Refining the nasal tip with Newer VDD techniques.

Vertical Dome Divison Rhinoplasty: 
 Author: John Hilinski, CoAuthors: Anil R. Shah & Kris S Moe

Nasal tip surgery is among the most complex and difficult tasks in rhinoplasty surgery. Vertical dome division (VDD) is one of a variety of techniques that may be used in refining nasal tip appearance. Collectively, vertical dome division (VDD) refers to one of many methods of vertically dividing the lower alar cartilage at or near the dome to modify nasal tip aesthetics. The technique was originally recommended as an alternative in altering tip projection and appearance while minimizing use of implants and the degree of postoperative tip ptosis. Vertical dome division (VDD) targets various nasal deformities, including overprojection or underprojection, suboptimal rotation, disproportionate lobule ratios, and broad or asymmetric tip. The surgeon must strive to achieve an aesthetically pleasing nasal tip that is in balance with the remainder of the nose without compromising nasal airway function.

The typical patient presenting for vertical dome division (VDD) usually has a poorly defined or malpositioned tip with a combination of abnormal projection/rotation, broad or amorphous lobule, asymmetric tip defining points, and/or boxy, trapezoidal base.

Adherents to this principle argue that horizontal excisional techniques rely too heavily on unpredictable and uncontrollable postoperative scarring to produce desired tip results. Proponents of vertical dome division (VDD) believe that vertical incisional and excisional techniques, on the other hand, offer a more definitive and reliable means to achieve desired tip changes.

In principle, the technique of vertical dome division (VDD) separates the medial and lateral crura into 2 independent units. By transecting the dome, the inherent spring within the arch is released and allows realignment of the newly divided medial and lateral segments to reconstruct the nasal tip.

Vertical dome division (VDD) is typically reserved for more complicated cases that require greater changes to effect tip refinement than could be achieved using other techniques. Nearly all variations of vertical dome division (VDD) used today involve some modification of the original Goldman technique

The lobule is defined as the portion of the nasal tip complex that is situated anterior to the nostrils; it extends from the tip defining point to the junction with the columella, as observed on base view. The alar cartilage (lower lateral cartilage) is C-shaped and can be divided into the medial, middle, and lateral crus. The middle (intermediate) crus comprises the domal segment and largely influences the shape of the lobule and, therefore, the form and definition of the nasal tip. The dome is considered the highest arching segment within the nasal vestibule.

The lobule size can be assessed in comparison to the columellar length. If the base view demonstrates a columellar-to-lobule ratio of approximately 2:1, the structural support and configuration of the nasal tip is considered adequate. A long nasal length reflects an acute nasolabial angle; a short length reflects an obtuse nasolabial angle.

The anatomy of the nasal tip is often described using the tripod concept to facilitate understanding of the key structural components and to provide a simple explanation of tip dynamics. According to this analogy, the cartilaginous framework of the lower third of the nose is compared to a tripod that is attached to the facial frontal plane. The 2 individual lateral crura represent 2 legs of the tripod, and the conjoined medial crura and caudal septal attachments correspond to the third leg.

By lengthening or shortening any or all legs of the tripod, the changes that will be effected in tip projection and rotation can be predicted. For instance, techniques that augment or lengthen the medial crural segment enhance projection. Shortening the medial crura or disrupting their septal attachments without reduction of lateral crural length decreases projection and rotation of the nasal tip. Shortening the lateral crura and maintaining or lengthening the medial crural segment would be expected to increase rotation.

Contraindications

Vertical dome division (VDD) is predominantly contraindicated in patients with relatively thin skin. These patients are particularly prone to developing visible cartilage edges along the nasal tip region. This results from contraction of the thin overlying skin and soft tissue envelope around the new and more prominent medial cartilaginous strut. A thick overlying skin and soft tissue envelope is better able to cushion the appearance of prominent cartilaginous structures, such as those in vertical dome division (VDD).

