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A 20-Year Review of the "New Domes" Technique for Refining the Drooping Nasal Tip
Fernando Pedroza, MD
Arch Facial Plast Surg. 2002;4:157-163.
ABSTRACT
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Objective To describe in detail a technique to achieve cephalic rotation, projection,
and narrowing of the nasal tip, the "new domes" technique.
Design Retrospective analysis of more than 3000 primary rhinoplasties performed
during the last 20 years.
Setting A private facial plastic surgery practice in Bogotá, Colombia.
Intervention Through an endonasal cartilage delivery approach to the nasal tip, we
mold and reorient the alar cartilages with transdomal and interdomal sutures.
Main Outcome Measures Photographic analysis with nasal and facial measurements taken directly
from the patient that allows precise diagnosis and preoperative surgical planning.
Results The new domes technique creates a more projected, cephalically rotated,
narrowed nasal tip. The results are predictable and stable over time, and
patient satisfaction is high because of the natural-appearing results. Complications
such as asymmetries, pinching, or retraction of the tip are rare.
Conclusion The new domes technique is a conservative, predictable, and stable technique
especially applicable for patients with drooped and wide nasal tips to achieve
a more projected, rotated, narrowed, and natural appearance.
INTRODUCTION
NASAL TIP surgery is considered the most interesting and difficult part
of rhinoplasty. It obliges the surgeon to perform a detailed presurgical analysis
of each patient, analyzing ethnic characteristics, skin thickness, cartilage
strength, and nasal tip shape and position. This analysis helps the surgeon
determine the patient's nasal anatomy and the precise changes that should
be performed surgically. The goal is to obtain a natural-looking result that
is proportional to the patient's face and aesthetically attractive as well
as stable and durable over time.
In this article, I describe the primary rhinoplasty patient with a drooping
nasal tip and normal skin thickness and alar cartilage. For this patient,
the nasal tip must be cephalically rotated, projected, and narrowed for aesthetic
improvement. I describe the postcartilaginous and precartilaginous (marginal)
incisions that allow endonasal access for a cartilage delivery approach, and
a conservative, predictable, and stable technique—the "new domes" technique,
which places these new domes in a position more lateral to the patient's own
domes. We suture the domes together, thus forming an aesthetic triangle that
results in a natural-looking nasal tip. This technique is generally complemented
with the resection of the vestibular skin of the membranous septum, the resection
of the caudal septum and, if necessary, the placement of a columellar strut
and columellar-septal fixation suture to secure the results. We believe that
this technique avoids the less predictable healing consequences of the vertical
dome division techniques.
REDISTRIBUTION OF LOWER LATERAL CARTILAGE
The medial and lateral crura, with the domes being the most projecting
part of the lateral crura, constitute the tip cartilages. The shape, position,
and strength of these cartilages, as well as skin thickness, determine the
appearance of the nasal tip. While shape is influenced by cartilage dimensions,
strength, and orientation, the position is influenced by dome location, crural
length, and the adjacent structures. In 1960, Fomon1
described the use of interdomal and transdomal sutures for narrowing and projecting
the nasal tip. To change the position of the nasal tip and obtain cephalic
rotation of the tip, we can change the position of the domes and the length
of the lateral and medial crura through direct techniques on the cartilage
and/or the modification of adjacent structures (ie, by using indirect techniques
to change the position of the nasal tip). To further explain the dynamics
of these direct techniques, Anderson2 proposed
a very useful concept of a structural tripod. The cartilaginous structure
of the nasal tip is considered a tripod in which 2 limbs are the lateral crura,
the third limb is the 2 conjoined medial crura, and the apex of the tripod,
the nasal domes.
In a drooped nasal tip, considering the lower lateral cartilage, the
domes are drooped (ie, counter-rotated and underprojected) owing to long lateral
crura and short medial crura. In other words, the distribution of the lower
lateral cartilage corresponds to a longer lateral crus and a shorter medial
crus than desired. What we do with the new domes technique is redistribute
the lower lateral cartilage by moving the dome position to a more lateral
location, which creates a shorter lateral crus and a longer medial crus.
In our technique we create new domes by placing transfixion sutures
3 mm or more lateral to the position of the patient's own domes such that
the lateral crura are shortened and the medial crura are lengthened. This
increases nasal tip projection and rotation, resolving the problem of the
droopy tip. Relating this to the tripod concept, the longer lateral limbs
are shortened and the shorter central limbs are lengthened, changing the position
of their apex as described.
