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Gennadiy Patlazhan

Background of study
Nasal tip surgery in patients with thick skin can be challenging. Bad skin contraction prevents forming of graceful tip. Possible lack of septal cartilage in patient with previous septal surgery causes problems with graft harvesting. We worked out some new methods to solve these problems. To improve skin contraction we undermine the soft tissue flap in two layers. To increase tip support we developed the “strut-suture”. To fill supratip depression we use “SMAS-flap” of the nose or graft from the SMAS layer.

From 2005 to 2011 we performed 563 open rhinoplasties. Bi-layer soft tissue dissection was performed in 441 patients, “strut-suture” was used in 51 patients, “SMAS-flap” to fill supratip depression was used in 78 patients, grafts from the SMAS layer to fill small depressions and nose contour – in 112 patients.

To improve the thick skin contraction we begin open rhinoplasty with subcutaneous soft tissue mobilization above the columella and further above the lower lateral cartilages until the level of upper lateral cartilages leaving the SMAS layer intact. Then we additionally undermine it from the lobules of lower lateral cartilages until the level of upper lateral cartilages. Later on SMAS-flap could be used to fill small subcutaneous depressions (for instance supratip depression). Otherwise it could be resected and used as soft tissue graft. To increase tip support in patients with lack of septal cartilage sufficient to create strut graft we worked out the “strut-suture”. It fixes ligament between medial crura of alar cartilages to caudal edge of septal cartilage. This suture creates good support without loss of tip flexibility.

In all cases we obtained good aesthetic results. In cases of SMAS flap using we didn’t observe it atrophy even in 6 years follow up. In cases of SMAS graft using we observed it atrophy up to 20% in volume.

Using these methods we correct very complicated cartilage deformations in tip area and also create graceful tip appearance in patients with thick skin. The strut suture is the alternative to strut graft, that make nasal tip less rigid.

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