Avoid classic vertical dome division (VDD) in patients who show evidence of already weakened lateral nasal walls. Dividing the domal region without reapproximation of the cartilage segments disrupts the integrity and continuity of the lower lateral cartilage. The lateral nasal wall is more susceptible to structural collapse than the newly reinforced medial footplates. As a result, lateral wall weakening and collapse are further potentiated.

The original technique is highly focused on manipulation and repositioning of only the medial crura, with no attempt made to reconstruct the remaining lateral crural segment and alar rim. Postoperatively, the medial crura and columella are sufficiently stable to resist loss of projection. Some loss of lateral support, which could result in lateral wall collapse and alar retraction, may occur. Vertical dome division (VDD) is also associated with bossae formation. This is most frequently seen in patients with thin skin and firm cartilages. Disruption of the underlying vestibular mucosa and skin, such as in the Goldman technique, also predisposes the patient to possible stenosis.

With use of newer modified techniques (Hockey stick excision, Lipsett, Simons, Adamson, and others) and caution, vertical dome division (VDD) can be used successfully in nasal tip refinement with limited postoperative complications and reliable long-term results. 

Most practitioners using vertical dome division (VDD) today perform some modification of the original Goldman tip procedure.

Adamson reported that approximately 5% of patients required revision surgery for postoperative tip abnormalities and irregularities attributed to use of vertical dome division (VDD).^[10] These abnormalities were primarily nasal bossae and lobule asymmetries. Abnormalities were nearly 3 times as likely to occur in revision cases as in primary rhinoplasty; incidence was lower with use of the incision and overlap method.

 Vertical dome division (VDD) is likely to remain controversial in the future. As knowledge of nasal tip surgery evolves, so too will further modifications of our existing tip techniques to attain more predictable outcomes.
 http://emedicine.medscape.com/article/841313-overview

The Endonasal Approach to Rhinoplasty
Robert L. Simons and Lisa D. Grunebaum Ch.68 Rhinology and Facial Plastic Surgery 

Today's trends in nasal tip surgeries are for improved visualization with preservation of the cartilage as well as better medial stabilization and support. These tenets are inherent in vertical dome division techniques. It is important to remember that VDD is an incisional technique that allows for repositioning of the nasal tissue and should not be combined with excisional techniques. One should always leave behind more than one takes. Preservation of at least 6-8mm of lateral crus will help prevent alar collapse and help stabilize the nasal base as well as allow for a strong natural-appearing tip.VDD allows for narrowing, rotation, and change in tip projection by repositioning rather than excision of any sizable amount of cartilage.

The Effectiveness of modified VDD Technique in reducing nasal tip projection in rhinoplasty

B.Gandomi, M.H. Arzaghi, M. Rafatbakhsh

The employed technique is a new modification of previous techniques. 3-10 The technique employs an open approach in which a strong columellar strut inserted and a portion of crura is removed near the dome (the cornerstone of our new technique of tip surgery). Depending on the deformity, this segment may involve intermediate, middle or lateral crura with or without removal of vestibular skin considering its thickness: thin skins are not resected, but thick skins are usually removed.

Our technique involves the overlapping of the incised edges of the medial and lateral segments, and suture approximation to restore the integrity of the alar cartilage. The technique allows a more stable configuration for the maintenance of nasal tip support. The overlapping and reapproximation of the medial and lateral units ensure the long-term stability of the newly reconstructed nasal tip complex, and reduce the tendency towards postoperative cartilaginous abnormalities that may accompany scar fibrosis and contracture. 

 http://ijms.sums.ac.ir/files/PDFfiles/07-Dr.%20Gandomi.pdf

Nasal tip complications and optional operative fixes

Complications in Rhinoplasty-Daniel G. Becker.  Ch.49 facial plastic and reconstructive surgery by Ira D. Papel

In the nasal tip;  

Over-reduction may violate critical tip support mechanisms (Table 49.1) which can lead to complications including tip ptosis and inadequate tip projection. Alternatively, overresection of the caudal septum can result in overrotation of the nasal tip with excessive shortening of the nose. Overresection may also contribute to other complication such as bossae, alar retraction, and alar collapse (external nasal valve collapse).

