Rhinoplasty – The Difficult Nasal Tip – Total Resection of the Alar Cartilages and Temporal Fascia Technique – A 24 Year Experience

Abstract

This technique begins with a secondary rhinoplasty case (operated 3 times previously) in 1987 with a highly unappealing nasal tip whose cartilages were completely broken. I had to choose between eliminating the whole nasal dome and resetting it with a new cartilaginous structure (taking cartilages from the ear), or removing all the cartilage remains and covering with two-layered temporal fascia. I decided on the second option, and the result was highly satisfactory (fig. 1). Why this unprecedented idea? It was an impulse. Because of my reflexive character and perfectionism, it seemed contradictory and, yet, I sensed that this nasal tip, so badly arranged and anti-aesthetic after 3 operations, would only withstand a fourth operation which guaranteed certain success. So I thought that submitting the patient to a reconstruction of the whole cartilaginous nasal tip structure was not the best solution. Amputating and reconstructing seemed more complex and bloody than amputating and covering with some soft tissue. I chose temporal fascia as it is soft and not very extensible, and would provide the new tip more solidity. It came to my mind in a flash and I acted with all the consequences to help my patient, Paquita. As I knew the patient, I did a follow-up and, years later, the result remained stable. However, as all the plastic surgery treaties and publications warn us about the importance of conserving an alar cartilage band of no less than 3-5 mm on its caudal edge to avoid collapses, I thought that this process could wait before being repeated. So gradually, I started performing more cases, and I saw that the result was no chance happening. I extended the indications and ventured with particularly difficult primary rhinoplasty cases involving extremely domed, flat and wide tips. The years went by and I continued improving and perfecting this process, which went against what was “technically correct”. I indicated it by taking great care and followed the results for as long as possible. After finishing the operation, I checked that the result remained aesthetic and that the nasal base was equilateral and stable; this was precisely one of the keys: a solid tripod and an equilateral stable base. To achieve this effect, I introduced some technical resources which helped me to convert a long-pointed or flattened nose into what ensured