Authors “T-excision” for nasal tip rotation is used to reduce long noses as an independent procedure or as a part of primary or secondary rhinoplasties. It consists of “en bloc” excision of the cephalic part of the greater alar cartilages and elongated caudal septum, using: 1) total retrocolumellar incision, prolonged in transcartilaginous incisions, through opposite nostrils, leaving only skin intact; 2) septal incision, perpendicular to dorsum to form correct dorsum length, prolonged into intercartilaginous incisions, through opposite nostrils, leaving only skin intact. Thus, the cephalic strip resection is done en bloc with the unnecessary excessive and prolonged septum and soft tissue. Two, three mattress transmucosal septocolumellar sutures for 2–3 weeks are enough to support healing. The T-excision technique is mini-invasive, nearly bloodless, and time-saving. It is safe; well-tolerated by patients; there is no pain after surgery; no need of plaster, tampons, and bandages. Patients can return next day to social life and work.
- long nose
- T-excision en bloc
- mini-invasive technique
- elongated septum
- primary or secondary
- retrocolumellar incision
- transcartilaginous incision
- intercartilaginous incisions
- perpendicular to dorsum septal incision
- no downtime
Facial analysis is critical in rhinoplasty. This procedure is not an operation of a separated nose; it is an artistic surgery to give aesthetic proportions and angles, as well as properly localized volumes as an aesthetic part of the whole face, which is the goal of beautification. Patient’s age, sex, skin quality, ethnicity should be considered. Nasal tip position has great importance in all cases of rhinoplasty and especially in cases of long and nonproportional nose. Cephalic strip resection of the lower lateral cartilages is performed to achieve upward tip rotation. The “en bloc” T-excision technique for adjustment of nasal tip involves new understanding of well-known incisions, based on anatomical knowledge and specific surgical skills. It minimizes trauma, it is nearly bloodless, achieving acceptable beautifying postoperative result with no downtime for the patient, requiring no plaster, no tampons, and nearly immediate return to work and social life. This technique prevents cartilages from iatrogenic trauma and devascularization and thus permits faster healing and a stable result. It includes cephalic strip resection and septal shortening (caudal septum and/or retrocolumellar mucosal elongation) en bloc.
The greater alar cartilages (lower lateral cartilages) are situated below the upper lateral nasal cartilages, forming the columella and the wings of the nostrils. The medial crura are loosely connected with the corresponding portion of the opposite cartilage. Together with the septum they stabilize the columella. In Caucasians, the columella is stable, unlike Asians, Afro-Americans, and Latino-Americans.
The author’s observations in Caucasian, Asian, and Afro-American noses show that the proper dorsocolumellar angle is very near to 900. Angles different from the right angle change the aesthetic proportions and disbalance the beauty triangle [1-9].
3. Tip rotation
Using the tripod concept, a long nose has longer superior legs (lateral crura of greater alar cartilages) and shorter central leg (medial crura and columella). Thus, the shortening of the lateral crura (cephalic strip resection of the lower lateral cartilages) gives upward tip rotation. (NB: Projection of the nasal tip is described by the author in the chapter, “Columella Sliding for Nasal Tip Projection.”)
Tip rotation is also related to “position of the tip to the alar crease.” The angle at the nasal tip has been described as the wide angle between the vertical line passing through the alar crease and a second line that is drawn from the alar crease to the nasal tip, on lateral view. The ideal tip angle is described to be 105º in females and 100º in males [7-9].
The author’s opinion is that such description can hardly guide a surgeon during the process of operation. His observation is that angles that are too different from the right angle at the nasal tip disrupt the aesthetic proportions and the “beauty triangle” composed of both cheeks and chin (Figures 17, -11). If the angle is more acute, the nose appears to be long and disproportional to the whole face, and the nasal tip (when seen enface) hangs into the area of the upper lip. If the tip angle is obtuse, the nose appears short and over-rotated, as in some Asian and Afro-American noses.
4. Patient consent
If the tip angle is correct, the nostrils in enface aspect are slightly visible. Usually, patients with long noses, who have never seen their nostrils, have difficulty in accepting that nostrils should be a bit visible in frontal aspect. It should be clearly explained that in order for the nostrils to be invisible, the tip angle should be sharp (about 700), which is not appropriate and the nose looks long in relation to the face (Figure 1). Patients should be informed, confident, and motivated for this change.
4.1. Design of the T-excision technique
Excision of the cephalic part of the greater alar cartilages, including unnecessary prominent caudal part of septum, permits rotation of the tip, i.e., shortening the length of the nose. The T-excision technique described below is made en bloc, using a closed rhinoplasty approach.
5. T-excision: Surgical technique
The initial local infiltration of anesthesia should not deform the nasal tip.
