A Chevron or V-shaped incision is designed on the columella, either where it contacts the lip, or at its narrowest portion (Fig. 38.3A1). The V-shaped incision at the base is preferable when the columella is short. With a 15 blade, the incision is made through the dermis, carried just inside the vestibule, then directed towards the tip for a distance of approximately 10 mm bilaterally. Using Converse scissors, blind subcutaneous dissection is performed connecting both vestibular rim incisions, taking care not to injure the inferior border of the medial crura (Fig. 38.3A2). The columellar incision is finalized by connecting these planes. The columellar flap is then elevated quickly, and the medial crura immediately visualized. From this point on, scissor dissection is guided by following the lower border of the lower lateral crura. A Converse alar retractor distracts the flap, while your assistant provides downward counter-traction on the medial crura with a single hook (Fig. 38.3A3). Dissection should stay on the cartilage to avoid interfering with the blood supply of the skin flap. When both lateral crura are visualized, the domes are distracted inferiorly with a double hook in order to provide the necessary counter traction and allow undermining of the dorsal flap. Undermining is started by first dividing the suspensory ligaments, which attach the skin to the underlying domal area. Then the correct dissection plane is identified by finding the bluish color of the dorsal septum (Fig. 38.3A4). Once the bony dorsum is reached, a Joseph elevator is used to complete the dissection, making sure that the attachments of the upper lateral cartilages to the nasal bones laterally are not violated.

Fig. 38.3 Surgical steps (see text).

The next step in the procedure is to address the dorsal height. If a reduction is deemed necessary, the upper lateral cartilages are separated off the dorsal septum in a subperichondrial plane, allowing for lowering the dorsal septum without violating the nasal dorsal mucosa. This will permit the subsequent placement of spreader grafts later during the procedure if they are deemed necessary. The bony dorsum is incrementally lowered with a sharp rasp. We avoid the use of osteotomes, since they are unreliable. An 11 blade is used to initiate a horizontal cut through the dorsal septum, particularly when minimal reductions are needed. The excess dorsal cartilage is then trimmed with an angled Fomon scissor. The dorsal height is lowered to a level shy of the final desired height, since spontaneous dorsal lowering occasionally occurs after septal surgery. Furthermore, the purpose of reducing the dorsal height to near the desired position is to be able to control the width of the horizontal strut if septal surgery is contemplated. The upper lateral cartilages are then lowered as well. If they exhibit significant dorsal excess, they can be folded over and used as autospreader grafts if the situation dictates for middle vault enhancement. If the lower lateral cartilages are large, they may obscure the caudal aspect of the dorsum. Thus they are trimmed at this stage, making sure to leave 5 to 7 mm of intact cartilage rim. This incision is performed with a 15 blade, taking care to stay parallel to the caudal border of the lateral crura. Spreading dissection is performed under the cartilage to be removed in order to release it from the underlying mucosa. An effort is made to maintain the integrity of the resected specimen, since it is often used as a radix graft or as an onlay tip graft.

The septum is approached at this stage if a septoplasty is to be performed. Local anesthetic is injected on both sides in the subperichondrial plane to help with the dissection and hemostasis. A clean and direct way to approach the septum is to separate the medial crura and identify the caudal septum (Fig. 38.3C1). This avoids additional mucosal incisions, and affords an excellent exposure of the septum. This approach tends to destroy some elements of tip support and will generally necessitate the later use of a columellar strut in order to restore and maintain tip support. If the tip is already under projected, this is of little consequence, as additional support is required anyway. The caudal septum can be shortened if needed, then the septal pathology is addressed (Fig. 38.3C2). An L-shaped strut is preserved, making sure to retain as much cartilage as possible. A 10 mm horizontal strip is the bare minimum. To avoid the use of postoperative nasal packing, the septal mucoperichondrial flaps can be re-opposed with the use of a quilting suture of 4-0 Plain Gut on an SC-1 needle (Fig. 38.3C3).

Osteotomies and infractures of the nasal bones are performed next. If spreader grafts are to be placed, the osteotomies should be executed prior to placement of grafts to avoid displacement. We prefer the use of a 2 mm sharp osteotome via the endonasal route, generally in a low-to-low fashion (Fig. 38.3D). Perforating lateral osteotomies are performed. Medial osteotomies are typically not necessary, especially if the dorsum has been reduced. Digital infracturing is performed, making sure that any evidence of an open roof has been eliminated by proper mobilization of the nasal bones.

