Incisor Show–based Selection of Tip Augmentation Rhinoplasty Technique

Abstract

 

Our recent studies show that the majority of patients seeking rhinoplasty have inadequate incisor show. Furthermore, some rhinoplasty maneuvers, such as a columella strut, can alter the lip position and consequently the incisor show. We report the senior author's (B.G.) algorithm for tip augmentation technique based on our previous studies and 44 years of keen observation in the field of rhinoplasty. The 5 most common scenarios are described. When there is a short columella with inadequate incisor show, bilateral extended spreader grafts and columella strut with a tapered posterior portion are recommended, serving as a reliable midline septal extension graft supporting the medial crura in a more anterior position with sutures and a positive effect on incisor show. When there is an optimal lip-incisor relationship, a columella strut with a tapered posterior end fixed to the septum, with or without extended spreader grafts, is a better choice to prevent a change in smile. If there is excessive gum show, the optimal tip augmentation technique is a columella strut without tapering or even wider posterior end, with fixation of the columella strut to the septum, with or without extended spreader grafts that will push the upper lip caudally. The remaining scenarios are described in detail. Tip augmentation maneuvers in rhinoplasty can have a significant influence on upper lip position, which is often detrimental to the smile. The preoperative position of the upper lip during smile should play an integral role in the selection of tip augmentation technique.

Level of Evidence: 5

The way manipulation of nose segments results in multiple interplays, the demand for submillimetric precision, and the functional impact of rhinoplasty maneuvers understandably make rhinoplasty an intimidating procedure for the novice surgeon and a humbling one for the seasoned. Due to its central location in the face, the nose is one of the first areas that our eyes are attracted to on facial observation.¹ The nose is integral in how we perceive the surrounding facial features, a fact that continues to be underappreciated, despite it being a well-recognized phenomenon in the literature.² For instance, one of the most noticeable changes in facial features with specific rhinoplasty maneuvers is the ostensible increase in intercanthal distance and nasal length after nasion deepening on a shallow radix.^3-7

In the latest American Society for Plastic Surgeons statistics report, nose reshaping procedures were the most common aesthetic procedure performed by plastic surgeons.⁸ Given its widespread prevalence, it is vital for the rhinoplasty surgeon to be fully aware of the dynamic interplay of rhinoplasty maneuvers with other facial features.⁹

Few studies have reported on the impact of rhinoplasty maneuvers on upper lip positioning. Most of these studies are logically focused on the influence of the depressor septi nasi muscle on lip position and incisor show.^10-13 Others have simply acknowledged the general impact of rhinoplasty on upper lip positioning.^14-16 An objective study in which these changes are analyzed was recently reported by our team.¹⁷ We demonstrated which specific maneuvers appear to have the most significant impact on upper lip position but did recognize the difficulty of controlling for each maneuver performed during a rhinoplasty to properly assess its independent impact.¹⁷

In Part 1 of this study, our group investigated the incidence of nasal tip and upper lip malposition in primary rhinoplasty.¹⁸ We found that a mere 34% of primary rhinoplasty patients present with an ideally positioned upper lip, with inadequate incisor show being the most common abnormality (61%) and excessive gum show the least common (5%). With such high prevalence, it is important that upper lip malposition in primary rhinoplasty is included in the surgeon's preoperative assessment and surgical plan. The current report is based on the senior author's (B.G.) over 40 years of experience, delineating a surgical algorithm and techniques for addressing incisor show when tip augmentation is planned during structural rhinoplasty.

All procedures performed were in accordance with the ethical standards of the institutional or national research committee and with the 1964 Helsinki declaration and its later amendments, or comparable ethical standards.

ALGORITHM

The algorithm provided (Figure 1) is founded on decades of work by the senior author and includes the most common scenarios that arise for rhinoplasty with inadequate tip projection. The techniques described can be utilized in isolation, or combined if needed. Undoubtedly, as with any surgical algorithm, it is an oversimplification. Nonetheless, understanding the principles and preventing detrimental changes to the preoperative upper lip position is the objective of this algorithm. All patients provided written consent, allowing their photographs to be included for scientific publication.

