Association of Nasal Tip Rotation Outcome Estimation With the New Domes Technique in Primary Rhinoplasty

This analytic cohort study assesses whether the definitive outcome of the rotation angle of the nasal tip in patients undergoing primary rhinoplasty can be determined with the new domes technique.

Key Points

Question

Is it possible to determine the definitive outcome in the rotation angle of the nasal tip after rhinoplasty with the new domes technique?

Findings

In this cohort study of 323 patients who underwent primary rhinoplasty with the new domes technique, the degree of rotation obtained in the nasal tip for every lateralized millimeter in the domes was measured. For every lateralized millimeter, the nasal tip rotated 3.57°, and this result was stable at 6 months at 3.42°.

Meaning

The new domes technique can estimate the long-term rotation angle of the nasal tip, thereby improving surgical planning.

Abstract

Importance

The postoperative changes in the rotation of the nasal tip in rhinoplasty must be estimated for the surgical planning.

Objective

To determine whether the outcome in the rotation angle of the nasal tip can be estimated in patients undergoing primary rhinoplasty with the new domes technique.

Design, Setting, and Participants

This retrospective analytic cohort study included 323 patients undergoing primary rhinoplasty with the new domes technique in a private clinic in Bogotá, Colombia, by a single surgeon from January 1, 2011, through January 31, 2016. Patients undergoing secondary rhinoplasty and those with less than 6 months of follow-up were excluded.

Exposures

Primary rhinoplasty using the new domes technique.

Main Outcomes and Measures

Measurement of the rotation angle of the nasal tip before and 1 week and 6 months after surgery. The main variable taken into consideration was the measurement, in millimeters, of the lateralized nasal domes.

Results

A total of 323 patients (288 women [89.2%] and 35 men [10.8%]; mean age, 27.8 years; age range, 13-70 years) were included in the study. The mean (SD) preoperative nasolabial angle was 92.7° (4.4°; range, 77°-107°); at 1 postoperative week, 105.5° (4.9°; range, 92°-120°); and at 6 postoperative months, 102.1° (4.6°; range, 90°-115°). The mean (SD) increase of the rotation that was achieved per lateralized millimeter was 3.6° (2.0°). The mean (SD) rotation angle at 6 months decreased to 3.4° (2.4°).

Conclusions and Relevance

The new domes technique was reliable and reproducible in most patients. Despite the unpredictable inflammatory changes, the exact lateralization in millimeters with the new domes technique allowed precise estimation of the long-term outcome of the rotation of the nasal tip, enabling the surgeon to determine from the preoperative plan the definitive rotation angle of the nose.

Level of Evidence

4.

Introduction

In the pursuit of the ideal nose, many techniques have been developed to achieve a pleasant result for the patient and surgeon. No unique technique can estimate the exact long-term results of rhinoplasty in the nasal tip, because several factors influence the outcome. Therefore, the correct preoperative diagnosis and design of a surgical plan that allows the most predictable results is important.

One of the measures in which surgeons and patients are more interested is the nasolabial angle of the nose. A number of techniques have been developed to achieve a pleasing angle. In 1975, Webster¹ described the lateral crural flap technique. In August 1985, McCollough and English² described a technique to create new domes by morselizing, incising, and suturing the lower lateral cartilages to narrow the nasal tip width. In September 1985, Pedroza³ described the new domes conservative technique at a meeting of the American Academy of Facial Plastic Surgery, followed by the 20-year experience using the same technique in 2002.⁴ The lateral crural steal technique, described in 1989 by Kridel et al,⁵ lateralizes the nasal dome to a new position by separating vestibular skin 5 mm lateral and medial of the new domes position and then approximating the domes with an intercrural suture, thereby allowing rotation and projection of the nasal tip. To determine how many degrees of rotation are achieved with every lateralized milimeter of the nasal tip domes with the new domes technique, we sought to construct a more objective surgical plan with this technique.

