Dome-Splitting Technique in Rhinoplasty With Overlay of Lateral Crura

Abstract

\s=b\While the majority of nasal tips respond to the more conventional and conservative surgical approaches, there are those patients who require a more radical approach. The prerequisites for the ideal nasal tip are outlined. The indications for the proposed technique are enumerated and the dome-splitting overlapping technique is described. The advantages and disadvantages are discussed and photographic results are presented. (Arch Otolaryngol 1983;109:586-592) The ideal nasal tip has a basically triangular basal shape, has rea¬ sonable definition, projects harmoni¬ ously with the other facial features, and has a normal relationship of the alar margin to the columella. The surgical dream is a tip that has these basic characteristics but perhaps has a minimal amount of lateral cephalic fullness that can be modified using simple surgical techniques. Often we are faced with more difficult tips with extremes of projection, trapezoid con¬ figuration, bulbous amorphous shape, or laterally displaced domes, and (Dr Brennan). extremes in tip columellar relation¬ ships. These difficult nasal tips seem to respond best to a dome-splitting overlapping technique that is de¬ scribed herein. INDICATIONSThere are basically four indications for the dome-splitting technique of tip surgery. These are (1) excess projec¬ tion, (2) a bulbous amorphous tip, (3) lack of projection in conjunction with a trapezoid basal configuration, and (4) an extreme in tip columellar rela¬ tionship. A prerequisite for this tech¬ nique is nasal skin that is easy to mold and that will conform to the more radical approach to nasal surgery. REVIEW OF LITERATUREMany varied approaches to the dif¬ ficult nasal tip have been described. Approaches that are similar to the dome-splitting technique are those that have been described by Goldman1 in which the tip cartilage is tran¬ sected lateral to the dome and advanced medially, the technique described by Lipsett2 in which the tip cartilage is transected medial to the dome, and the technique described by Safian3 and others in which the tip cartilage is transected at the dome. BASIC TECHNIQUEA complete transfixion incision is performed in the conventional manner. The nasal dorsum is skeletonized.A marginal incision is made at the caudal border of the tip cartilate (Fig 1), the tip cartilage is freed and deliv¬ ered in the conventional manner. The ideal projecting point of the lower cartilage is identified (Fig 2) and the tip cartilage is transected, preserving the high point. The lateral crural flap is then delivered (Fig 3). The cartilage of the crural flap is then sculptured to suit the needs of the particular patient. Sculpturing ordinarily is per¬ formed by resecting cephalically but can also include developing a caudal facet by resecting an ellipse of carti¬ lage from the caudal-most border (Fig 4). The vestibular skin of the medial end of the crural flap is then under¬ mined for a distance of a few millime¬ ters (Fig 5). The flaps are checked for symmetry. The crural flap is then repositioned and the me...

Topic Collection

“…When excising the dome, one must take care to include enough of the lateral crura so as not to allow the lateral crural ends to override the medial crural ends. Although the overlap of lateral crura over medial crura was advocated by Brennan, 21 we believe that such a technique may also lead to bossae formation. The use of crushed cartilage placed in the infratip lobule region has been a mainstay when performing a vertical dome division maneuver such as the hockey-stick approach.…”

Tip Plasty: A New Modified Vertical Dome Division. “How I Do It?”

“…Brennan 9 in 1983 also published a dome-splitting technique. He transected the cartilage (with vestibular skin) lateral or medial to the dome depending on the tip projection desired, with undermining of vestibular skin for few millimeters then overlapping the LC on the MC without suturing the cartilage cut ends.…”

A Multivariate Analysis of Nasal Tip Deprojection

“…9 Safian 10 suggested domal excision, and others have modified his technique. 7,11,12 Deprojection by scoring and weakening the nasal dome has also been described 13 and refined. 6,14,15 Finally, division of both the lateral and medial crura has been described, ranging from Fredrick's' full-thickness excision of the columella and alar bases, to the more limited approaches that divide and set back cartilage as described by Rees 16 and Foda.…”