Spreader grafts are used next if the middle vault appears narrow, or if the dorsal septum is deviated. These strips of cartilage measure approximately 4 mm in width, and should be long enough to traverse the distance from the keystone region to just short of the septal angle (unless they are intentionally to be used as extended spreader grafts to lengthen the nose.) When placing these grafts, the mucosa is dissected off the dorsal septum after the final dorsal height has been determined. No change in dorsal height is possible after the grafts are secured in position. The cephalic portion of the spreader graft is carefully placed under the caudal portion of the nasal bone at the keystone area in order to avoid its postoperative displacement and visibility. We secure these grafts with 5-0 PDS in mattress fashion to reduce the chance of their displacement (Fig. 38.3E). Single or multiple grafts can be placed unilaterally to correct a dorsal deviation, bilaterally to correct a narrow middle vault, or to lengthen the overshortened nose when they are extended beyond the septal angle.

At this point, the dorsal height has been established, as well as the width of the nose. The shape and the projection of the nasal tip are evaluated next. Intercrural sutures of 6-0 PDS are used to improve domal definition. A tight pocket is created between the medial crura to accept the columellar strut if one is needed (Fig. 38.3F1). The dissection is not carried down to the nasal spine, in order to avoid a clicking sensation between the base of the strut and the underlying bone. The strut is placed into the pocket and pushed down with forceps while the domes are symmetrically grasped with a double hook and distracted forward, away from the facial plane (Fig. 38.3F2). Two 25-gauge needles are passed through the columella complex in order to maintain a relationship of tension between the strut and the adjacent medial crura. Perfect symmetry is mandatory in both the coronal and sagittal planes in order to avoid the creation of a columellar asymmetry. Horizontal mattress 4-0 Plain Gut on a straight SC-1 needle is used to percutaneously fixate the strut in position (Fig. 38.3F3). PDS sutures are also used to approximate the strut to the medial crura. The strut is then trimmed so it does not protrude beyond the domes (Fig. 38.3F4), and an interdomal suture is placed in the cephalic portion of the domes to bury the strut. Divergence of the caudal aspect of the domes is maintained (Fig. 38.3G).

In cases where these maneuvers have not created adequate tip projection, additional tip grafts are considered. Several types of grafts are appropriate, and the choice is often dictated by the severity of the under projection and the thinness of the nasal skin. Cap grafts made of resected alar cartilage are commonly used to centralize the tip and add a subtle degree of projection. Shield grafts are reserved for patients with thick tip skin in need for significant enhancement of tip projection. They are secured first between the medial crura. Then the distal border is contoured by shaving it with the edge of a 15 blade, so as to avoid postoperative graft visibility.

The skin is redraped, and final assessments performed. The strength of the middle vault is assessed by pinching the region (Fig. 38.3H). Feel the dorsum for any irregularities; assess for supertip break by supporting the columella with your thumb and placing the index finger in the supertip. Confirm that the nose is straight by looking from the head of the bed down. On the profile view and basal view, check for any alar notching or retraction. These can be addressed with alar contour grafts (also know as alar rim grafts).

Closure is performed next. 6-0 nylon is utilized in simple fashion, first aligning the “V” of the Chevron incision and then both lateral edges, taking particular care to appropriately medialize and inset the edges of the columellar flap (Fig. 38.3I). 5-0 chromic is utilized for closure of the infracartilagenous component of the incision. If contour grafts have been placed, they can be secured during this closure by taking a small bite of the medial portion of the graft.

Final assessment is performed, and then taping/splinting is carried out. This is a key portion of the procedure, as it maintains the soft tissue relationship with the underlying framework in the postoperative edema phase. The dorsum is prepared with mastisol, and then -inch paper tape is applied in overlapping strips across the dorsum (Fig. 38.3J1). The tape is first placed exactly at the supertip break and then three or four more strips are placed moving cephalad. Two long strips are placed following the dorsal nasal lines, and are pinched together across the tip (Fig. 38.3J2). A heated thermoplastic nasal splint is then applied over the tape and allowed to harden while mild digital pressure is applied to contour its shape (Fig. 38.3J3). A 2 × 2 gauze is folded into a triangle as a drip pad, taped across the vestibule, and the case is complete.