Methods

We reviewed 323 patient files from January 1, 2011, through January 31, 2016. The rhinoplasty procedures were performed in a private clinic (Clinica LaFont, Bogotá, Colombia) by one of us (F.P.). In all patients, the new domes technique was used. Only patients with no previous nasal surgery were included. Patients with a follow-up of less than 6 months were excluded. This retrospective study assessed the changes in the rotation angle of the nasal tip with the surgical technique described below. This study was approved by the ethics board of CES University, and written informed consent was obtained from all patients.

The patient information in the database was collected from the surgical descriptions and the photographic records in the preoperative and 1-week and 6-month postoperative evaluations (Figure 1). All general demographic information, the lateralization measurement (in millimeters) of the cartilaginous nasal domes, and the nasal tip rotation in the preoperative and 1-week and 6-month postoperative evaluations were included. We also considered the presence of a strut graft, a long shield graft, and septocolummellar stitches.

Figure 1. Representative Patients Undergoing the New Domes Technique With and Without the Banner Technique.

The photographs were taken with a commercially available camera (D7000 with AF Macro Nikkor 60-mm f/2.8D lens objective; Nikon) and were analyzed with Mirror Suite software (version 1999-2013; Canfield Clinical Systems). The rotation angle of the nasal tip was measured by the nasolabial angle according to the technique described by Rohrich et al.⁶ The nasolabial angle was measured by drawing a straight line through the most anterior and posterior points of the nostrils as seen on the lateral view. The angle formed by this line with a perpendicular line to the natural horizontal facial plane, or the Frankfurt line, is the nasolabial angle (Figure 1).

Surgical Plannning and Technique

Nasal Tip Rotation Planning

To plan nasal tip rotation, we measure the existing nasolabial angle and project the nasal profile with the new rotation angle that the patient wants and that fits his or her face. The difference between the preoperative nasolabial angle and the planned postoperative angle defines the amount (in millimeters) that we have to lateralize the nasal domes to achieve the desired rotation of the nasal tip (Video).

Video. New Domes Technique for Rotation of the Nasal Tip.

Download video file ^{(466.7MB, mp4)}

The New Domes Technique

Based on the preoperative facial analysis, we draw a 10-mm horizontal line in the desired position of the nasal tip, then a vertical line from each side of the horizontal line, perpendicular to the lateral crura to define the new domes position (Figure 2). Once the precartilaginous and postcartilaginous incisions have been made and the lower lateral crura has been dissected in a bipediculated flap, the site of the nasal domes is marked in the most anterior point of the lower lateral cartilage, which generally corresponds to the union between the lateral and medial crura. The new domes position is then defined, lateralizing the dome position of the patient as necessary to obtain the planned rotation, which will correspond to the site of the dome at the level of the horizontal line previously marked in the nasal tip skin.

Figure 2. Example of the New Domes Technique.

Cephalic Resection of the Alar Cartilage

Several authors^7,8 have described cephalic resection of the alar cartilage. We measure the width of the cartilage at the level planned for the new dome. If the width is greater than 5 mm, we perform a conservative cephalic excision of the additional cartilage, leaving at least a 5-mm width at this new dome level. The vestibular skin is not excised, dissected, or separated from the lower lateral cartilage. We continue this cephalic excision laterally, leaving the lateral crus with a width of 7 mm at its medial half, without extending the excision to the distal posterior half of the lateral crus (Figure 3A). This conservative procedure preserves sufficient cartilage to ensure tip support and avoids late postoperative complications such as collapsing and pinching.

Figure 3. Graphic Representation of the New Domes Technique.

A, Marking of the new domes with conservative cephalic excision of the lower lateral cartilage without extending to the lateral half. B, Transdomal sutures (2 mm from the new domes) create more lateral and narrowed domes. C, An intercrural strut is made and sutured in place. D, The interdomal sutures achieve the aesthetic triangle.