This conservational technique, which I first reported in 1985,3 provides the desired aesthetic result while maintaining
cartilage continuity, integrity, and support. It avoids using the vertical
cartilage division, such as the lateral crural flap, which can cause alar
pinching and inspiratory alar collapse, especially in patients with very thin
skin.
PREOPERATIVE ANALYSIS
The clinical history, findings from nasal and facial examinations, and
a preliminary analysis of the options for nasal and facial aesthetic improvement
with frontal and profile views are done during the patient's first office
visit. Computer imaging helps the patient appreciate the nose he or she wishes
to have. The preoperative aesthetic analysis at the second visit is crucial
to the success of the rhinoplasty. In addition, appropriate laboratory investigations,
medical assessment, sinus radiography, computer imaging, and photographic
analysis are performed.
The patient's goals are determined and facial proportions analyzed so
that realistic results can be discussed and agreed on. These are traced on
the profile photograph for the patient's approval (Figure 1). This pictorial appreciation of the expected results is
of great psychological benefit for patients in accepting their new postoperative
appearance.
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Figure 1. Presurgical aesthetic study. Right
profile photograph analysis with patient measures and surgical planning marks
on the tracing paper.
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SURGICAL PROCEDURE
The new domes technique for nasal tip rotation, projection, and narrowing
consists of the following 5 steps: (1) marking the new domes; (2) making the
necessary postcartilaginous and precartilaginous (marginal) incisions; (3)
obtaining endonasal access with the delivery approach; (4) creating and fixing
the new domes; and (5) performing any necessary complementary techniques.
A detailed description of these steps follows.
Marking the New Domes
Using violet dye, we draw 2 dots on the nasal skin to demarcate the
location of the patient's own domes (Figure
2A) and vertical lines to identify the level of the new domes (Figure 2C). To aid in defining the level
of the new domes, we press on the inferior nasal tip with the index finger,
rotating it cephalically to the desired position. This action causes the lower
lateral cartilage to redistribute itself, and through the skin it is possible
to see the new dome, located more lateral to the patient's own dome, which
corresponds to the apex of the new arch formed by the cartilage as the index
finger presses down on it (Figure 2B). In addition, the edges of the lower lateral cartilages are outlined with violet
dye also to show the techniques to be performed on them as described by Webster
et al.4 This includes the cephalic cartilage
resection, which generally accompanies the use of the new domes technique,
hump removal, osteotomies, and any other desired procedures (Figure 2D and E).
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Figure 2. Intrasurgical marking of the rhinoplasty
planning. A, The patient's own domes (2 dots); B, pressing on the nasal tip
with the thumb or index finger and rotating it cephalically to the desired
position; and C and D, marking completed.
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Incisions
The postcartilaginous incision, described in
1978,5 is made at the cephalic border of the
lower lateral cartilage as follows: It is begun 3 mm from the valvular edge
at the posterior aspect of the lower lateral cartilage and is continued anteriorly
until reaching the cephalic border of the medial crus. An incision is then
made at the cephalic margin of the medial crus and is connected, from the
posteriorly to anteriorly, to the first incision at a right angle in the apex
of the vestibular vault (Figure 3A).
The tissue is dissected through the incision, and the flap is held toward
the lateral part using mosquito forceps, thereby providing ample access for
the septal and the nasal dorsum surgery.
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Figure 3. Incisions for the nasal tip surgery.
A, The postcartilaginous incision; B, the precartilaginous or marginal incision;
and C, illustration of the 2 incisions. (Copyright 2002 Cassio Lynm.)
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The precartilaginous (marginal) incision1-2,4, 6-10
is made at the caudal border of the lower lateral cartilage (Figure 3B) and is performed as follows: The double hook is placed
at the edge of the naris while putting pressure with the finger on the alar
cartilage, thereby everting and visualizing the vestibular skin. The caudal
border of the lower lateral cartilage is identified and an incision made in
the skin. The incision is made posteriorly to anteriorly following along the
lateral crus, and then anteriorly along the caudal medial crus.