SURGICAL TECHNIQUES

Scenario 1: Short Columella, Optimal Nasal Length, Inadequate Incisor Show

When the columella is short on a patient with inadequate incisor show and ideal nasal length, tip augmentation can best be achieved with extended spreader grafts and a columella strut graft as a septal extension graft (Figure 2). Since their first description by Sheen in 1984, spreader grafts have served as long-lasting, stabilizing structures between the upper lateral cartilages and dorsal septum functioning to improve aesthetic dorsal lines, stabilize the midvault, improve internal nasal valve airway patency, and prevent an inverted V deformity after dorsal hump reduction.¹⁹ Extended spreader grafts, as described by the senior author, extend caudally beyond the anterocaudal septum and can be especially helpful in lengthening a short nose when paired with a columella strut, such as in the tongue-and-groove technique.^20-25 If the nasal length is optimal, the width of the anterior columella is matched with the width of the medial crura to prevent elongation of the nose. The columella strut should include an anterior extension (usually 4-6 mm) beyond the dorsal level proportional to the extra tip projection needed. The posterior end is tapered. The columella strut is fixed to the septum and the spreader grafts. The anterior (cephalocaudal) width of the columella strut equals the width of the medial crura. The medial crura are then advanced anteriorly and secured over the newly constructed frame with 5-0 PDS sutures (Ethicon, Raritan, NJ) (Figure 3).

Scenario 2: Short Columella, Optimal Nasal Length, Optimal Incisor Show

If the columella is short and the nasal length is optimal with ideal incisor show, tip augmentation is best performed with a columella strut that is tapered posteriorly (Figure 4) and fixed to the septum with 5-0 PDS figure-of-8 suture, with or without extended spreader grafts if there is a tendency for overlap of the columella strut on the septum. Even a minimal doubt about the stability should lead to placement of extended spreader grafts. In the absence of enough cartilage for extended grafts, short pieces of thin septal cartilage can be placed on each side of the junction and sutured to stent the columella strut juxtaposed with the caudal septum. This maneuver of tip augmentation will minimize the caudal shift of the upper lip (Figure 5). Furthermore, every attempt is made to maintain the depressor septi nasi muscle intact.

Scenario 3: Short Columella, Excessive Gum Show

When the columella is short and there is excessive gingival show during smiling, tip augmentation can be achieved with a columella strut that is wide posteriorly (Figure 6). The posterior cephalocaudal width should be dictated directly by the position of the footplates, subnasale, and amount of gingival show. If the footplates are divergent and wide in the cephalocaudal dimension, some caudal advancement of the subnasale and the upper lip following approximation of the footplates is expected. Under these circumstances, the combined effect of a wide columella and approximation of the footplates could be exaggerated, therefore one has to exercise caution to avoid causing inadequate incisor show. The columella strut is fixed to the septum with 5-0 PDS figure-of-8 sutures to minimize the overlap. Should there be any question about the stability of the columella strut, bilateral extended spreader grafts or the previously described stents are utilized to secure the frame (Figure 7).

Scenario 4: Short Columella, Short Nasal Length, Inadequate Incisor Show

The nose length and projection are improved as in Scenario 1, the difference being that the anterior portion of the columella strut that is engaged between the spreader grafts is wider cephalocaudally, proportional to the deficiency in the nasal length, serving again as a septal extension graft. The ideal length of the extended spreader graft is equal to the distance from the anterocaudal nasal bone edge to the anterocaudal septal angle plus the desired amount of nasal lengthening.²⁵ The amount of graft needed to accomplish this frame may not be available, and it may not be necessary if the dorsum has an ideal width of 7 to 8 mm. In this scenario, the columella is secured to the septum with 2 stents and 5-0 PDS. If there is a gap between the caudal septum and the cephalic edge of the medial crura preoperatively, the measured gap should be added to the length of the extended spreader grafts to prevent the columella strut from settling in that space and precluding proper elongation (Supplemental Figure 1, located online at www.aestheticsurgeryjournal.com).