Under-reduction may be simply due to overcaution but is commonly due to a failure to correctly assess preoperatively the anatomical situation. For example, failure to recognize an overprojected nose, or to diagnose the steps required based on the patient's anatomy to adequately address this, can lead to a persistent overprojected state. Failure to adequately resect cartilaginous dorsum may result in a pollybeak deformity.

Asymmetries of the nasal tip may be due to unequal reduction of the lower lateral cartilages or to asymmetric application of dome-binding sutures. It may also be caused by unequal scarring that can occur during the natural healing process and may not be evident for months or even years after surgery. Also, assymmetry is often present preoperatively and should be recognized and pointed out to the patient prior to surgery.

Table 49.1 Tip-Support Mechanisms

Major tip-support mechanisms
1. Size, shape, and strength of lower lateral cartilages
2. Medial crural attachment to caudal septum
3. Attachment of caudal border of upper lateral cartilages to cephalic border of lower lateral cartilages
[the nasal septum is also considered a major support mechanism of the nose]

Minor tip-support mechanisms
1.Ligamentous sling spanning the domes of the lower lateral cartilages (i.e. interdomal ligament)
2.Cartilaginous dorsal septum
3.Sesamoid complex of lower lateral cartilages
4.Attachment of lower lateral cartilages to overlying skin-soft tissue envelope
5. Nasal spine
6. Membranous septum

Specific Complications:

Ptotic tip-loss of tip support may lead to a droopy tip (tip ptosis with an overly acute nasolabial angle (angle defined by columellar point to subnasale line intercepting with subnasale to labrale superious line) is 90 to 120 degrees.Within this range, a more obtuse angle is more favorable in females, a more acute angle in males. Loss of tip support can lead to a ptotic, underprojected drooping nose. Treatment of complications relating to a ptotic nose rely on restoration of tip support and tip projection.

Overrotated Tip-Conversely, one may face a patient with a nose that has been overrotated, with an overly obtuse angle. Overresection of the caudal septum is a common cause of overrotation of the tip. Overrotation of the nose creates an unsightly, overshortened appearance. Treatment rely on maneuvers that lengthen and counterrotate the nose.

Bossae- a bossae is a knuckling of the lower lateral cartilage at the nasal tip due to contractural healing forces acting on weakened cartilages. Patients with thin skin, strong cartilages, and nasal tip bifidity are especially at risk. Excessive resection of lateral crus and failure to eliminate excessive interdomal width may play some role in bossae formation. As an isolated deformity, bossae are typically treated through a small marginal incision with minimal undermining over the offending site followed by trimming or excising the offending cartilage. In some cases, the area is covered with a thin wafer of cartilage, fascia, or other material to further smooth and mask the area.

Alar retraction

Cephalic resection of the lateral crus of the lower lateral cartilages is commonly undertaken to effect refinement of the nasal tip. If inadequate cartilage is left, then the contractile forces of healing over time will cause the ala to retract. This is commonly seen squelae of overresection of the lateral crus. The surgical rule of thumb is to preserve at least 6 to 9mm of complete strip. From a study 20 percent of patients had a thin alar rim. These patients may require even more conservative approaches to avoid the risk of alar retraction and/or external nasal valve collapse. Also vestibular mucosa should be preserved, as excision of vestibular muscosa contributes to scar contracture with alar retraction. Alar retraction may be treated by cartilage grafts in more minor cases (1-2 mm). Auricular composite grafts are commonly used in more severe cases.

