Advances in Plastic & Reconstructive Surgery © All rights are reserved by Dr. José Durán.

*Address for Correspondence: Dr. José Durán, MP 2339, Coronel PuchST. 497 C.P. 4600, Jujuy – Argentina; Tel: +54 9 388 5842524; E-Mail: joseduran _cirugia@hotmail.com

Received: April 19th, 2019; Date Accepted: June 06th, 2019; Date Published: June 07th, 2019

Dr. José DuránMP 2339, Coronel PuchST, 497 C.P. 4600, Jujuy-Argentina

AbstractIn this work we present a technique to refine the nasal tip and wing base using a Punch, weakening the wing crura with the extraction of individual grafts which are later set on the domes. This technique is suitable for patients who present protruding external cruras, in which a weakening or refinement can be made using a 4-5 mm Punch, cartilage extracted as grafts in the domes, trying to improve their luminous points. This is done as a complement of a simple or combined rhinomodelling (osseous and cartilaginous hum presection).

Keywords: : Broad Nasal Tip; Wide Alar Base; Punch Grafts.

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Technique ISSN: 2572-6684

Refinement of the Nasal Tip and Wing Base by Means of Punch and Grafts

Surgical Technique In all the cases local anaesthesia was used (Xilocaine 2% and

Epinephrine). The external crura of the area to be weakened is previously marked, always as a complement of the rhinomodelling.

In these cases an infiltration in the nasal mucous membrane is added. A Little incisión is made with an intra-cartilaginous No 15 blade, then it is dissected with curve scissors. Afterwards the external crura cartilage is resected, on the area previously marked, using a 4-5 mm Punch depending on the case, without involving the wing cephalic edge. That is to say, it is an intracartilaginous cylindrical resection of the wings. In this way the suspensory ligament of the nasal tip is preserved.

Explanatory Model

Introduction There are several refining techniques of the external crura with

cartilage grafts on the tip, including closed rhinoplasty techniques [1-8].

In this publication this technique is presented as a complement of the rhinomodelation with simple or combined thread indicated in patients with a broad nasal tip at the expense of external hair.

Traditionally, Sheen [9] or Peck [10] type grafts are used, among others, a good alternative to refine it but in this case using a Punch to achieve individual cylindrical grafts in the domes, trying to improve the luminous points of them.

As for the narrowing of the alar base, there are different techniques for specific cases such as those described in Chapter 9 of "Rhinoplasty" by Ortiz Monasterio [11].

Direction Simple and combined rhinomodelling in thin and not very thin-

skinned patients, with wide nasal tip and wide wing base.

Materials And Methods

• 3, 4 or 5 mm Punch

• Polidioxanona (PDS) 4/0

• Local anaesthesia was used (Xilocaine 2 % and epinephrine)

This technique is used since June 2018. Up to now 16 patientswere operated. 10 of them were operated on refining the nasal tip with Rhinomodelling combined with thread. The other 6 were operated on refining the base wing; 4 of them as a complement of Rhinomodelling and the other 2 as single ones.

The extracted cartilage is put into a physiological solution and a stitch is put into both sides of the bloody area, only taking cartilagi-nous tissue with PDS 4-0.

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Jóse Durán. Refinement of the Nasal Tip and Wing Base by Means of Punch and Grafts. Adv Plast Reconstr Surg, 2019;3(1): 259-261.

As soon as the external crura refinement is observed, the mucous membrane is stitched up with the same material.

In this way, we get a refinement of the external cruras, using the extracted cartilage as single grafts of the domes, to define the luminous points better.