Transdomal Sutures

With the cephalic cartilage resection completed, we measure the distance between the new dome and the patient’s existing dome, which corresponds to the amount of lateralization required. Using polyglactin 5-0 suture (Vicryl; Ethicon), we place a transfixion suture 2 mm from the level of the new dome without tightening to conserve an arch at the new dome level (Figure 3B). From the medial toward the lateral face, we pass the needle through the new dome and then place another more tightened transfixion suture at 1 mm of the new dome to achieve more definition. The tension of the transfixion sutures must be controlled without tightening the suture so much that the lateral and the medial sides of the domal cartilage come together. This technique maintains the natural arch of the cartilage at the level of the new dome.

The new domes technique is always complemented with the placement of a columellar strut graft between the medial crura, an interdomal suture in the posterior edge of the cartilage at 2 mm from the new domes, and 1 intercrural suture between the anterior edges of the medial crura, at 6 mm from the new domes (Figure 2C and D). In this way, the angle of divergence of the new domes is maintained to obtain a luminous aesthetic triangle at the level of the nasal tip.

The Banner Technique

Based on the thickness of the patient’s nasal skin, a long shield graft is used to achieve more definition of the tip (Figure 4). This graft is fixed to the new domes and the medial crura in different locations to guarantee the symmetry and adequate definition of the nasal tip. The long shield graft is placed at the same level of the new domes or 1 to 5 mm from the new domes to acheive the desired projection⁹ (Figures 2 and 4). Placement is at the same level in thin skin, 1 mm from the new domes in regular-thickness skin, and 2 mm or more from the new domes in thick skin.

Figure 4. Example of the Banner Technique.

To support the long shield graft and prevent it from being rotated cephalically, the intercrural strut placed in the the new domes technique must surpass the level of the new domes and extend to the whole length of the graft. This restrospective analytic cohort study investigates the definitive rotation angle of the nasal tip that is achieved using the new domes technique in the long term. The goal is to improve the estimation of the outcomes with this rhinoplasty technique.

Statistical Analysis

In the statistical analysis, we looked for an association between the postoperative results in the nasal tip and the intraoperative maneuvers that were described. We calculated the maximum and minimum and mean (SD) of the descriptive outcomes for the continuous variables. We used proportions and frequency tables for the qualitative variables. We used the paired, 2-tailed t test to compare between means (SDs) of the quantitative variables. All the analyses were performed with P < .05 indicating statistical significance. Scatter diagrams were used to analyze the changes of the variables. The data were processed in Excel software (version 2010; Microsoft Corporation).

Results

A total of 323 patients (288 women [89.2%] and 35 men [10.8%]; mean age, 27.8 years; age range, 13-70 years) were included in the analysis. The follow-up was 6 months for all the patients. The mean preoperative angle was 92.7° (4.4°; range, 77°-107°); the mean 1-week postoperative angle, 105.5° (4.9°; range, 92°-120°); and the mean 6-month postoperative angle, 102.1° (4.6°; range, 90°-115°). The mean gain in postoperative week 1 was 12.8° (4.5°). The mean rotation at 6 months with regard to the initial achievement decreased by 3.4° (2.4°). The mean definitive gain at 6 months was 9.4° (4.2°) (Figure 5).

Figure 5. Representative Preoperative and Postoperative Photographs of the New Domes Technique With and Without Banner Technique.

All postoperative photographs were taken 6 months after surgery.

We analyzed the mean rotation of the nasal tip by the lateralized domes, resulting in 3.57° (2.01°) per lateralized milimeter. We performed the paired, 2-tailed t test to compare the mean lateralized millimeters in the new domes and the initial and definitive rotation degree of the nasal tip. The result was statistically significant (P < .001).

We did not find any statistically significant correlation when we compared the level, in millimeters, where a long shield graft was placed over the domes and the rotation degree of the nasal tip. We found no correlation when we compared the level, in millimeters, of the septocolumellar suture with the rotation degree of the nasal tip.

