Concept of Anatomic Columellar Strut Grafting in Rhinoplasty: An Algorithmic Approach — Suleyman Tas PubMed

Letter to the Editor Dr Santareno is a resident, Department of Plastic Surgery, North Lisbon Hospital Centre, Lisbon, Portugal. Dr Taş is a plastic surgeon in private practice in Istanbul, Turkey. Corresponding Author: Dr Sofia Santareno, Hakkı Yeten Cad, No: 11, Terrace Fulya, Center: 1, Apt: 97 Şişli, Istanbul 34349, Turkey. E-mail: sofiasantareno@gmail.com; Twitter: @DraSantareno DOI: 10.1093/asj/sjz272 www.aestheticsurgeryjournal.com Concept of Anatomic Columellar Strut Grafting in Rhinoplasty: An Algorithmic Approach Sofia Santareno, MD; and Süleyman Taş, MD, FEBOPRAS Editorial Decision date: October 1, 2019; online publish-ahead-of-print November 1, 2019. Employing a columellar strut in rhinoplasty is a powerful tool to achieve stability of the tip especially when the nose ligaments are dissected or the medial crus (MC) of the lower lateral cartilages are weak. A columellar strut helps to avoid several complications and provides an extra de- gree of structural integrity on the lower third of the nose.1,2 Topkara,3 Robotti,4 and Rodrich5 recently described some surgical options for a stable strut. The new columellar strut should be suitable for the natural columellar anatomy. We present our approach to this strut, which addresses the important angles to obtain an aesthetically pleasing result. Surgical Anatomy Regarding the lower lateral cartilage stability and tip aes- thetics, there are several angles described to consider (Figure 1): the inter-domal angle α (between the top of the dome, transversal plane), which is 80° to 90° in men and 90° to 100° in women6; the columellar-lobular angle θ (columellar break point, sagittal plane), which is 30° to 45° in women7; and the MC division angle ς, (columellar break point, transversal plane), which has, to our know- ledge, never been highlighted in the literature. We con- sider 3 different options to create an anatomic γ columellar strut graft. Surgical Technique The senior author (S.T.) performed all surgeries included in this study under general anesthesia with an endonasal approach. After infiltration of local anesthetic solution (1/100,000 adrenalin) to the incisions, undermining of the nasal framework in a submembranous fashion was per- formed. The concept of anatomic columellar strut grafting includes 3 options: 1. Keystone γ columellar strut (Figure 2): after blunt dis- section of the medial limbs of the upper lateral cartil- ages from the septum, the amount of dorsal reduction was calculated; approximately 3 mm of cartilage of the dorsal septum was removed with septal scissors while protecting the cartilage that goes under the bone at the keystone area; the entire upper lateral cartilages were preserved, as autospreader flaps may be needed. 2. Lower septal cartilage γ columellar strut (Figure 3): after the regular septoplasty in subperichondrial plan, the lowest part of the septum over the maxillary crest was exposed and harvested with the 3-mm vertical length. 3. Tailor-made anatomic γ columellar strut (Figure 4): a septal cartilage strip was tailored to the desired size and γ shape with a longitudinal cut-up incision (partial thickness) to mimic the horizontal limbs. After intradomal sutures (hemi-transdomal fashion), lat- eral crural steal, and MC overlap (if needed), the anatomic γ columellar strut graft was placed into the pocket formed © 2019 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals. permissions@oup.com Aesthetic Surgery Journal 2019, 1–7 Downloaded from https://academic.oup.com/asj/advance-article-abstract/doi/10.1093/asj/sjz272/5610970 by guest on 03 November 2019

between the MC, which were sutured to the graft one by one utilizing several loop sutures for each of them (Figures 2C, 3B, and 4C). Lateral crural steal is applied if there is an excessive lateral crus, which allows us to determine a new domal point. MC overlap is applied if there is excessive MC due to lateral steal procedure or by primary cause. METHODS The patients included in our study were both primary and revision cases in whom an anatomic γ columellar strut was employed; they underwent operated between January 2015 and December 2018 performed by the senior author (S.T.). This study was conducted in accordance with the guidelines set forth in the Declaration of Helsinki. Written informed consent was obtained from all patients. Skin thickness was accessed and based on its thickness, the strut was chosen (Figure 5). RESULTS In 328 patients, the anatomic columellar strut was em- ployed to support the tip. All 277 patients who completed the first year of follow-up were retrospectively analyzed. The mean follow-up was 18 months (range, 12-26 months). The mean age was 26.4 years old (range, 17-43 years) for 272 females and 56 males. We performed 114 keystone struts, 106 lower septal struts, and 108 tailor-made struts. All the patients presented a stable and aesthetic new tip. The interdomal and MC angles were both maintained (Figure 6). Cost This procedure represents no additional cost to the sur- gery, because our algorithm shows that either the cartil- aginous remnants of the dorsal hump reduction or of the classical septal strut may be utilized to provide an aes- thetic and supported new tip. DISCUSSION One of the most important areas for tip support and aes- thetics is the projection and support of both MC of the lower lateral cartilages. The utilization of a columellar strut is a known tool to achieve this and avoid several AB Figure 1. Several angles should be considered regarding the lower lateral cartilage stability and tip aesthetics. (A) The interdomal angle α and the medial crus division angle ς (columellar break point, at the transversal plane). Notice that the interdomal angle α narrows in a downwards direction: it is wider at the upper part (red), intermediate at the columellar break point (yellow), and narrower at the end of medial crus (green). (B) The columellar-lobular angle θ (columellar break point, at the sagittal plane). 2 Aesthetic Surgery Journal Downloaded from https://academic.oup.com/asj/advance-article-abstract/doi/10.1093/asj/sjz272/5610970 by guest on 03 November 2019

