Augmentation of nasal tip projection using shield grafts harvested from the alar cartilage in closed rhinoplasty

Nasal tip surgery is one of the most difficult and contradictive matters of rhinoplasty. In the treatment of constitutional or acquired losses of nasal tip projection, cartilages harvested from the nose itself or other sites can be used; varied suture techniques have been introduced as well. The septal cartilages are recently often preferred. However, shield grafts harvested from the septal cartilage which have thick and hard structure may lead to aesthetic contour problems as definition underneath the skin (silhouette deformity) and feeling with palpation. In this study, shield grafts harvested from the alar cartilages were used and results were evaluated anthropometrically, in order to decrease aesthetic complications and improve the outcomes in augmentation of nasal tip projection. In the study, 31 patients (study group) who had closed rhinoplasty with alar shield graft (ASG) and 30 patients (control group) who had standart closed rhinoplasty between 2009 to 2016 in Department of Plastic Reconstructive and Aesthetic Surgery, Faculty of Medicine, Ataturk University, were compared retrospectively. Mean ages of the patiens were 23,77 ± 4,45 years in study group and 26,4 ± 6,17 years in control group. The average follow-up times were 16, 48 and 10,12 months in groups. Evaluation was performed with physical examination and anthropometric analysis of the measurements obtained from preoperative and postoperative standart photographs; data were comparad statistically. In postoperative routine controls and photos, resorbtion, migration and silhouette deformity pertaining to ASG were not encoutered in any of the patients. Outcomes were satisfying for both surgeon and patients. Surgical revision related to ASG was performed in none of the patients. In study group, mean values of alar groove-tip (AG_T) which shows nasal tip projection were 30,61 ± 4,10 mm preoperatively and 31,64 ± 4,01 mm postoperatively, and there was a significant difference (P = 0,0004). In control group, mean values of AG_T were 32,92 ± 3,44 mm preoperatively and 32,24 ± 4,01 mm postoperatively, and no significant difference was found (P = 0,086). In comparison of preoperative AG_T values of both groups, there was a significant difference (P = 0,021), whereas no significant difference was found between postoperative AG_T values (P = 0,563). In study group, mean values of subnasal-tip (Sn_T) distance which shows nasal tip projection were 19,00 ± 2,84 mm preoperatively and 21,99 ± 2,55 mm postoperatively, and there was a significant difference (P = 0,000). In control group, mean values of Sn_T were 20,58 ± 2,32 mm preoperatively and 20,86 ± 2,41 mm postoperatively, and no significant difference was found (P = 0,406). In comparison of preoperative Sn_T values of both groups, there was a significant difference (P = 0,021), whereas no significant difference was found between postoperative Sn_T values (P = 0,080). In study group, mean values of labio-columellar angle (LCA) were 95,89 ± 11,17 degrees preoperatively and 104,52 ± 7,87 degrees postoperatively, and there was a significant difference (P = 0,000). In control group, mean values of LCA were 99,02 ± 8,12 degrees preoperatively and 102,08 ± 7,82 degrees postoperatively, and there was a significant difference (P = 0,0006). In comparison of preoperative and postoperative LCA values of both groups, no significant difference was found (P = 0,217 ve 0,228, respectively). The ASG used in our study is adequately hard so as to provide an effective tip projection and soft so as not to become evident underneath the skin, and easily shaped, as well. Thus, it camouflages the irregular structures below very well and increases the nasal tip projection. The ASG can be easily applied in closed and open rhinoplasties with no extra donor site morbidity. In objective evaluation of outcomes based on the anthropometric analysis, our technique was found to be sufficient, effective and long term in loss of tip projection. Complication and revision rates were too low. However, it may not be enough alone and can be combined with tip support grafts and sutures in case of severe projection loss. The columellar strut alone was seen to keep stable and not to decrease the tip projection, even if it was not able to increase. Our technique was able to be evaluated objectively, because anthropometric analysis based on the measurements obtained from photographs was standartized. Key Words: alar, anthropometry, cartilage, graft, nose, projection, rhinoplasty, rotation, shield, tip