Cartilage Delivery
By visualizing the marginal incision with the help of the 10-mm double
hook and external pressure with the middle finger over the alar cartilage
and using sharp curved iris scissors, the caudal border of the cartilage is
dissected. One should dissect superiorly as close as possible to the cartilage
of the lateral crus, preserving the fat and subcutaneous tissues adjoined
to the nasal skin. Dissection is continued above the domes and the caudal
edge of the medial crura. We dissect between the domes and the medial crura
until the cartilage is well released between the precartilaginous (marginal)
and postcartilaginous incisions, leaving only the distal ends of the lateral
and medial crura undissected. This creates a bipedicled chondrocutaneous alar
flap because the tip cartilages are almost totally released; only their feet
remain connected to the underlying tissues. The vestibular skin remains connected
to the cartilage. Using a single hook in the vestibular vault, the cartilage
is pulled outside of the nasal cavity, providing a direct view of the cartilage
and allowing application of the techniques for redistribution of the lower
lateral cartilage (Figure 4).
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Figure 4. The dome is delivered with a hook.
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The New Domes
The area for the new domes was initially marked out using violet dye
by drawing vertical lines on the skin of the nasal tip. By placing the single
hook at the corresponding level in the vestibular vault, the cartilages are
delivered and we are able to observe and corroborate the place to locate the
new dome, usually several millimeters lateral to the patient's own dome.
Cephalic Resection of the Alar Cartilage
Several authors have described this procedure.1-2,4, 6-10
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 5 mm width at this new dome
level. The vestibular skin is not excised. 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 5A). This conservative
procedure preserves sufficient cartilage to ensure tip support and avoids
late postoperative complications such as bossae.
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Figure 5. The new domes technique. A, Mediocephalic
excision of the lower lateral cartilage; B, the transdomal sutures creating
new domes more lateral, projected, and narrowed; C, the interdomal sutures
achieve the aesthetic triangle. (Copyright 2002 Cassio Lynm.)
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Transdomal Sutures
With the cephalic cartilage resection completed, we measure the distance
between the new dome and the patient's own dome, which corresponds to the
amount of lateralization required. Using polyglactin 5-0 suture (Vicryl; Ethicon,
Somerville, NJ), we place a double transfixion suture 2 or 3 mm from the level
of the new dome (Figure 5B). From
the medial toward the lateral face, we pass the needle through the new dome,
returning to the same level but with a 2- or 3-mm separation from the lateral
to the medial side, knotting and taking another suture, to make it double.
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 maintains the natural arch of the cartilage at the level
of the new dome. We perform this procedure with the right alar cartilage first
and then the left.
The cartilages are replaced from both sides into the nasal cavities
at their original positions to check the results obtained. Specifically, the
new position of the nasal tip and its degree of rotation, shape, and symmetry
are assessed. If the new domes are not located at the same level, one of them
must be corrected. The initial transfixion suture is removed and relocated.
This correction is performed as many times as necessary until the new domes
are symmetrical and in the desired position. An additional transfixion suture
of polypropylene 6-0 (Prolene; Ethicon) ensures the stability of the new domes.
We next insert the cartilage strut, obtained from the patient's nasal
septum, between the medial crura, fixing it with polyglactin sutures at the
caudal edges of the medial crura. This complementary technique, which is meant
to strengthen the medial crura to support the nasal tip, is described later
in greater detail.
Interdomal Sutures
With the cartilage delivery approach for cartilage release, the dissection
between the domes and the medial crura interrupts the ligaments between them.
These supports must be reconstructed using sutures between the domes and the
medial crura to secure their structural integrity and overall tip symmetry.
We use polyglactin 5-0 sutures, beginning with a suture between the cephalic
edges of the medial crura 2 mm from the domes, followed by a suture between
the caudal edges of those crura 6 or 8 mm from the domes (Figure 5C). These interdomal sutures I described in 1981.11 In this way, we reconstruct the cartilage in its
ideal anatomic position and create a triangle formed by the caudal edges of
the new domes separated from each other by 6 or 8 mm, and the caudal edges
of the medial crura are connected to each other 6 or 8 mm below the new domes.
This is how the aesthetic triangle described by Sheen10
is achieved, and it provides the corresponding external highlights that give
the tip a natural appearance.
We replace the cartilage into the nasal vestibule and reconfirm the
position and symmetry of the nasal tip. The marginal incision is closed with
polyglactin 5-0 sutures. The nasal tip is now cephalically rotated, more projected,
and narrowed.
