdomal and transdomal sutures are performed with 5-0 polydioxanone sutures. For providing the new tip definition, support, and fullness, bilateral mini-spreader grafts in a right-angle triangular or trapezoid (approximately 7 × 5 mm and approximately 1 mm thick) and flag-like shape, are attached with 5-0 polydioxanone sutures bilaterally on both sides of the upper part of the strut graft by use of Kim cartilage graft forceps. A shieldshaped graft for increasing the improving contour of the infratip lobule is placed adjacent to the caudal edge of the upper part of the strut graft (Fig. 2). The upper part of the strut graft is camouflaged with soft tissue. A silastic dorsal I-shaped implant is placed into the tight dorsal pocket with the caudal end of the implant sutured to the cephalic end of the bilateral mini–spreader grafts. The transcolumellar and infracartilaginous incisions are closed with 6-0 nylon and 5-0 Vicryl (Ethicon, Inc., Somerville, N.J.) sutures. Statistical Analysis First, to determine survey subjects’ general characteristics, frequency analysis was carried out (Table 1). Second, to examine the time-based difference, the t test, which is a means of verifying the mean difference, was conducted. To compare it with the ideal figure, a univariate t test was implemented. The empirical analysis in this study was verified at the significance level of p < 0.05. The
Fig. 2. A shield-shaped graft is placed adjacent to the caudal edge of the upper part of the strut graft. (Left) Lateral view. (Right) Caudal view.
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Volume 135, Number 4 • Tip Plasty for Asian Rhinoplasty Table 1. Survey Subjects’ Demographic Information* Characteristic
No. (%)
Age 10–19 yr 20–29 yr 30–39 yr 40–49 yr 50–59 yr 60–69 yr ≥70 yr Sex Male Female Total
10 (6.2) 81 (50.3) 36 (22.4) 18 (11.2) 14 (8.7) 1 (0.6) 1 (0.6) 32 (20.5) 128 (79.5) 161 (100)
*Examining the survey subjects’ demographic information, the age group was indicated to be in order of 50.3 percent for those aged 20 to 29 years, 22.4 percent for those aged 30 to 39 years, and 11.2 percent for those aged 40 to 49 years, and can be known to be distributed from the teens to the 60s and 70s. Sex was shown to be male with 20.5 percent and female with 79.5 percent.
statistical processing was analyzed by using IBM SPSS Version 21.0 (IBM Corp., Armonk, N.Y.).
RESULTS Using an open rhinoplasty, 161 patients underwent the flag technique by a tip-strut complex in a flag-like shape in 137 patients undergoing primary
rhinoplasty and 24 patients undergoing secondary rhinoplasty. Additional procedures included lateral crural grafts (n = 3)7 and columellar Medpor (Orthovita, Inc., Malvern, Penn.)–septal complex strut grafts (n = 2). The postoperative complications included tip deviation (one patient) and suboptimal outcome (one patient). The correction of tip deviation caused by a weak columellar septal strut graft was performed by the replacement of the columellar Medpor–septal complex strut graft. In this study, there were six parameters used to evaluate tip projection: (1) the ratio of nasal length (radix to tip) to tip projection, or the tip projection–to–nasal length ratio; (2) the ratio of tip projection (to the distance from the tip to the vertical line of the upper lip (vertical line drawn adjacent to the most projecting part of the upper lip and perpendicular to the natural horizontal Frankfort plane), or the tip to vertical line of upper lip–to–tip projection ratio; (3) the ratio of alar base width to the width between each side of the tip-defining points, or the tip-defining point–to–alar base width ratio; (4) the tip-to-nostril ratio; (5) the columellar-labial angle; and (6) the columellar-lobular angle.8 In
Table 2. Paired Sample t Test Statistics of Parameters for Evaluating Tip Projection Preoperatively and Postoperatively* AT/RT ratio Preoperative Postoperative TV/AT ratio Preoperative Postoperative Tip/nostril proportion Preoperative Postoperative Columellar-labial angle Preoperative Postoperative Columellar-lobular angle Preoperative Postoperative Nasofrontal angle Preoperative Postoperative TD/AW ratio Preoperative Postoperative
Mean
N
SD
Mean Difference
t
p
0.5005 0.5258
161 161
0.10743 0.12720
−0.02530
−2.704†
0.008
0.3803 0.5088
161 161
0.14484 0.60371
−0.12850
−2.742†
0.007
0.9724 0.9710
65 65
0.27260 0.20076
0.00136
0.045
0.964
114.5375 116.0438
160 160
10.47002 11.70569
−1.50625
−1.538
0.126
25.2063 24.1688
160 160
9.60745 10.64949
1.03750
0.937
0.350
143.0566 143.2390
159 159
25.37622 12.54534
−0.18239
−0.087
0.931
0.5274 0.4706
161 161
0.07889 0.16470
0.05679
4.326‡
0.000
AT/RT, tip projection–to–nasal length ratio; TV/AT, tip to vertical line of upper lip–to–tip projection ratio; TD/AW, tip-defining point–to–alar base width ratio; CLA, columellar-labial angle; CLoA, columellar-lobular angle. *The criteria of the ideal tip projection are that the ideal AT/RT ratio is 0.67, the ideal TV/AT ratio is 0.5 to 0.6, the ideal tip/nostril ratio is 0.5, the ideal TD/AW ratio is 0.4, the ideal CLA is 95 to 110 degrees, and the ideal CLoA is 30 to 45 degrees. The paired sample t test statistics of parameters for evaluating tip projection were determined preoperatively and postoperatively. The AT/RT ratio was 0.50 preoperatively and 0.52 postoperatively. Thus, postoperatively, it showed a significant difference because of having been indicated to be relatively high (p < 0.01). The TV/AT ratio was 0.38 preoperatively and 0.50 postoperatively. Thus, postoperatively, it showed a significant difference because of having been indicated to be relatively high (p < 0.01). The TD/AW ratio was 0.52 preoperatively and 0.47 postoperatively. Thus, postoperatively, it showed a very significant difference because of having been indicated to be relatively high (p < 0.001). †p < 0.01. ‡p < 0.001.
