The Supratip Triangle

Abstract

Sir: When practicing resection of the cephalic portion of alar cartilage to improve nose aesthetics, loss of the continuity of the cartilage that is naturally interposed between the skin and the mucosa increases the possibility of scar formation and scar contractures that can deform this area. Naturally, the tissue anarchy created when the tissues of the soft envelope are in contact with the underlying mucosa leads to scar tissue formation that can eventually alter the shape of the tip. The authors propose an alternative to avoid the interaction of these tissues by the interposition of a triangular flap of cartilage sculpted from the cartilage to excise from the cephalic portion of the alar cartilage. This technical variation allows the preservation of the tissue planes of the nose, avoiding secondary skin contractures. Tissue characteristics, tissue dynamics, and anatomy are the issues that ultimately determine the success or failure in aesthetic nose surgery.1 It is important to consider the relationship of the soft-tissue envelope with the underlying bony framework that supports it, and efforts should be made to respect the anatomical planes of the nose. Reshaping the nasal tip by excision of a strip of cartilage from the cephalic portion of the lateral crus is a commonly used procedure. It results in a decrease of the volume of the cephalic part of the tip combined with an upward rotation and an improved definition of the lateral aspect of the tip. This technique is not completely free of risk, especially when associated with hump excision, as it can lead to incompetence of the internal nasal valve.2 It also causes a loss in the continuity of the cartilage that is naturally interposed between the skin and the mucosa, increasing the possibility of scar formation and scar contractures that can deform this area. After carefully exposing the tip of the nose using a transcolumellar approach, the amount of cephalic margin of alar cartilage is marked, including in the marking a triangle in the caudalmost portion of the alar cartilage. The triangle is then incised to separate it from the rest of the alar cartilage to be excised, respecting its attachment to the mucosa. The portion of alar cartilage to be removed is carefully separated from the underlying mucosa as is normally done. The triangular flap is pushed downward and caudally to maintain the cartilaginous plane in this zone and decrease the possibility of scar formation and skin retraction, maintaining a good definition of the supratip region (Figs. 1 and 2).Fig. 1.: The supratip region is covered using a bilateral cartilage triangular flap from the alar cartilage after trimming of the medial crura and the triangular cartilages. The triangle is then incised to separate it from the rest of the alar cartilage to be excised, respecting its attachment to the mucosa.Fig. 2.: The triangular flap is pushed downward and caudally to maintain the cartilaginous plane in this zone and decrease the possibility of scar formation and skin retraction, maintaining a good definition of the supratip region.The disruption of the anatomical structures and planes of the nose leads to anarchy of the tissues of the soft envelope of the nose, causing prolonged edema, skin contractures, and thus a mediocre definition of the tip of the nose. We consider that in most cases a combination of sutures to respect the structural integrity of the nose and resection of exceeding segments to sculpt the nose is the best solution. In our opinion, any factor that contributes to the preservation of the anatomical planes of the nose might help in the reduction of postoperative complications involving the soft envelope. This turns out to be even more important in this specific region, where the removal of the cephalic portion of the alar cartilages creates a dead space and allows the direct contact of the subcutaneous tissue of the skin envelope of the nose with the underlying mucosa. The addition of these factors predisposes to scar formation and skin contractures. Franz W. Baruffaldi Preis, Prof. Victor J. Urzola Herrera, M.D. Alberto Mangano Maurizio Cavallini, M.D. Guido Maronati, M.D. Istituto Ortopedico Galeazzi University of Milan Milan, Italy DISCLOSURE There are no financial interests or commercial associations from any of the authors related to this communication.