The columella strut should include an anterior extension (usually 4-6 mm) proportional to the extra tip projection needed beyond the dorsal plane, as described in Scenario 1. On its anterior portion at the septal level, the cephalocaudal dimension of the columella strut should equal the width of the medial crura plus the desired nasal lengthening. On its posterior portion, the cephalocaudal width of the strut depends on the position of the columellar base, subnasale, and the amount of incisor show. The strut should taper at the anterior nasal spine level, to prevent pushing the upper lip further inferiorly and worsening the insufficient incisor show. The extended spreader grafts are secured to the septum, and the columella strut is secured to the spreader grafts as well as the septum to ensure stability, appropriate tip projection, and nasal length.²⁵

Scenario 5: Insufficient Lobule Volume

When a tip augmentation is required due to lobule volume deficiency, a tip graft is placed, with either (1) septal cartilage, intact or gently crushed, depending on the thickness of the overlying soft tissues, or (2) conchal cartilage with or without perichondrium, which is decided based on soft tissue thickness. In general, costal cartilage graft is not an optimal choice for tip augmentation except in exceedingly rare patients with extremely thick skin, because firm cartilage has a tendency to reduce the soft tissue thickness over time and may become visible. The tip graft has a predictable effect on multiple nasal tip aesthetic parameters and can be precisely tailored to address the residual underlying tip deficiencies. A tip graft is solely suitable for lobule augmentation when there is either a pure anteroposterior volume deficiency, which will require an onlay graft, or a cephalocaudal as well as anteroposterior deficit, which will mandate a shield graft. Various design modifications from the Sheen and Peck grafts have proven this graft to be reproducible, efficient, and effective at addressing both tip projection and infratip lobule volume.^19,26,27 In patients with thick skin, a solid septal graft may be superior in creating tip definition. Whenever a solid graft is placed, the margins of the graft are beveled to minimize the potential for visibility over time. Notwithstanding the shape or the nature of the cartilage graft, it is sutured directly onto the crural cartilage with 6-0 Monocryl (Ethicon, Raritan, NJ), viewing it 3-dimensionally to prevent misalignment or displacement. It is intriguing that often the graft that seems perfectly positioned from the surgeon's view is found grossly asymmetric from above the head or the basilar view. The side-to-side dimension of the graft should be 8 to 11 mm, depending on the thickness of the overlying skin. The senior author has designed a tip graft punch to provide a precisely shaped graft that facilitates carving the graft, notwithstanding the source.^28-30

Scenario 6: Hanging Columella

When there is excess columellar show (“hanging” columella) as a result of excessive septal length, not as a consequence of alar retraction, and tip augmentation is needed, the Fred technique can address both shortcomings.³¹ Also known as the tongue-and-groove technique, the Fred technique is a powerful maneuver that can address tip projection, tip rotation, and columellar show, simultaneously or independently.^32-41 The medial crura are separated, repositioned and secured to each side of the caudal septum more cephalically, depending on need, while avoiding excessive retraction of the columella. When the goal is to decrease columellar show and slightly increase tip projection, they are repositioned cephalad and slightly anterior as needed.³¹ It is important to note that this can also dynamically increase tip rotation and raise the upper lip, if needed. The Fred technique is typically only intended to decrease columellar show; however, the degree and direction of the medial crura riding over the septum can be varied based on the upper lip position and amount of incisor show. The patient who is undergoing this maneuver should be informed that the nose is going to become slightly more rigid. In our opinion, this operation is rarely indicated and is grossly overused, resulting in inadequate columella show in poorly selected cases.

