268

Open Rhinoplasty Concepts in Facilitating Tip

Reconstruction
Marcello Carminati, MD1 Enrico Robotti, MD1

1 USC Chirurgia Plastica (Department of plastic Surgery), Ospedale Address for correspondence Marcello Carminati, MD, USC Chirurgia
Papa Giovanni XXIII, Bergamo, Italy Plastica (Department of Plastic Surgery), Ospedale Papa Giovanni
XXIII, Via Martin Luther King, 24129 Bergamo, Italy
Facial Plast Surg 2014;30:268–276. (e-mail: [email protected]).

Abstract The nose is a frequent site for skin cancer, accounting for approximately 26% of basal cell

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carcinomas and approximately 13% of spinal cell carcinomas of the facial district. Also
melanomas, mostly as lentigo maligna melanomas, are frequently located at the nasal
pyramid. Although defects can be of varying size and depth, some even involving the
whole trilaminar structure of the nose, most remain superficial and seldom reach and
infiltrate the underlying framework. In contrast, they can be wide, thus requesting large
flaps to resurface the defect. Although a technically well-planned and well-performed
surgery can lead to excellent aesthetic results, scars from both donor and recipient sites
can be noticeable. Since skin cancers generally affect older people, we often deal with
aged noses. Such noses typically present some common features such as plunging tip,
increased length, and a prominent hump due to several reasons, already well described
Keywords in the literature. In this scenario, by reducing and addressing the framework, we can
► nasal framework obtain a variable quota of downsizing of the original defect, thus requiring less skin for
► nasal reconstruction coverage, and thus reducing the size of needed flaps and consequent scars. This is
► aging nose greatly facilitated by the open rhinoplasty approach. Most of the maneuvers aimed at
► open rhinoplasty reducing the framework are indeed the same.

In our clinic, we deal with a large number of new cases (80 Only at the end of these steps, we plan the final soft tissue
new cases a year on average) of nose cancers; most of them coverage; we generally use the most reliable and time-
are superficial and generally involve only skin, although the honored flaps, as bilobed flap, nasolabial flap (based on
resulting defect can be very large.1,2 superior or inferior pedicle), the glabellar and extended
We routinely apply the concept of framework downsizing glabellar flap, and others. Sometimes, even transverse direct
when we deal with aged noses, and also when we deal with suturing end up being feasible, which could be impossible to
big humps, of course, after prior discussion with the patient. be done without previous skeletal downsizing.
This allows us to simplify the coverage techniques, often The additional time of “downsizing surgery” generally is
switching on lesser flaps that request smaller scars, and compensated by sparing time in performing the skin cover-
giving the patients a better aesthetic result. age, thus adding only relatively little more time to the surgery
We start by exactly planning the extent of tumor resection, as a whole. Clinical cases are presented, showing long-term
enlarging the defect as required following the aesthetic results.
subunit. Once this is done, the framework remodeling is
planned. According to the specific case, we decide how and
Methods
how much we can modify the cartilaginous-skeletal struc-
ture, by using, as described subsequently, several different Defects of the nasal tip can present in a huge variety of size,
maneuvers. depth, involvement of different neighboring tissues, but

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 Open Rhinoplasty Concepts in Facilitating Tip Reconstruction Carminati, Robotti 269

usually they limit their depth to the underlying skeleton.3 The 4. The hump prominence that becomes more evident. The
traditional reconstructive approach is aimed at restoring, final look shows an increased length of the nose, with
where possible, the starting morphology (the “status quo plunging and enlarged tip, and a relative higher hump.7
ante”) through the restoration of the affected areas, trying to
precisely replace the tissues. Moreover, some noses show, independently from age,
Switching from the concept of simple restoration to the typical morphologies that themselves could be a concern
concept of nasal remodeling requires a “step-by-step” plan- for the patients, like high hump or/and large tips. In these
ning consisting of, in sequence, the following: cases, by remodeling the framework, even apart from oncol-
ogical purposes, we provide several benefits to the patient.
1. Tumor excision and preparation of the defect
Aging noses with drooping tips, along with noses with
2. Framework remodeling
bulbous and large tips, always improve by elevating and
3. Skin coverage.
thinning the tip itself, thus gaining a functional benefit to
Each step is performed in sequence independently. the nasal valves, and large humps can be judiciously resected,
with evident aesthetic benefits. Of course, this surgery is to be