Santareno and Taş 3 A B C Figure 2. This 23-year-old female in whom the keystone γ columellar strut was applied. (A) The keystone excision material after dorsal hump removal. (B) The bone part (upper) and the keystone γ columellar strut achieved after the separation of the bone (lower). (C) Inset of the graft with the maintenance of interdomal angle α and medial crus protection. complications.1-6 For an aesthetic result, the ideal colu- mellar strut should address its natural anatomy. Sheen and Sheen first described the nose surface aes- thetics in 1978, considering the geometric position of the cartilages and its soft tissues.8 After detailed cadaver and clinical examination with surface analysis of the nose, its polygons and several other concepts regarding the tip (supratip break point, infratip breakpoint, columellar breakpoint) were defined.9 Daniel highlighted a dome def- inition angle with both a convex segment along the lateral dome and a concave one at its junction with the MC.10 Toriumi defined the importance of highlights and shadows; for a more natural tip, he proposed the creation of a hor- izontally oriented tip highlight that transitions smoothly from the tip lobule to the alar lobule.11 Although these artistic approaches make sense to create an aesthetic tip, we still lack adequate published details about all the ideal angles to achieve it. The reg- ular strut commonly employed to support the tip seems to cause an aesthetically operated appearance because the interdomal angle α may be destroyed when both domes are sutured together in a straight line, which is more often due to misapplied sutures. The closure of the angles and how this affects nasal aesthetics is somehow difficult to understand for inexperienced surgeons; however, according to the senior author’s experience (S.T.), employing a normal columellar strut causes more pointed tips because it eliminates the angles between the MC as well as the infra-lobular segment, requiring a rim graft to the soft triangles to correct this pinching deformity. Thus, utilizing an anatomic columellar strut protecting these angles leads to an ideal and natural shape and eliminates the operated appearance of the tip. Dorsum cartilage is utilized because it perfectly fits Downloaded from https://academic.oup.com/asj/advance-article-abstract/doi/10.1093/asj/sjz272/5610970 by guest on 03 November 2019

BA Figure 3. In this 28-year-old female patient, the lower septal cartilage γ columellar strut was employed. (A) The lower septal cartilage γ columellar strut resembles the keystone cartilage angles. (B) Inset of the graft with the maintenance of interdomal angle α and medial crus protection. CBA Figure 4. This 30-year-old female in whom the senior author utilized a tailor-made anatomic γ columellar strut. (A) A septal strip is harvested from the septum. (B) Caudal septal insertion. (C) Inset of the graft with the maintenance of interdomal angle α and medial crus protection. 4 Aesthetic Surgery Journal Downloaded from https://academic.oup.com/asj/advance-article-abstract/doi/10.1093/asj/sjz272/5610970 by guest on 03 November 2019

Santareno and Taş 5 the space between both MC. This space under the col- umellar defining point is diamond shaped; below it, the shape becomes narrower, so we may define this entire structure as trapezoid shaped (Video, available online at www.aestheticsurgeryjournal.com). Naturally, the MC division angle ς should also be addr essed. Our al- gorithm considers 3 options for an aesthetic γ-shaped anatomic columellar strut: (1) The keystone γ columellar strut: The shape of the dorsal septal cartilage at the key- stone is angled in both vertical and horizontal planes. The vertical arm acts like a columellar strut that protects the interdomal angle α (goes to the posterior part of the MC), whereas the horizontal part may be employed as a shill graft. Moreover, because the horizontal and ver- tical limbs create a γ-shaped structure, together they may also provide an MC division angle ς; (2) Lower septal cartilage γ columellar strut: According to our clinical ob- servations, both the angle of the keystone cartilage be- tween the vertical and horizontal parts and the angle of the lowest part of the septal cartilage between the vertical and horizontal limbs over the maxillary crest are very close to 30° to 40°, resembling the interdomal angle α. Of course, individual difference makes sense. (3) Tailor-made anatomic γ columellar strut: Additionally, we can achieve an anatomic γ tailor-made strut by incising to the caudal part of a regular strut harvested from the remaining central septum when neither of the previous options is available or in thin-skinned patients. When all 3 options are available, the keystone or the lower septal cartilage γ columellar strut were preferred in moderate-/thick-skinned patients; hence they are stronger and more stable. In thin-skinned patients, we have pri- oritized the use of the tailor-made anatomic γ columellar strut (Figure 5). CONCLUSION The authors present 3 different options of an γ-shaped anatomic columellar strut to ensure the preservation of the anatomy between the MC while warranting a supported tip. The dorsum cartilage at the keystone area and at the lowest part of the septum over the maxillary crest have a similar shape, resembling the interdomal angle α (30-40°); their γ shape also helps to support the MC angle ς. This paper highlights the importance of these angles and how some simple maneuvers that do not increase surgery cost and time may contribute to protect the MC anatomy, aes- thetically supporting the new tip. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. Figure 5. A clinical algorithm to approach the columellar strut in rhinoplasty according to both the skin quality of the patient and the available material. Video 1. Watch now at https://academic.oup.com/asj/ articlelookup/doi/10.1093/asj/sjz272. Downloaded from https://academic.oup.com/asj/advance-article-abstract/doi/10.1093/asj/sjz272/5610970 by guest on 03 November 2019

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