Pre-Surgery

See procedure video in: https://www.youtube.com/watch?=PKS2U-xaPwR8

Refinement of the Wing Base

In case of suggesting only the narrowing of the wing base, or as a complement of a rhinomodelling, a 3, 4 or 5 mm Punch is used, depending on the thickness of the wing tissue to get a symmetrical refinement without involving the nasal mucous membrane. Once the fatty cylinders are extracted (they can be used to augment the radix, with the epidermis previously removed), a wing base suture is made with Polidioxanone(PDS) 3/0 or4/0. First, two pointed incisions must be made on the wing edge with a No 11 blade; then using a straight needle with PDS, a stitch is put in order to close the holes caused by the Punch.

If it is necessary, single additional stitches can be put in each wing edge, without tightness, using mononylon 5-0.

When the Alar rim conceals the columella, the resection can be combined with Punch of the Alar Base plus elliptical resection of the alar ridge as suggested by Millard [13].

Refinement of the Nasal Tip with Punch Conclusions• Symmetrical refinement of the nasal tip with Punch.

• The suspensory ligament of the nasal tip is preserved.

• Great advantage in the use of cartilage as single grafts for eachwing dome.

Graft Presentation

Combining with a rhinomodelling (simple orcombined) [12], once the guiding thread is fixed on the SMAS of the Radix and tied to the nasal columella, the cartilage grafts are placed through 6- 8 mm marginal incisions previously made.

Firstly, the grafts are taken with PDS 4-0, then the thread goes through a Poget straight needle. In this case threads appear through the dermis of the nasal tip.

The thread can also be used in a curve or traumatic needle. Here the threads appear through the mucous membrane of the wings. In both cases a grooved probe is used to avoid the adjacent tissues to be pinched. The threads are cut three or five days after the Post-Surgery.

Post Surgery

Refinement of the Wing Base with Punch Conclusions

• Symmetrical narrowing of the wing base.

• Dehiscence in the mucous area of the nasal base is prevented.

• -Minimum scar.

Cases of Wide Wing Base (Punch of 3mm)

Pre-Surgery Post Operative

Immediate Post Operative 5 days

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Jóse Durán. Refinement of the Nasal Tip and Wing Base by Means of Punch and Grafts. Adv Plast Reconstr Surg, 2019;3(1): 259-261.

Punch 4mm. Pre-surgery Postoperative Immediate

Punch 5mm. Pre-surgery Postoperative Immediate

References

1. Aufricht G. A few hints and surgical details in rhinoplasty. Laryngoscope.1943;53:317. [Crossref]

2. Aufricht G. Symposium on corrective rhinoplasty. Plast Reconstr. Transplant Bull.1961; 28:241. [Crossref]

3. Sheen JH. Archieving more nasal tip projection by the use of small autogenousvómer or septal cartilage graft. Plast Reconstr Surg. 1975. 56:35-40. [Crossref]

4. Sheen JH. Secondary rhinoplasty. Plast Reconstr Surg. 1975; 56:137-145. [Crossref]

5. Sheen JH. Aesthetic Rhinoplasty. St Louis CV. MosbyCompany, 1978. [Crossref]

6. Sheen JH and Sheen AP. Aesthetic Rhinoplasty. St. Louis CV. Mosby Company,1987. [Crossref]

7. Ortiz Monasterio F, Olmedo A, Oscoy LO. The use of cartilage grafts, in primaryaesthetic rhinoplasty. Plast Reconstr Surg. 1981; 67:592. [Crossref]

8. Rethi A. Raccourcissement du neztrop long. Rev Chir Plast. 1934; 2:85. [Crossref]

9. Peck G. Rhinoplasty. Philadelphia, JB Lippincott, 1990. [Crossref]

10. Fernando Ortiz Monasterio, Fernando Molina. Rinoplastia Capítulo 9, 1996; ISBN950-06-1614-9-84-7903-271-5. [Crossref]

11. José Durán. Rinomodelación con hilo - Fundamento anatómico. Revista Argentina de Cirugía Plástica. 2018; 1:0033-0038. [Crossref]

12. Millard DR Jr. Alar marging sculpturing. Plast Reconstr Surg. 1967; 40:337-342.[Crossref]

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