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Tumor Excision and Preparation of the Defect widely and carefully discussed with patients. They generally
The defect preparation leads to an accurate analysis of the do not look for image changes, but in our experience, not only
component layers. When one of the two epithelial surfaces is they often do accept nose modification but sometimes they
intact, skeletal support and cover can often be delivered request us to do this.
expeditiously and reliably. When substantial amounts of all Our main purpose in framework surgery however remains
three layers are lacking, the reconstruction becomes more to downsize the defect: by remodeling cartilage and bone, we
complex. always obtain a noticeable reduction of cutaneous defect size
Anyway, the respect to the aesthetic areas is a main allowing us to switch on easier and less demanding skin
purpose (as Burget and Menick4,5). If the nasal defect encom- coverage solutions, and let the patients also benefit of smaller
passes more than 50% of the aesthetic unit, it should be scars both in the donor site and in the defect area. Moreover,
enlarged to the boundaries of the aesthetic unit; to achieve
this goal, the sacrifice of healthy tissue is aimed at obtaining
well-hidden scars and a better color and texture match.
On the contrary, if the skin defect is less than 50% of the
aesthetic unit, it is best to ignore it rather than convert the
defect into a larger loss. This is our routine behavior in ablative
surgery. Other authors have recommended that, due to the
high quality of the scars which is possible to obtain in this area,
the surgeon should not necessarily follow these rules.6
We generally start by carefully evaluating the tumor extent
under loupe magnification and drawing the boundaries of the
neoplasia; then we add a strip of further margin (dimension
varying with the different kinds of skin cancer and ranging
from 3/4 to 10 mm and more) and eventually extend the
planned resection areas by following the aesthetic unit con-
cepts. After local infiltration, we perform the tumor resection, Fig. 1 Lateral crural trimming.
leaving, as far as possible, tumor-free margins after a “single
bloc” resection.

Framework Remodeling
This is our critical issue; after obtaining the defect, we
accurately study the tridimensional nose framework that
shows a high variety of shapes.
As we generally deal with aged noses, we commonly
encounter the typical nose changes due to aging. Aging alters
the nasal contour by the following:

1. The fall down of the tip, due to the progressive disruption

of intercartilaginous ligaments located between the lateral
crus and the triangular cartilage.
2. The widening of the alar cartilages themselves that con-
tributes to the tip elongation and enlargement.
3. The loss of bone in the pyriform area that weakens the
support of the lateral crura. Fig. 2 Alar sutures.

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270 Open Rhinoplasty Concepts in Facilitating Tip Reconstruction Carminati, Robotti

cranial aspect is generally harvested. This helps rising and

thinning the tip, also providing grafting material (►Fig. 1).
It reduces the vertical extension of the tissue loss. Direct
access is commonly used, but in lateral defects, a marginal
incision along with the delivery technique is often performed
but in lateral defects.

Tip Sutures
Sutures are crucial in tip reshaping; intra/interdomal sutures
are very effective in thinning an enlarged tip, they help giving
tip projection, and along with septocrural stitches do stabilize
the tip in the new higher position, preventing tip relapse.
These sutures are widely performed.
The alar-septal sutures are important in maintaining tips

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in upward position, and they cannot be avoided when tips are
significantly to be raised. They have to be accurately planned
and they are fashioned according to the tongue-in groove
technique. These sutures reduce both vertical and horizontal
extension of the tissue loss.