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Plastic and Reconstructive Surgery • April 2015 statistical analysis, a significant difference was not shown in the tip-to-nostril ratio, columellar-labial angle, columellar-lobular angle, or nasofrontal angle, but was shown in the tip projection–to– nasal length ratio (p < 0.01), tip to vertical line of upper lip–to–tip projection ratio (p < 0.01), and tip-defining point–to–alar base width ratio (p < 0.001) (Table 2). Examining the results of one-sample t test statistics with postoperative statistics, an ideal figure in tip projection–to–nasal length ratio and tipdefining point–to–alar base width ratio showed a significant difference at the significance level of p < 0.001. In other words, the postoperative outcome showed a difference from the ideal figure in Westerners. Inspecting the results of one-sample t test statistics with postoperative statistic, an ideal figure in tip to vertical line of upper lip–to– tip projection ratio has not shown a significant difference at the significance level of p < 0.05. Accordingly, the postoperative outcome can be known to show no difference from the ideal figure in Westerners.
CONCLUSIONS There are significant improvements in three parameters for evaluating tip projection preoperatively and postoperatively. When compared with the ideal figure, the results are very effective in tip to vertical line of upper lip–to–tip projection ratio, but have significant differences in tip projection–to– nasal length ratio and tip-defining point–to–alar base width ratio. The significant differences possibly show the difference between the anatomy of Asians and Westerners. Thus, this technique is particularly indicated in improving greater than 3 mm higher of tip projection without the septal extension grafts or extended spreader grafts in Asian rhinoplasty. The flag technique by a tip-strut complex in a flag-like shape is an alternative method in the tip plasty of Asian rhinoplasty patients with insufficient septal cartilage. (See Figures, Supplemental Digital Content 1 through 4, which show preoperative and postoperative views of four cases, http://
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links.lww.com/PRS/B248, http://links.lww.com/PRS/ B249, http://links.lww.com/PRS/B250, and http:// links.lww.com/PRS/B251, respectively.) Cheol Hwan Kim, M.D. Department of Plastic Surgery Winners Clinic Dongyang Building, 824 Nonhyeon-ro, Gangnam-gu Seoul 135-893, Republic of Korea
[email protected]
patient consent
Patients provided written consent for the use of their images. ACKNOWLEDGMENTS
The author gives special thanks to his wife, parents, children, and staff at the Department of Plastic Surgery, Winners Clinic. REFERENCES 1. Toriumi DM, DeRosa J. The Asian nose. In: Rohrich RJ, Adams WP Jr., Ahmad J, Gunter JP, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. Vol. 2, 3rd ed. St. Louis: Quality Medical; 2014:1226–1229. 2. Byrd HS, Andochick S, Copit S, Walton KG. Septal extension grafts: A method of controlling tip projection shape. Plast Reconstr Surg. 1997;100:999–1010. 3. Rohrich RJ, Kurkjian TJ, Hoxworth RE, et al. The effect of the columellar strut graft on the nasal tip position in primary rhinoplasty. Plast Reconstr Surg. 2012;30:926–932. Erratum in Plast Reconstr Surg. 2012;130:1399. 4. Rohrich RJ, Hoxworth RE, Kurkjian TJ. The role of the columellar strut in rhinoplasty: Indications and rationale. Plast Reconstr Surg. 2012;129:118e–125e. 5. Peck GC, Peck GC Jr, Adams WP Jr. Long-term follow-up of the onlay tip graft and umbrella graft. In: Gunter JP, Rohrich RJ, Adams WP Jr, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. St. Louis: Quality Medical; 2002: 291. 6. Sheen JH. Achieving more nasal tip projection by the use of a small autogenous vomer or septal cartilage graft: A preliminary report. Plast Reconstr Surg. 1975;56:35–40. 7. DeRosa J, Watson D, Toriumin DM. Structural grafting in secondary rhinoplasty. In: Gunter JP, Rohrich RJ, Adams WP Jr, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. St. Louis: Quality Medical; 2007: 869. 8. Ghavami A, Janis JE, Acikel C, Rohrich RJ. Tip shaping in primary rhinoplasty: An algorithmic approach. Plast Reconstr Surg. 2008;122:1229–1241.