Complementary Techniques
Based on the new position of the nasal tip and the columella, we analyze
the caudal septum and the membranous septum for redundancy. If redundancy
is present, resection is performed to secure the new nasal tip position and
the proper degree of columellar show (4 mm). To provide greater strength to
the medial crura and nasal tip, we place a cartilaginous strut between the
medial crura. We also place columellar-septal fixation sutures to at least
maintain, or possibly increase, nasal tip projection.
Caudal Septum Shortening1-2
Pushing the columella upwards into the desired position with a finger,
we observe whether the caudal septum is long. If so, we resect the excess
caudal septum so that it has an anatomically normal curvature (Figure 6A). The ideal amount of columellar show is usually about
4 mm from the alar margin to the inferior columella.
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Figure 6. The complementary techniques.
A, Caudal septum shortening; B, vestibular skin reduction; C, columellar strut
placement and fixation; and D, columellar-septal fixation. Note the tip projection
achieved. (Copyright 2002 Cassio Lynm.)
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Vestibular Skin Reduction1
Pushing the columella into the desired position with a finger replaces
the vestibular skin to its original position, and we can observe the amount
of excess skin. This is excised in a triangular shape, usually 2 or 3 mm,
or wider for very long drooped noses (Figure
6B).
Columellar Strut Placement and Fixation
The importance of the cartilaginous strut for tip support was described
by Fomon1 and emphasized by Anderson.2 We use an autologous graft from septal cartilage about
2 mm thick, 4 mm wide, and 15 to 20 mm long. It is molded with an anterior
convex curvature and is inserted as follows: Dissection is performed through
the precartilaginous (marginal) incision of the columella to form a tunnel
between the medial crura without separating them at their posterior edges.
The cartilage strut is placed inside the tunnel so that its distal end does
not extend beyond the distal medial crura, and the convex edge of the strut
is placed at the same level as the anterior edges of the medial crura. The
anterior end of the cartilage strut is located 6 or 8 mm from the domes. It
is fixed with polyglactin 5-0 sutures between the medial crura (Figure 6C). The length and strength of the medial crura dictate
the length and width of the columellar strut—the weaker the medial crura
are, the larger and stronger the columellar strut should be.
Columellar-Septal Fixation
This suture was described by Fomon1 and
Berman.7 Our technique is as follows: With
polypropylene 5-0, we place 2 sutures (Figure
6D). The first is placed at the posterior end of the medial crura.
The suture is begun through the skin from the right side superiorly to inferiorly,
and from inside to outside. The needle is reintroduced through the same point
of exit and transfixes the skin from right to left, passing through the right
skin, right crus, columellar strut, the left crus, and the left skin so that
it comes out at the same level as its entry. Once again, the suture is placed
through the same point of exit, passing through the left skin from outside
to inside and from inferiorly to superiorly, with the knot being made behind
the columella.
The second suture is placed at the middle of the columella in the same
manner and, after knotting it without cutting, the suture is passed through
the caudal septal edge 3 mm or more anteriorly, where it is knotted so that
the columella slides anteriorly over the caudal septum. This increases projection
and fixation of the medial crura and the nasal tip, as desired. It is important
to bear in mind that nasal tip projection decreases postoperatively by 2 or
3 mm as edema resolves. Therefore, the intrasurgical position of the nasal
tip must be projected 2 or 3 mm more than the planned position for the nasal
tip.
RESULTS
We have used the new domes technique on more than 3000 patients over
20 years and found it a reliable method to precisely achieve increased projection
and cephalic rotation of the nasal tip (Figure
7). Our results have been predictable and stable over this long
follow-up period. Patient satisfaction has been almost 100% in terms of nasal
tip placement and in maintaining a natural appearance. We believe this is
due to our ability to precisely set the tip position and to maintain its stability
by maintaining crural continuity.
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Figure 7. A, C, E, and G, Preoperative photographs
of a 18-year-old woman with wide and drooped nose tip. B, D, F, and H, Postoperative
views after the new domes technique for the nasal tip, caudal septum, and
vestibular skin reduction and columellar strut and columellar-septal fixation.
The patient has also had hump removal and alar reduction.
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The symmetrical and exact positioning of the new domes is of prime importance
to achieve the exact cephalic rotation desired and to avoid deviation or asymmetry
of the nasal tip. If we are not satisfied after using the technique, we replace
the transdomal and interdomal sutures until we are fully satisfied. It is
important to maintain a calm demeanor since this surgical procedure is not
simple, and it is preferable to obtain the necessary corrections during the
initial surgery rather than be faced with revision surgery.