Alar-Columellar Disproportions (protruding or hanging columella)

The range of normal columellar show is generally considered to be 2 to 4 mm. The surgeon should avoid excessive resection of the caudal septum and should avoid resection of the nasal spine. Treatment of a protruding or hanging columella may include resecting full thickness tissue from the membranous columella, including skin, soft tissue, and perhaps a portion of the caudal end of the septum itself. If the medial crura is excessively wide, excision may include a conservative excision of the caudal margin of the medial crura. Retracted columella may be improved with plumping grafts inserted at the base of the columella to address an acute nasolabial angle; columellar struts may also be helpful for minor deformities. A cartilage graft may be used to lengthen the overshortened nose. The use of composite grafts have also been described.

Pollybeak- A pollybeak refers to postoperative fullness of the supratip region, with an abnormal tip-supratip relationship This may have several causes, including failure to maintain adequate tip support (postoperative loss of tip projection), inadequate cartilaginous hump (anterior septal angle) removal, and/or supratip dead space/scar formation. Management of the pollybeak deformity depends on the anatomical cause. If the cartilaginous hump was underre­sected, then the surgeon should resect additional dorsal sep­tum. Adequate tip support must be ensured; maneuvers such as placement of a columellar strut may be of benefit. If the bony hump was overresected, a graft to augment the bony dorsum may be beneficial. If pollybeak is the result of exces­sive scar formation, Kenalog injection or skin taping in the early postoperative period should be undertaken prior to any consideration of surgical revision.

Operative Maneuvers:

 Increase Rotation: Lateral crural steal, Transdomal suture that recruits lateral crura medially, Base-up resection of caudal septum (variable effect), Cephalic resection (variable effect), Lateral crural overlay, Columellar struct(variable effect), Plumping grafts (variable effect) Illusions of rotation: increase double break, plumping grafts (blunting nasolabial angle)

Decrease Rotation (Counter-rotate) Full -transfixion incision, Double-layer tip graft, Shorten medial crura, Caudal extension graft, Reconstruct L strut as in rib graft reconstruction (integrated dorsal graft/columellar strut) of saddle nose.

Increase Projection: Lateral crural steal (increased projection, increased rotation), Tip graft, Plumping grafts, Premaxillary graft, Septocolumellar sutures (buried) Columellar strut (variable effect), Caudal extension graft,

Decrease Projection: High-partial or full transfixion- incision, Lateral crural overlay (decreased projection, increased rotation), Nasal spine reduction, Vertical dome division with excision of excess medial crura with suture reattachment

Increase Length: Caudal extension graft, Radix graft, Double-layer tip graft, reconstruct L strut

Decrease Length: See "increase Rotation, Deepen nasofrontal angle

Secondary External Rhinoplasty
David W.Kim, Benjamin A. Bassichis, and Dean M. Toriumi,  Chapter 31; Revision Surgery in Otolaryngology. By David R. Edelstein.

Persistently Wide or Bulbous Tip

A persistently wide tip after primary rhinoplasty may be due to the failure of the surgeon to account for a thick, inelastic SSTE (soft-skin tissue envelope) when modifying the dome region. In these patients, performing dome-binding sutures alone may improve the shape of the alar cartilages themselves, but this change will not necessarily  transmit through the thick SSTE. Failure to project the tip into the skin envelope and effectively stretch it to conform to the underlying tip shape will lead to this problem. Study of the overall projection and rotation of the tip, the nasolabial angle, and nasal length should be performed to determine how best to project the tip and restore optimal tip shape. A shield-shaped tip graft may be sutured to the intermediate and medial crura to provide the desired augmentation to the infratip lobule and tip. Although the nasal base remains unchanged, the leading edge of the shield graft may project the domes by as much as 8mm. A buttress or cap graft may be placed cephalad to the leading edge of the graft to support the graft and camouflage the transition to the supratip. Lateral crural grafts are placed on the existing lateral edge of the shield graft when the tip graft projects > 3mm above the existing domes. These also provide additional support and camouflage to the shield graft. Lateral crural grafts also bolster lateral alar support in cases in which the native lateral crura have been weakened or removed.

