Dr. Alejandro Nogueira's Case #3HRIAGCE

The total absence of septum had lead to a total loss of tip support and its collapse, tip droopiness, lack of tip definition, broad nostrils, sunken columella, severely sunken supratip and abnormally large alar flare; on the other hand the excessively long tip was untreated and over the years without septal support it became a Pinoccio's nose deformity.

This was also a hybrid dorsum case in which, simultaneously, do coexist a prominent hump and a sunken saddle nose deformity at the dorsal profile.

It is a matter of highly experienced aesthetic judgment determining what is the right level of a dorsum; such a decision has to take into consideration the tip level, the frontal bone level, the overall facial profile balance and the final nasal size wished or planned.

The same perfect and straight profile can be set at different levels or heights, as long as the radix, the bony dorsum, the cartilaginous middle vault, the supratip and the tip are in the right alignment; deciding what is the adequate alignment line is important in many cases but in those like the one shown here it is extremely difficult to assess and much more to execute technically.

After a thorough reflection it was deemed, evident by the final outcome, necessary applying the principle of the three elevators, one ascending and the other two descending in order to meet at the right level.

On one side there is an excessive hump at the upper dorsum, made up by oversized nasal bones which was aggravated by the multiple fractures happened leading to bone thickening; on the other side there is a sunken profile or saddle nose deformity at the lower half of the dorsum or middle vault, caused by the total absence of the supportive caudal septum making a collapsed supratip; finally, the tip, in this specific case, was deemed excessive in projection, considering the facial balance of this patient and his own personal preferences.

With that said, the right neo level for the dorsal profile is somewhere between the bony hump and the tip as top excess and the sunken middle vault a bottom shortfall; setting the right level at the bony hump and tip would lead to a straight profile by means of massively raising the sunken part so that hump and tip are joined in a straight line, however this would entail an oversized nose; setting the right dorsum at the sunken middle vault would force to perform an aggressive reduction scooping of the nasal bones and deproject the tip, ending in a disproportionately small and flat nose, like some ethnicities; this patient's nose needed both, lowering the upper part of the dorsum plus deprojecting the tip and raising the sunken lower part.

The reconstructive procedure began with open approach, debridement or cleansing of fibrosis and identification of structures; this allowed proper planning and decision making about the grafting strategy.

A large rib cartilage harvesting was the only option to rebuild this nose; once extracted and the donor site carefully closed with layered sutures, the phase of grafts shaping, tailoring and sculpting began, which actually is the most difficult, challenging, creative and somehow artistic part of this procedure.

Two long and firm grafts from the rib were shaped to act as septocolumellar caudal extension grafts to provide nasal length support, act as spreader grafts to repair the middle vault and as dorsal graft to raise the sunken supratip; they were sutured to the remnants of the upper lateral cartilages as stand point.

A septal replacement graft was sutured in between the septocolumellar grafts in a two on one fashion, and at the very lower end of this scaffold a strong columellar strut was assembled to provide the right tip support.

The damages of the alar cartilages could be luckily repaired in a direct form.

The tip was aggressively deprojected by means of trimming a segment of both the lateral and medial cruras of the lower lateral cartilages, reassembled to secure the deprojection; the oversized and split tip and the also bifid columella were managed by cephalic resection of the alar cartilages and scoring of the tip domes plus a posterior transdomal plication of them.

Finally and in view of the transparency of the dorsal work, leading to visible irregularities, a temporalis fascia graft was harvested and applied like a blanket of camouflage leading to a smooth outcome without any trace of irregularities; at the end of the procedure the patient received an alar wedge excision to reduce the flare and the nostrils.