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 Dr. Perkins |
Dr. Perkins says he often uses the external columellar approach in lobular reconstruction or tip refinement because it allows him to perform advanced nasal tip suturing techniques and to secure cartilaginous grafts with sutures.
"When we do these advanced suturing techniques, we are defining the narrow or bulbous tip, or correcting boxy tips, divergent medial crura and effaced bifidity. But we're also creating strength in the soft lobular cartilages," he says. "Therefore, we can increase tip support and projection" and address rotation as well.Dr. Perkins says he takes a graduated approach that typically begins with cephalic margin trimming, "But I most often use individual dome narrowing sutures, double-dome or transdomal binding sutures, alar spanning sutures, the medial crural overlay and the lateral crural flap."
The double-dome technique allows for individual dome treatment as well as reconstitution of the domal unit in a more symmetrical fashion, Dr. Perkins says. When using this technique, "I like to separate the vestibular skin from the undersurface of each individual dome before I place the single domal unit suture" to narrow the domal structure. "I don't like to bunch the vestibular skin," he says, because the suture holds better when one doesn't do this. "Additionally, I certainly don't want to suture transvestibular skin."
Transdomal suturing can be done endonasally or through the external columellar approach, bringing the domal units together. "But don't make the nasal tip too narrow," Dr. Perkins says. "I define bulbous as being a little more rounded at the tip." He also reminds physicians that in correcting such defects, "Start with the basics — the single- and double-dome unit suture," which may suffice in some cases.
The single- and double-dome unit sutures don't always suffice for correcting a triangulated, boxy tip, however. The double-dome tip suture can create too narrow of a tip, Dr. Perkins says, depending on the pre-existing anatomy and how tightly one binds that suture. This is exactly what happened in a case involving a young woman with a very divergent, boxy nasal tip, Dr. Perkins says. The procedure produced a narrower tip, "And I thought she would accept that because it was a significant refinement." However, he says the appearance of this narrow tip was somewhat incongruous with the overall width of her nose.
He then used the external columellar approach to widen the tip and place an interdomal graft. "This case taught me that if I'm narrowing a tip with the double-dome unit suture but it seems to be getting a little too narrow, why not place an interdomal graft right then and prevent the problem entirely?" he says.
Other problems with the endonasal approach can include an inability to adequately correct the convexity of the alar cartilages, Dr. Perkins says, adding that when he trained as a facial plastic surgeon, standard techniques here included morselizing the cartilages and trimming the cephalic margin to weaken the alar cartilages. This can lead to potential problems with re-curvature and collapse, he says.
Instead, the alar spanning suture can remove the biconvexity from the lower lateral cartilage without creating these problems, Dr. Perkins says. "It completes the narrowing of an overly wide, convex, strong lateral crus. It's placed more cephalically than the domal suture. It can be located right at the immediate supertip region" to leave divergence of the more caudal aspect of the domal cartilages, and yet reduce the convexity of the nasal tip while also providing strength.