  Another common error of omission leading to a persistently wide tip is the failure to straighten convex lateral crura. Domal narrowing will not result in a defined triangular tip appearance if the lateral walls of the triangle are curving outward. Unless the curvature is straightened with suture technique or lateral crural struts, persistent tip width will be present. These problems may be detected through the study of the base view of the nose. If lateral crural struts will be needed, strong segments of cartilage are required to overcome the curvature of the existing alar cartilage. These grafts are placed between the undersurface of the lateral crura and the vestibular skin that should be carefully elevated. The caudal attachment of the lateral crus and skin should remain intact to prevent caudal migration of the graft. The graft should extend from just lateral to the domes to the lateral aspect of the lateral crura. The lateral crural strut graft may be stabilized with a full thickness chromic suture, but it should be finally secured to the lower lateral crura with a 5-0 clear nylon suture.


Nasal Tip Management Utilizing the Open Approach. Russell W.H. Kridel and Peyman Soliemanzadeh  Ch.69 Rhinology and facial plastic surgery by Fred J. Stucker
Prior to contouring the nasal tip, the surgeon must stabilize the base of the nose. If tip support is found to be lacking, a sutured in place columellar strut can effectively stabilize the base. This graft is placed into a pocket dissected between the medial crura. When it is necessary to alter tip projection, the alar columellar relationship, and the nasolabial angle the Tongue-in-groove technique can be utilized to stabilize the base. Specifically, if the patient has a hanging columella and prominent caudal septum that would otherwise require trimming, the surgeon can set the medial crura back on the midline caudal septum. Bilateral membranous septum excision is almost always necessary to remove excess tissue which results from the TIG technique. The TIG can also be varied in order to enhance rotation and or to increase projection.

 Tip deprojection can be accomplished by removing an equal amount of lateral crura and medial crura in a technique called dome truncation (DT). 

 http://archfaci.ama-assn.org/content/7/6/374.full

 http://www.drphilipmiller.com/Assets/Structuralapproach.pdf 

The Nose Tip: Dimensional Analysis 101

Advanced Therapy in Facial Plastics and Reconstructive Surgery  By: Dr. Regan Thomas

Tip Support Mechanisms
 Nasal tip shape is largely determined by the shape and integrity of the LLC (lower lateral cartilage). The tip surface is divided into the dome, alae, soft triangles, and columella. The major tip support mechanisms include the size, shape and integrity of the LLC, the attachment of the medial crus to the septal cartilage, and the attachment of the LLC to the ULC (upper lateral cartilage).  The minor support mechanisms are the interdomal ligament, dorsal portion of anterior septal angle, sesamoid cartilages, the LLC attachment to skin/soft tissue, and the nasal spine.

 http://www.lamfacialplastics.com/resources/learning-modules/rhinoplasty-tutorial/

Nasal Profile Projection   Minas Constantinides M.D. and Michael Carron M.D.
Unlike nasal length, which is relatively difficult to change, nasal projection can be changed easily. Because of this ease, however, changes are often overdone. Secondary corrections of overdone projection changes are among the biggest challenges faced in revision rhinoplasty.  Projection of the tip is the actual measured distance from the alar-facial plane to the tip. A change in nasal projection requires either an increase or decrease in the distance the nasal tip extends from the vertical facial plane. The Goode method and the 3:4:5 triangle are the two most common ways of measuring projection. [See Fig.23-4, Fig 23-5]

Although nasal tip rotation is not purely a profile adjustment, it is most easily scrutinized from the profile view. Simons describes rotation of the nasal tip as an arc with the radius maintained. [See fig.23-6  Male b/a]  As the tip is rotated, there is some illusion of increased projection although none exists. Tip rotation is defined as the tip angle from the vertical alar crease to the tip. In women, this angle is approximately 105 degrees and in men 100 degrees. The degree of rotation may be affected by the intrinsic properties of the nasal tip (lower lateral cartilages) or external properties (caudal septum).

