Abstract: Changing Nasal Tip Projection Via Purposeful Manipulation of the Medial Crura: A Surgical Experience with Resecting the “Unresectable”

Abstract

GOALS/PURPOSE: A belief exists that dissection and resection of the medial crura should be discouraged to avoid compromise of the tip support. We believe that judicious resection of the columellar portion of the medial crura can be an effective and predictable technique to control or reduce tip projection. This is pertinent in cases of tip overprojection, increased columellar show, or intraoperative findings of significantly buckled medial crura, where this technique allows for greater precision in controlling tip projection. Concern for loss of tip support can be obviated by buttressing the resulting structure with a columellar strut graft. We describe the routine use of dissection and resection of medial crura by the senior author (TAM) and present a brief review of the results. METHODS/TECHNIQUE: METHODS: A single institution, retrospective review of all consecutive patients who underwent rhinoplasty with resection of the medial crura by the senior author (TAM) during a single year was conducted. TECHNIQUE: All rhinoplasties were performed using an open technique. After conservative lateral crura resection in most cases, the nose is opened using a combination of blunt and sharp sub-mucoperichondrial dissection. Septoplasty is performed via a hemitransfixion incision, followed by dorsal rasping. The medial crura are dissected from the soft tissue envelope and the tip is shaped with a routine cephalic trim of the lateral crura and any dome suture maneuvers necessary. The projection of the tip is assessed and the appropriate (usually 3-5mm) amount of medial crura is resected from the mid-columellar segment. The columellar strut graft is placed and the cut ends of the crura are overlapped and sutured over the strut graft using 5-0 PDS. RESULTS/COMPLICATIONS: Nineteen patients matched inclusion criteria, with a mean age of 39 years old. Six patients (32%) had a history of a prior rhinoplasty procedure. In addition to resection of the medial crura, thirteen patients (68%) also had resection of their lateral crura. All patients underwent a septal resection and 18 (95%) received a columellar strut. Three (16%) patients had spreader grafts inserted and three (16%) patients had a tip graft placed. There were no complications in this series. Postoperative cosmesis was considered excellent by both patient and surgeon in all cases at mean follow-up of 11 months. CONCLUSION: Manipulation of the medial crura of the lower lateral cartilages is not inherently detrimental to tip support if performed judiciously and reinforced with a columellar strut graft acting as a buttress to the caudal medial crura. This technique is most useful to decrease tip projection or when tip projection is at goal, but domal shaping sutures would increase it and create over-projection. In both scenarios, resecting a portion of the mid-columellar medial crura leads to a predictable decrease in tip projection. We have not encountered any cases of support deficiency postoperatively. We encourage incorporating this technique to address over-projected noses and to prevent over-projection that may result from domal suture techniques.