5.1. First incision
A total retrocolumellar incision is performed to separate the columella from the septum. In cases of dropping columella, this incision should follow a desired design. To remove dropping columella, the incision should leave an equal thickness along the length of the columella. Any other form should be previously designed according to patient’s desire and informed consent. The retrocolumellar incision is then prolonged into transcartilaginous incision, which separates the lateral wing of the greater alar cartilage in cephalic and distal parts. In the past, the author used methylene blue dye to mark the transcartilaginous incision, but it is not always easy to exactly reflect the line that has been drawn on the external skin. Actually, this is not totally necessary, because the transcartilaginous incision is a prolongation of the retrocolumellar incision in each nostril, parallel to the nostril border. The transcartilaginous incision is performed in each nostril through the opposite nostril, using the opening of the retrocolumellar incision – this gives better visibility to the surgeon and permits for better orientation. This incision cuts mucosa and cartilages, leaving the skin intact. To be precise, both alae nasi are held with thumb and index of the other hand, feeling the scalpel below the skin with the fingertips. Transcartilaginous incisions should be located 4–5 mm cephalic to the caudal margin of the lateral crus of the lower cartilages. Finishing both transcartilaginous incisions and leaving only the skin intact, one has separated the lateral wings of the greater alar cartilage in cephalic and distal parts, whereupon the cephalic parts will be removed with the T-excision en bloc.
5.2. Second incision
The reduction of the length of the nose in the caudal septum region is selective. The second incision line is a “90o-to-dorsum” septal incision, starting from a selected dorsum point in a downward direction, perpendicular to the nasal dorsum to meet the retrocolumellar incision (forming the medial excision triangle), which usually happens above the nasal spine. This incision is total, including caudal septum and both sides of mucosa at once (or, in many cases, only elongated mucosa). The “90o-to-dorsum” septal incision is then prolonged into intercartilaginous incisions in both nostrils, each one through the opposite nostril using the opening of the “90o-to-dorsum” septal incision. The intercartilaginous incision should be placed minimum 2 mm caudal to the valve on the lateral crura side, in order to prevent nasal valve stenosis. The intercartilaginous incision in this technique leaves intact only the skin under the fingertips of the guiding hand, as described above. Intercartilaginous incisions meet the transcartilaginous incisions laterally, forming the 2 lateral triangles of the T-excision. Thus, cephalic parts of greater alar cartilages are separated together with the unnecessary elongated septum (or only mucosa), forming 3 triangles of the “T-excision en bloc”: two lateral triangles in the nostrils and one medial triangle in the septal retrocolumellar part. The tissue of the “T-excision en bloc” is still fixed to the alar skin from which it will be separated and removed by using blunt tip scissors, guided by the other hand to prevent the alar skin from trauma.
The surrounding skin is slightly undermined with the scissors in 2–3 mm distance to permit rotation of the nasal tip and skin adaptation.
T-excision could be used separately in long noses, or as a part of rhinoplasty with hump removal and other additional techniques. The operation is ambulatory, under local anesthesia. The author uses additional IV sedation. The procedure is almost bloodless and atraumatic. Two to three transmucosal mattress sutures are used to fix columella to septum. Stitches are removed after 2–3 weeks, if not absorbed. There is no need of any bandages or tampons. Patients return to their social life almost immediately.
In aesthetics, there is another important aspect – the “beauty triangle,” forming the mid and lower face beauty. It includes the two cheekbones and the chin. The tip of the nose should not disrupt the upper line of the triangle connecting the projection of the two cheekbones, i.e., its prominence has to be on the line between the two cheekbones. Thus, the nasal tip presents an important aesthetic facial volume, forming a straight line together with the volume of the cheekbones (Figure 7).
6. Clinical cases
Immediately after operation, local anesthesia and postoperative edema raise the dorsum and make the nasolabial angle obtuse, which gives an impression of over-rotation of the nasal tip. It is a false impression. With the diminishing of the edema in the first 5–7 days, the correct angle takes shape and the tip falls into place.
Beautification is a work of art. Rhinoplasty, including shortening of a long nose, aims at obtaining exact aesthetic proportions, volumes, and angles of the face. The nose cannot be separated aesthetically. T-excision en bloc, including cephalic strip and elongated caudal septum resection can rotate the nasal tip to obtain correct proportions of the face. The procedure takes a very short time, even shorter than a medical injection rhinoplasty. It is atraumatic, nearly bloodless, does not require plaster fixation, tampons, and downtime. The results are permanent.
Patients return to work and social life almost immediately. There is no bruising. Edema is not visible for observers. Swelling can minimally change the tip position only in the first 5–7 days. After that it becomes natural and in the right position. T-excision is the shortest rhinoplasty procedure to correct long noses and dropping columella, with the most stable and permanent results, due to very small or lack of trauma to the greater alar cartilages and surrounding tissue.
7.1. In cases of over-rotation or short upper lip
If the upper lip is shortened by a too long septum or shortening of the whole pyramid of the nose is necessary, the prominent posterior septal angle can be excised, together with the prominence of the anterior nasal spine. This maneuver deepens the nasolabial angle. It elongates the upper lip and can also correct an over-rotated nasal tip (see Chapter 2)