Nasolabial angle and columella. The nasolabial angle is the angle formed between the columella and upper lip. Ideally, the naslabial angle is 90 to 95 degrees, in men and 95 to 105 in women. [see fig.23-7]

The Nasal Tip as it relates to Profile - Changes in Length, Projection and Rotation

 The position of the nasal tip determines the caudal endpoint of the nose, establishing with the radix nasal length. Changing the projection and rotation of the tip directly affects nasal length. 
 Anderson's tripod principle is most helpful not only in evaluating each tip's unique position but also in guiding what changes will affect tip positon postoperatively. Every step in tip-plasty will somehow affect nasal length, projection, and rotation.  Instead of directly altering the cartilages of the lobule, other more indirect methods to affect relative alar cartilage position include lateral crural overlay or medial crural feet division. These techniques leave the dome area unaffected, whereas affecting the tripod laterally (lateral crural hinge areas) or medially at the feet of the medial crura. A combination of these techniques can create fine changes to tip rotation and nasal length, whereas always decreasing tip projection.

 If the surgical goal is to increase tip projection, then either lateral or medial alar cartilages must be recruited into the lobule area, or onlay cartilage grafts must be added. Lateral or medial crural steal techniques, stabilized by cartilage struts or septal extension grafts, achieve small increases in tip projection. Tip grafts can add substantially more projection, if needed.

Alar Retraction/Hanging
Many expert surgeons now routinely implant small rim grafts at the conclusion of most of their rhinoplasty's to stiffen the alar rim and counteract any tendency for retraction. Occasionally, significant retraction in the revision case will require composite skin-cartilage grafts from the ear to fill the tissue void and scar contracture, especially when it involves the soft tissue triangle. In cases of Hanging ala, rotation changes of the lobule will always improve this subtle deformity.   

Nasolabial Angle

The junction of the columella and lip creates the nasolabial angle; changing its anatomic components can subtlety improve the final rhinoplasty result, uncovering the lip and improving the smile.

Caudal Septum/Spine -{Improve your smile}
The inferior caudal septum and nasal spine comprise the rigid framework for the top of the upper lip. Typically, prominence in this region will increase the nasolabial angle and, of greater esthetic consequence, make the upper lip look pulled up by the nose. Deepening the nasolabial angle by removing inferior cartilage or bone will improve this appearance but may also increase the apparent length of the upper lip. If the nasal depressor muscles are widely detached during this maneuver, the upper lip may also drop, hiding the upper teeth more during smiling. In cases where the smile is already too "gummy" with too much gingival show, this can be a significant  improvement. However, if the upper teeth are already slightly hidden with the preoperative smile, then any muscle detachment should be avoided in this area.

Too acute a nasolabial angle may arise from a deficient premaxilla or too aggressive caudal septal shortening. A premaxillary onlay cartilage graft will help to fill this deficit. Typically, temporary suture fixation of this free graft to the overlying lip helps to keep it in place during the early recovery period.

Columella

 Columellar position is the second component of the nasolabial angle. It may be hanging or hidden.

  Hanging.  A hanging columella is typically seen in two scenarios: either the caudal septum is long, as in a tension nose, or the septocolumellar attachements have been weakened by previous full transfixion rhinoplasty. When the septum is long, shortening it must be accompanied by elevating and reinforcing the medial crura, typically with a strut or tongue-in-groove technique. If the hanging is severe, then a small fusiform excision of membranous columella may also be required. If the septum has been shortened, and the medial crura left unsupported by previous surgery, then re-support with a strut and/or septal extension graft, often with membranous columella excision, will be required.

  Hidden  A hidden columella is typically a postoperative problem, often from over-shortening of the caudal septum or too aggressive a tongue-in-groove technique. A plumping graft that is placed caudal to the medial crura will help to avoid this problem. If unrecognized during an open rhinoplasty, the unsupported open scar will contract during healing, leaving a deficit that will be difficult to correct post-operatively.