Aesth. Plast. Surg.

17:163-166, 1993

Aesthetac _ Plasuc Surgery

1993Springer-VerlagNew York Inc.

Use of Umbrella Graft for Nasal Tip Projection

M. E. Mavili, M.D. and T. Safak, M.D. Ankara, Turkey

Abstract. An adequate nasal tip projection is of the utmost

importance for good nasal aesthetics. Conventional rhinoplasty procedures are not adequate for achieving nasal tip projection in "tips with inadequate projection" (TIP). This article describes our technique of using an umbrellashaped cartilage graft to the tip. The graft is carved from caudal septal and ajar cartilages. The results and advantages of the technique are discussed.

Key words: Rhinoplasty--Nose tip--Cartilage graft

The nasal tip is an important feature in facial appearance. An adequate projection of the tip and an improvement in the acute nasolabial angle are the key points to a pleasing nasal profile, especially for cases with "tips with inadequate projection" (TIP deformity). Numerous procedures have been described for achieving a well-projected tip in aesthetic rhinoplasties. The prosthetic implants for supporting the nasal tip have many drawbacks, one of them being a possible extrusion. Survival of rib and septal cartilage grafts was demonstrated by Peer [10]. The clinical application of septal grafts were first proposed by Cohen [2] and Metzenbaum [6]. Foman et al. [4] used a button graft carved from septal cartilage for nasal tip projection. Anderson [1] and Millard [7] promoted the concept of using columellar cartilage struts in rhinoplasty. Falces and Gorney [3] described a "Gull-wing" conchal cartilage graft for additional support for the nasal tip. Poller [11] used cartilaginous grafts from the ear, septal cartilage grafts, and cartilage grafts

provided by the resected nasal hump for different indications. Sheen [12] described the use of a specifically designed septal cartilage or vomer bone graft on the columellar-lobularjunction. Ortiz-Monasterio, Olmedo, and Ortiz [8] used septal or conchal cartilage grafts in two independent pockets for the tip and the columella. Garcia-Velasco [5] projected "Mestizo noses" with cartilage grafts from the cartilaginous hump. Peck [9] proposed the onlay cartilage graft technique for nasal tip projection. He combined the onlay with a strut if nasal tip augmentation greater than 6 mm was necessary. He called this type of graft an "umbrella graft." Most of the techniques mentioned above have some shortcomings in nasal tip projection. The discussion of these techniques will be held after presentation of our technique.

Surgical Technique
A standard rhinoplasty was performed on each case. The caudal portion of the cartilaginous septum was resected with cartilage scissors (Fig. la,b). The amount of caudal septum to be excised was determined preoperatively by the degree of reduction necessary in nasal height. In most cases with TIP deformity, a reduction of at least 5 mm was indicated (Fig. lc). The cephalic portions of the alar cartilage were excised using the bipedicle alar flap technique. Strips of alar cartilage 3-4 mm long were preserved to avoid any collapse (Fig. ld,e). The septal and alar cartilage grafts were cleaned of soft tissue. A proper graft for each case was then carved from the excised portions of the septal and alar cartilages. In most cases septal cartilage was tailored to measure a 10-mm x 3-mm graft. The alar

Correspondence to M. Emin Mavili, M.D., Paris Cad. No:60/7, Kavaklidere, Ankara, TR-06540, Turkey

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Umbrella Graft for Nasal Tip Projection

e@h

Fig. 1. Construction of the umbrella graft: (a) Dissection of the caudal septum. (b) Resection of cartilaginous septum with a cartilage scissor. (e) Excised portion of caudal septum. (d,e) Excision of alar cartilages using the bipedicle alar flap technique, if, g) The alar cartilages trimmed to form two circular grafts. The smaller graft is sutured over the bigger one with 6-0 chromic catgut. (h) The alar cartilages are sutured over the end of septal cartilage graft to form an umbrella graft

Fig. 2. Two alar cartilages measuring 6 and 8 mm in diameter and the septal cartilage strut

Fig. 3. Parts collected together to form an umbrella graft

cartilage was trimmed to form two circular grafts 4 and 6 m m in diameter, respectively (Fig. 2). The smaller graft was attached o v e r the bigger one with 6-0 chromic catgut. This cartilage complex was then sutured o v e r the end of septal cartilage graft to create an umbrella type of graft (Figs. l f - h , 3). The handle of the umbrella was cut in fish-tail fashion in order to minimize any d o w n w a r d displacement of the graft. The constructed umbrella graft was inserted through a rim incision on the right side of the columella. The skin was undermined with F o m o n scissors to f o r m a p o c k e t b e t w e e n the alar cartilage and the dermis, j u s t large enough for the graft. The d o m e of the umbrella was placed o v e r the strips of alar

7,

Fig. 4. Position of the umbrella graft, basal view

M.E. Mavili and T. Safak

165

Fig. 5(A) Preoperative right lateral view of a 21-year-old female with TIP deformity. (B) Postoperative right profile. (C) Postoperative oblique profile

Fig. 6(A) Preoperative right lateral view of a 26-year-old female with TIP deformity. (B) Postoperative right profile. (C) Postoperative oblique profile

Fig. 7(A) Preoperative right lateral view of a 19-year-old female with TIP deformity. (B) Postoperative right profile. (C) Postoperative oblique profile

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Umbrella Graft for Nasal Tip Projection

cartilage while the base of the umbrella rested in a narrow groove between two crura (Fig. 4). In most cases the graft was guided to its place with the use of a piece of 6-0 chromic catgut on a straight needle. This suture also helped to stabilize the graft in its pocket.

