AAPS, American Association of Plastic Surgeons
AAPS, American Association of Plastic Surgeons
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2008 Annual Meeting Abstracts

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Treatment of Dynamic and Static Nasal Tip Deficiency
Mehdi N. Adham, M.D., F.A.C.S.
University of Oklahoma, Oklahoma City, OK, USA.

PURPOSE: Treatment of dynamic and static nasal projection deficiencies with classic rhinoplasty often produces unfavorable results due to loss of support of the lower third of the nose or inadequate augmentation. Cadaveric and clinical studies have revealed deformities are due to lack of premaxillary structure support, with and without active digastricus nasi-septi labialis (digastric muscle), and with or without tip projection insufficiency. This presentation examines the utilization of the tip graft, using columellar strut cartilage graft, and bone graft as an adjunct to the classic rhinoplasty to provide more aesthetic nasal tip support.
METHODS: The approach for mild to moderate insufficiency is endo-nasal, and in severe cases intra-oral and endo-nasal. After correcting the airway obstruction, the nasal spine and premaxilla are freed of all restricting subcutaneous tissues, dividing the digastric muscle if it is a deforming force. If the nose is over-projected, the nasal spine is reduced and a columellar graft is used to maintain the desired tip projection. If the anterior nasal spine is inadequate and tip projection is desired, a bone graft is used to create a new foundation, and on top of it a columellar strut is used as a column to support the nasal tip. The tip is modified last and if determined that a tip graft is needed, it is incorporated. For severe deformity, the correction is done through an upper buccal incision. The premaxillary and piriform aperture area are freed subperiosteally, and the floor and lateral wall of the nose are freed as well. The mucosa is incised at a level about 1.5 cm inside the nose. The paranasal area is augmented, first laterally, and then centrally. The columella is supported with a cartilage graft if there is inadequate support. To get more central lip fullness, the mucosal incision is closed in a V-Y fashion by advancing the soft tissue of the upper lip forward. The rest of the rhinoplasty is then completed.
RESULTS: This procedure has been performed in 50 patients with primary and secondary rhinoplasty over the past 16 years with satisfactory results. All patients reported they subjectively felt their appearance improved with the procedure. None of the patients experienced breathing difficulties. Complications include one patient eventually requiring additional grafting of the middle one-third of the nose. Two patients had slight asymmetry of the nasal tip. One patient complained of upper lip lengthening.
CONCLUSION: Results of the classic rhinoplasty used for the treatment of dynamic and static nasal tip deficiency can be significantly improved by adjunctive use of premaxillary bone or cartilage graft, columella strut graft, and tip graft. These steps help to establish adequate nasal tip projection to provide more aesthetically-pleasing results. The downside of this procedure is that it lengthens the time in the operating room. Long-term results have maintained very high patient satisfaction and a low complication rate. Overall, this procedure can be beneficial as an adjunct to the standard rhinoplasty for the treatment of nasal tip support deficiencies.


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