Septal Cartilage Strip—Shortening the Distal Septum

Fig. 3 Spreader grafts. Removing an inferior septal cartilage strip helps elevating the
columella and helps rotating upward the tip. This is per-
skeletal approach is largely favored by the defect itself, and a formed by direct access, or at least by a transfixion incision.
real “open rhinoplasty” surgery is performed.8 The most
frequent maneuvers we perform are listed below. Hump Resection
It has to be performed with extreme care, always keeping well
Lateral Crural Trimming—Cephalic Trim in mind the great impact it has on nose shaping; also, it largely
This is the most common maneuver we perform; lateral crura contributes in reducing the defect size. When performed, we
are often wide in old people, and a generous strip in the always associate spreader flaps or grafts to stabilize the new

Fig. 4 Total nasal skin flap (Marchac). (A) Basal cell carcinoma of the tip: planning the flap. (B) The defect. (C) Shaping the flap and framework
remodeling (sutures). (D) Moving the flap. (E) Intraoperative result.

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 Open Rhinoplasty Concepts in Facilitating Tip Reconstruction Carminati, Robotti 271

hump (►Fig. 2). Basal bone fractures are rarely performed, largely performed too. Careful final check of the new shape
particularly in the elderly, due to the well-known problems in will allow us to evaluate the final aesthetic aspect of the nose.
dealing with brittle bones. At the end of the framework surgery, we can decide about the
required soft tissue coverage.
Grafts
Multiple incisions in the nose and nose flaps can lead to Skin Coverage
retracting or deforming scars; grafting the nose when needed Skin restoration will follow the common principles of nose
will give proper support to the new skeletal shape; onlay reconstruction. Technical solutions are largely known and
grafts on the tip, spreader grafts, and columellar grafts are well established; we routinely adopt a selection of the
routinely used (►Fig. 3). multitude of flaps described in the literature, that is, those
Supporting and stabilizing the tip by sutures or/and grafts workhorses, relatively few in number, that in our hands
is of utmost importance to achieve a long-lasting result. If we guarantee the most predictable results.
need onlay graft for the tip, we generally use cartilaginous The key point is the need of smaller flaps after skeletal
material harvested by the cephalic trim. All kinds of onlay surgery that allows us to expedite this part of surgery but,

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grafts are performed, according to the single case. When above all, to reduce donor site morbidity. Switching
columellar support or spreader grafts are requested, cartilage toward simpler and smaller solutions (i.e., direct sutures,
harvesting is performed on the septum, with the classic L inferior pedicled nasolabial flaps instead of superior pedi-
strut sparing technique. Ear and rib cartilage can be harvested cled ones, bilobed or dorsal nasal flaps instead of forehead
if the graft material is not available locally. flaps) is a constant benefit of skeletal reduction. Our first
As we mentioned earlier, the access is largely indicated by choice flaps are listed below, according to the type of the
the tumor resection, but rim or transfixed incisions are tip defect.

Fig. 5 Superior pedicle nasolabial island flap. (A) Basal cell carcinoma of ala: planning the flap (choice between a bilobed flap and a nasolabial
flap). (B) Defect and “islanded flap,” tunnel creation. (C) Moving the flap into the defect. (D) Intraoperative result.

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272 Open Rhinoplasty Concepts in Facilitating Tip Reconstruction Carminati, Robotti

Small Central Tip Defects Small Lateral Tip Defects

Small/medium size central tip defects can be well addressed Similarly to central defects, many of them benefit from the
by direct sutures in big noses and aged tips; by remodeling tip nasal reshaping and can be easily addressed with primary
and hump, we can obtain even a 2-cm-in-height defect closures or by interpolation of small island tip flaps pedicled
primary closure. Wide undermining in the correct subcuta- on the SMAS system. Results are excellent and scars are
neous plane is often requested. scarcely noticeable.
If we want to reduce the tip elevation, we generally
interpolate an island flap from the lateral aspect of the defect, Medium–Large Central Tip Defects
pedicled on the nasal superficial muscular aponeurotic system If the defect cannot be solved by primary closure, we gener-
(SMAS). This flap is variously shaped and generally fashioned ally perform a total nasal skin flap, which is, in practice, an
like an irregular ellipse, and it is moved into the most central extended glabellar flap.9 It has been described by many
part of the defect, thus balancing the final harmony of the nose. authors in several ways but in our unit, it is routinely
The nasal SMAS is well represented in old people, especially in performed by pivoting the whole nasal skin on the angular
males. By detaching the overlying skin from the SMAS, and the vessels. This pedicle lets the flap free to move downward and