It is also crucial to analyze each patient accurately to determine the
need for the complementary techniques that stabilize the surgical results.
Resection of the caudal septum and vestibular skin may be necessary to improve
a hanging columella. A columellar strut can improve the strength and length
of the patient's medial crura, and the columellar-septal fixation sutures
can help to sustain or increase nasal tip projection.
We keep in mind that the intrasurgical estimate of nasal tip projection
should be about 2 or 3 mm greater than the final planned projection, since
tip projection diminishes postoperatively by approximately that amount. Through
our postcartilaginous incision, we have not seen any valvular disturbance
or any obstructive scarring at the nasal valve level. Using the new domes
technique, we have not found any alar retraction or pinching, nor has there
been alar inspiratory collapse because we preserve the continuity and resistance
of the alar cartilage.
In conclusion, drooped nasal tips pose a challenge to the surgeon, requiring
accurate preoperative analysis and precise surgical techniques to achieve
nasal tip positioning in the desired and appropriate position for each patient's
face. The new domes technique allows us to obtain a nasal tip that is more
projected, cephalically rotated, and narrowed through the use of a suture
technique that preserves the integrity and continuity of the lower lateral
cartilage. This creates a tip that is natural in appearance with no risk of
cartilage pinching or retraction, the telltale signs of aesthetically undesirable
adverse effects of surgery.
AUTHOR INFORMATION
Accepted for publication June 11, 2002.
This procedural description was presented at the Third World Congress
of the International Society of Aesthetic Surgery, Tokyo, Japan, April 10,
2000; the Seventh Rhinoplasty and Facial Plastic Surgery Course, Barcelona,
Spain, May 11, 2000; the 103rd Annual Meeting of the Trilogical Society, Orlando,
Fla, May 15, 2000; the 30th Colombian Otorhinolaryngology–Head and Neck
Surgery Meeting, San Andres, Colombia, June 3, 2000; the First Congress of
the International Federation of Facial Plastic Surgery Societies, Cancun,
Mexico, June 16, 2000; and the First Chilean Rhinology Meeting, San Pedro
de Atacama, Chile, August 26, 2000.
Corresponding author and reprints: Fernando Pedroza, MD, Carrera
16, No. 82-95 Cons 301, Bogotá, DC Colombia (e-mail: fpedroza{at}cable.net.co).
Dr Pedroza is in private practice in Bogotá, Colombia.
REFERENCES
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1. Fomon S. Cosmetic Surgery, Principles and Practice. Philadelphia, Pa: JB Lippincott Co; 1960.
2. Anderson JR. New approach to rhinoplasty. Arch Otolaryngol. 1971;93:284-291.
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3. Pedroza F. Choosing the most suitable surgical technique for the nasal tip. Presented at: the American Academy of Facial Plastic and Reconstructive
Surgery Fall Meeting; September 1985; Atlanta, Ga.
4. Webster RC, Davidson TM, Smith RC. External marking in rhinoplasty planning. Laryngoscope. 1977;87:126-133.
PUBMED
5. Pedroza F. An integrated technique for septal rhinoplasty. Presented at: the 16th Pan-American Otorhinolaryngology Meeting;
May 1978; Acapulco, Mexico.
6. Hinderer KH. Fundamentals of Anatomy and Surgery of the Nose. Phoenix, Ariz: Aesculapius; 1971.
7. Berman WE. Surgery of the nasal tip. Otolaryngol Clin North Am. 1975;8:563-574.
ISI
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8. Bernstein L. A basic technique for surgery of the nasal lobule. Otolaryngol Clin North Am. 1975;8:599-613.
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9. Webster RC. Advances in surgery of the tip. Otolaryngol Clin North Am. 1975;8:615-644.
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10. Sheen JH. Aesthetic Rhinoplasty. St Louis, Mo: Mosby; 1978.
11. Pedroza F. Nasal tip surgery. Presented at: the 21st Colombian Otorhinolaryngology Meeting; October
1981; Pasto, Colombia.
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
A Review of 25-Year Experience of Nasal Septal Perforation Repair
Pedroza et al.
Arch Facial Plast Surg 2007;9:12-18.
ABSTRACT
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Seagull wing graft: a technique for the replacement of lower lateral cartilages.
Pedroza et al.
Arch Facial Plast Surg 2006;8:396-403.
ABSTRACT
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