DISCUSSION

Columella struts can produce multiple changes, including elongating or straightening of the columella, widening the nasolabial angle, advancing the subnasale, or reducing gingival show.³ The most aesthetic position of the upper lip during smiling should be at the gingival margin, to allow full visibility of the central and lateral maxillary incisors, often with a minimal amount of gingival show.⁴² In the context of gingival show, there are subtle nuances to the design of a columella strut graft that can help achieve the desired goals. Several studies have been published describing the effects of the depressor septi nasi muscle on upper lip position.^10-13 Only a few have actually assessed the effects of other maneuvers on upper lip position, as previously indicated.^14-16 Furthermore, as our recent study shows, a mere 34% of primary rhinoplasty patients present with an optimally positioned upper lip, which indicates the high prevalence of a malpositioned upper lip in these patients. However, guidance for the rhinoplasty surgeon in choosing which maneuver is indicated to favorably influence the upper lip position, specifically during tip augmentation, is lacking in the literature. In this study we sought to fill that void by providing our decision algorithm, developed over 40 years of experience, with observations on the effect of tip augmentation on the upper lip and listening to patient complaints about changes to their smile after rhinoplasty. Most seasoned rhinoplasty surgeons would attest to the frequency of such a complaint, which could be minimized with adherence to this algorithm.

One of the biggest challenges with rhinoplasty is that the surgeon can produce positive or negative effects on other surrounding facial features, despite only manipulating other nasal regions. For this reason, it behooves the surgeon to learn the nuances of these effects and how to prevent them. Even though surgical algorithms such as the one provided (Figure 1) may be oversimplifications of clinical reality, the most important takeaway points are the concepts provided. Having awareness of how each of these tip augmentation maneuvers impacts the upper lip and what is indicated for each type of smile is critical. When a patient with excessive gingival show presents solely for rhinoplasty, one of the worst case scenarios would be to inadvertently raise the upper lip, exacerbating their “gummy smile.” Similarly, if the patient has suboptimal incisor show and presents solely for rhinoplasty, the surgeon should do everything possible to prevent lowering the upper lip further. Strict adherence to the algorithm presented, while not leading to a perfectly positioned upper lip on every patient, at the very minimum, should guide the surgeon to preventing worsening of the upper lip position and providing some degree of improvement whenever feasible.

In this study we sought to provide the most common permutations encountered during rhinoplasty. Some scenarios are simply either too rare, traumatic, iatrogenic, or signal an underlying osseous problem, requiring a more complex surgical approach, beyond the scope of this study. One such scenario is a short columella, short nose, and excessive gingival show, which is not only rare as a primary presentation, but usually points to other underlying facial abnormalities, if not traumatic or iatrogenic in nature. A good example of this presentation is the a case of cocaine abuse nasal deformity with a severely shortened nose, representing the most drastic changes influenced by nose surgery on the smile, as seen in Figure 8. This condition requires a very wide (in the cephalocaudal dimension) columella strut with a pair of extended spreader grafts anchored to the remaining portion of the anterior septal bar, if it exists, or to a solid dorsal cartilage graft.

The most significant shortcoming of this report is that it is purely observational and does not include any objective measurements. However, it includes observations made over decades of work and clinical practice. Furthermore, it is meant to provide a logical sequence with a basic, common sense approach that is directly applicable clinically.

CONCLUSIONS

Tip augmentation maneuvers in rhinoplasty can have a significant effect on upper lip position, which commonly is detrimental. The preoperative position of the upper lip during smile should play a cardinal role in the selection of tip augmentation technique. If the surgeon fails to notice it preoperatively, excessive gingival show or insufficient incisor show can inadvertently worsen. Even though tip augmentation maneuvers may not fully optimize upper lip positioning, careful technique selection is vital to improve and, at minimum, not exacerbate the suboptimally positioned upper lip.

Supplemental Material

This article contains supplemental 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.

REFERENCES

Author notes