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SMAS from perichondrium, we can obtain safe flaps that can be to reach the tip easily. Scars are directly placed in the
easily transposed into the defects. genionasal folds to hide them as far as possible. The glabellar

Fig. 6 Clinical case no. 1. (A) Basal cell carcinoma of the tip: frontal view. (B) Lateral view: see the bulbous and drooping tip (aging nose). (C)
Preoperative plan: wide tumor resection, tip reduction, and rising, closure by direct suture, with a small SMAS flap interpolation (to limit tip
elevation). (D) Intraoperative: planning the crural trimming and raising the flap. (E) Intraoperative result. (F) Follow-up, frontal view: notice the
impact on tip width, tip rising, thus maintaining a natural look. (G) Follow-up, lateral view.

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 Open Rhinoplasty Concepts in Facilitating Tip Reconstruction Carminati, Robotti 273

part of the flap is advanced in a VY fashion and the flap itself is central and lateral defects of the tip, but they are not useful for
trimmed to avoid long-lasting edema. the nasal ala.
Trimming is not performed in the distal part where it has to
perfectly match with the thick tip skin. This flap is very reliable, Alar Defects
very pliable, and fits well in most situations. By combing this Alar defects are well addressed with genionasal flaps. This
flap with the principles of defect downsizing, we often are able flap can be pedicled either distally or proximally.
to avoid the use of the more demanding forehead flap and the
multiple stages it requires (►Fig. 4A–E). Also useful in central Proximally Pedicled Nasolabial Flap
or in slight lateral tip defects is the bilobed flap. We prefer to This flap is the workhorse for alar defects; a large amount of
pedicle it medially to minimize central scars and draw the first tissues can be carried allowing coverage of wide size defect
lobe at the level of the alar crease, hiding the subsequent scar as and easily reaches the tip. Main indication is alar reconstruc-
much as possible. The second lobe will be necessary vertical or tion; we generally perform it as an island flap and we
slightly oblique. Main drawbacks of these flaps are the ten- interpolate, when possible, a small bridge of alar tissue,
dency to create bulbous tips by narrowing the dorsum, and the aiming to obtain some trapdoor effect and mimic the thick

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potentially noticeable dorsal vertical scars. If carefully planned, tissue of the alar skin. Heterotopic cartilage grafts are often
anyway, those flaps lead to excellent results. They will solve necessary to provide stable alar support.

Fig. 7 Clinical case no. 2. (A) Basal cell carcinoma of the ala: lateral view: see the big hump. (B) Frontal view. (C) Preoperative drawing: by planning
the hump reduction and a slight tip elevation, surgery can switch from the more demanding (especially in a young lady) superiorly based to the
inferior pedicle genionasal flap. (D) Intraoperative: harvesting the flap after hump reduction and tip surgery (trimming of the lateral crura, intra/
interdomal sutures, removing of a septal cartilage caudal strip). (E) Intraoperative result. (F) Follow-up, lateral view: note the new nasal shape and
the slightly visible scars. (G) Follow-up: frontal view.

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Combined alar and lateral tip defects are best solved with large amount of skin when combined with hump resection.
this flap. The flap is raised distally, and care is taken in The scar is always well concealed in the fold.
including any kind of perforators from the facial artery system
to gain maximal mobility. Main drawbacks are the flattening Main Defects
of the nasolabial crease, although the donor site always heals Large defects combining tip, alar, and/or dorsum tissue loss
very well with almost invisible scars, and some difficulty in are routinely solved with forehead flaps that we perform and
shaping and setting it without creating some bulk area at the fashion with a two- or three-step surgery, as well described
pedicle level (►Fig. 5A–D).10,11 by Burget and Menick. This flap, of course, remains the gold
standard for wider defects.
Distally Pedicled Genionasal Flap The multitude of nasal shapes necessarily leads to a
Defect downsizing often permits to switch on this flap for alar custom-made approach; similar defects can be solved with
reconstruction; this flap is smaller than the previous one, but different flaps, according to the different framework reshap-
easy to deal and presents less donor site morbidity. Exactly ing; surgical planning is to be performed in a largely free and
planned at the boundary of the nasal side wall, it can carry adaptable way, concerting every surgical step to every single