We compared the changes in the nasal tip rotation between patients who underwent the Banner technique (with the long shield graft) with the new domes technique and those who underwent the new domes technique alone (without the long shield graft). We found that among patients in whom the Banner technique was used, the definitive mean gain of the rotation angle was 9.7° (4.3°); for the group of patients with the new domes technique, the mean gain was 8.2° (3.3°), resulting in a minimum difference of 1.4°. The mean preoperative difference of both groups was 1.5°. The mean rotation at 6 months in patients with the new domes technique decreased by 3.8° (2.1°); in patients with the Banner technique, 3.3° (2.4°).

Discussion

Nasal tip surgery presents a challenge for every ear, nose, and throat surgeon. Multiple factors intervene and depend on the surgical technique and on the inflammatory process of each patient. Trying to define a surgical plan that allows estimation of the definitive grades of the nasal tip rotation is an even bigger challenge. The number of surgical techniques and variables that intervene in the process make the scientific analysis difficult. In the present study, we attempted to analyze a few variables with an acceptable number of patients. However, we found some difficulties in the long-term follow up. Most of the patients did not have a strict follow-up after 6 months because of nonattendance to the clinic.

Our outcomes confirm that the new domes technique, based on the tripod theory of Anderson,¹⁰ achieves greater gain of rotation with more lateralized millimeters, as shown in previous studies.^11,12,13 As shown in a previous study,¹² we revealed that the mean rotation degree in the nasal tip achieved with every lateralized millimeter in the domes was 3.6°. In our analysis of the outcomes, we determined that 307 patients (95.0%) were in the 2- to 4-mm group; therefore, data in these groups carry more weight.

To define the utility of the septocolumellar suture and the implication of the presence of a long shield graft and its level in relation to the domes (Banner technique) and the gain or loss of rotation is not possible with our outcomes, as described in a previous study.¹² The loss of rotation observed at the 6-month follow-up may be owing to the resolution of swelling and a weakening of the interdomal sutures because they use absorbable material. Such a decrease in rotation should be taken into account at the time of surgical planning when using this technique to achieve the desired long-term results.

However, we define and reconfirm aspects of the technique that were not described previously. Dome lateralization generated a mean gain of 3.6° for every lateralized millimeter in the lower lateral cartilages, and at 6 months the rotation decreased by 3.4° in the nasal tip.

Although the placement of grafts on the tip can affect rotation, this maneuver did not significantly affect the rotation obtained by the new domes technique (a difference of 1.4°) in our study. This result can be explained because in our Banner technique, the long shield graft and intercrural strut avoid the change in rotation achieved with the technique of the new domes. Therefore, we consider that the long shield graft placement and the septocolumellar suture are only support measures that apparently have an effect in the nasal tip projection and definition, especially in patients with thick skin, but no effect in the rotation. This fact supports the finding of a minor loss of rotation at 6 months in patients in whom the Banner technique was used because of the greater nasal tip support achieved.

Limitations

The influence on the rotation of the nasal tip of the complementary procedures (eg, septal caudal edge resection, cephalic resection of the alar cartilages) is variable and can be adapted to the needs of the patient. We performed no lateralizations greater than 6 mm in the nasal domes; therefore, no data address the effect this has on the rotation, definition, and projection of the nasal tip. Studies are needed comparing the use of the technique with sutures of nonabsorbable materials to verify the effect they have on the technique, especially in the long term.

Conclusions

In nasal tip surgery, multiple factors determine the final rotation of the nose. Estimation of this outcome is a constant analysis theme. With the new domes technique, a rotation of the nasal tip is achieved with outcomes that can be estimated and, in the long term, obtain a rotation of 3.5° by each lateralized milimeter of the domes. Based on the gain of degrees by lateralized millimeter and taking into account the decrease in 3.4° of rotation at 6 months, we can infer that to achieve an outcome that most closely approaches the visualized objective in the surgical plan, the new domes must be lateralized for the planned millimeters plus 1 mm.

The new domes technique does not include the Banner technique because the purpose of the new domes technique is to achieve a greater effect in the nasal rotation, whereas the Banner technique seeks to obtain definition and, if necessary, projection of the nasal tip, especially in patients with thick skin. For this reason, these techniques are different and can complement one another as needed.