Results

T w e n t y eight female patients with TIP deformity were operated on between May 1988 and May 1991. All the patients in this series have been reexamined one year after the operation. The postoperative results have been quite satisfactory. There has been no displacement of any graft and no reabsorption. The shape and projection of the tip has been adequate in all cases (Figs. 5-7).

Discussion

A well-projected nasal tip can be obtained in noses with TIP deformity with the use of cartilaginous grafts. Among the numerous techniques described, a few have been accepted for widespread clinical application. The button graft does not have any projection potential. In some cases, it causes a circumferential scarring around the graft. The columellar struts, if they are long enough to be effective, frequently cause an obvious pointing and blanching in the nasal tip. The tenting columellar strut in some instances can perforate the skin of the nasal tip. The use of vomer or septal cartilage grafts, as described by Sheen, may cause some problems especially in thin-skinned noses. Although this graft, carved of vomerine bone, provides a satisfactory projection in noses with TIP deformity, it may cause blanching and surface irregularity in thin-skinned individuals, since a bone graft or hyaline septal cartilage are not as pliable or as curved as fibrocartilage to fit the delicate structure of the nasal tip. Combination of an onlay graft with a strut was described by Peck. Our technique differs from his in some aspects. He uses the columellar strut and the onlay graft as separate pieces. The relationship between the onlay graft and the columeUar strut is determined either by the skill of the surgeon or by chance. We construct the umbrella graft outside the nose and insert it into the tip as a unit. The sutures that secure the strut to the dome of the umbrella prevent any displacement of the dome part of the graft over the strut part. Another difference is in choice of the material. Peck prefers ear cartilage

for most cases. We use the cartilages excised in a standard rhinoplasty operation for graft construction, thus avoiding any disturbance to another anatomical site such as the concha of the ear. Peck defines the excised portions of the lower lateral cartilages as too thin or weak. Of course, alar cartilage segments are generally thin and weak structures and do not have any projection potential, if they are used alone. In our Opinion, the c o n v e x i t y and pliability of thin alar cartilages are advantages for the surgeon in that they help avoidance of any abrupt demarcation or unnatural appearance on the nasal tip when the grafts are supported with a columellar strut of septal cartilage. The umbrella graft exerts a force adequate enough to project the tip. The dome part o f the graft, made o f alar cartilages, disperses this force onto a larger area on the nasal tip thus avoiding a tent effect or blanching. As the healing process progresses, the soft tissues of the nasal tip decrease the volume of the pocket around the graft. By the time the 6-0 chromic sutures that hold the graft together are reabsorbed, the graft is stabilized in the desired position.
References

1. Anderson JR: New approach to rhinoplasty. Arch Otolaryngol 93:284, 1971 2. Cohen S: Role of the septum in surgery of the nasal contour. Arch Otolaryngol 30:12, 1939 3. Falces E, Gorney M: Use of ear cartilage grafts for nasal tip reconstruction. Plast Reconstr Surg 50:147, 1972 4. Foman S, Goldman IB, Neivert H, Schattner A: Management of deformities of the lower cartilaginous vault. Arch Otolaryngol 54:467, 1951 5. Garcia-Velasco J, Garcia-Velasco M: Tip graft from the cartilaginous dorsum in rhinoplasty. Aesth Plast Surg 10:21, t986 6. Metzenbaum M: Replacement of the lower end of the dislocated septal cartilage versus submucous resection of the dislocated end of the septal cartilage. Arch Otolaryngol 6:282, 1929 7. Millard DR Jr: Adjuncts in augmentation mentoplasty and corrective rhinoplasty. Plast Reconstr Surg 36:48, 1965 8. Ortiz-Monasterio F, Olmedo A, Ortiz LO: The use of cartilage grafts in primary aesthetic rhinoplasty. Plast Reconstr Surg 67:597, 1981 9. Peck GC: The onlay graft for nasal tip projection. Plast Reconstr Surg 71:27, 1983 10. Peer L: Fate ofautogenous septat cartilage after transplantation in human tissue. Arch Otolaryngol 34:697, 1941 1t. Poller J: Three autogenous strutsfor nasaltip support. Plast Reconstr Surg 49:527, 1972 12. Sheen JH: Achieving more nasal tip projection by use of a small autogenous vomer or septal cartilage graft. Plast Reconstr Surg 56:35, 1975