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Fig. 8 Clinical case no. 3. (A) Basal cell carcinoma of the tip, frontal view note the bulbous, aged tip. (B) Lateral view: note the hump and the tip
descent. (C) The defect. (D) Intraoperative: hump and tip remodeling. (E) Intraoperative result. (F) Follow-up, frontal view: the bulbous tip is
thinned and elevated. (G) Follow-up, lateral view: note the hump reduction and tip elevation. Scars are barely noticeable and fall into natural folds.

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 Open Rhinoplasty Concepts in Facilitating Tip Reconstruction Carminati, Robotti 275

situation. The surgeon has to keep well in mind two things Nasal framework surgery allowed us to plan a distally based
during his reconstructive pathway: the best esthetical shape genionasal flap instead of the more demanding proximally
in every single patient along with the less costly scar price. pedicled nasolabial flap as a coverage solution. The result
shows a pleasant nose with minimal donor site scar. Patient is
perfectly healed (►Fig. 7A–G).
Clinical Cases
Case Report 1 Case Report 3
A 68-year-old male patient, aging nose with bulbous and A 68-year-old male patient, with humped and aged nose,
drooping tip, developed a basal cell carcinoma in the lateral developed a basal cell carcinoma, involving lateral tip and
aspect of the tip. Wide excision was performed, leaving a wide medial part of left ala. Wide resection was performed,
slightly asymmetrical tip defect. Tip was addressed by trim- leaving a large mediolateral tip defect. Aggressive frame-
ming of alar cartilages, inter- and intradomal sutures, alar work surgery has been performed, involving hump resec-
mattress sutures. Trimming of the septal cartilage and mini- tion, along with spreader grafts, tip remodeling by using
mal hump resection were also performed. The large defect has alar and septal trimming, intra/interdomal sutures, and a

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been reduced both horizontally and vertically, allowing an small onlay graft. Skin coverage has been obtained with a
almost direct closure with the interpolation of a small SMAS- total nasal skin flap. Postoperative controls show a pleasant
based island flap. Results show a pleasant nasal shape, nose, according to the patient age, but with considerable
according to age, a noticeable tip improving, especially in hump reduction and tip rising, and with much concealed
frontal view. Scars are minimal and the patient is perfectly scars (►Fig. 8A–G).
healed (►Fig. 6A–G).
Case Report 4
Case Report 2 An 89-year-old female patient presented a basal cell carcino-
A 38-year-old female patient, with humped nose, developed a ma of the right lateral tip. After tumor resection, hump
basal cell carcinoma on the ala. After tumor resection, a hump reduction and tip elevation were performed (alar trimming,
resection (along with spreader flaps interposition) was per- alar-septal sutures, intradomal sutures, and septal trimming).
formed, along with a tip remodeling by alar and septal The small post-framework reduction defect has been success-
cartilage trimming and intra/interdomal sutures positioning. fully addressed with a bilobed flap (►Fig. 9A–F).

Fig. 9 Clinical case no. 4. (A) Lateral tip basal cell carcinoma, lateral view and surgical plan (bilobed flap). (B) Intraoperative: the defect. (C)
Intraoperative: rising the flap and framework reducing surgery. (D) Immediate result. (E) Long-term follow-up: frontal view. (F) Long-term follow-
up: lateral view: note the pleasant nasal shape, according to age, and the scarcely visible scars.

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276 Open Rhinoplasty Concepts in Facilitating Tip Reconstruction Carminati, Robotti

Conclusion Conflict of Interest

The authors declare that they have no conflict of interest as
Nose skin cancers are very common; they need a proper free- defined by the guidelines of the International Committee
margin resection to obtain stable and recurrence-free heal- of Medical Journal Editors.
ing. This surgery can often lead to large defects that can
request large flaps with noticeable donor site morbidity.
Framework remodeling can help reducing defect size, leading
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