Nasal Tip Depressor Manipulation through Upper Buccal Sulcus Approach in Selected Open Primary Rhinoplasties

Abstract

During smiling, the prominent action of nasal tip depressors (NTDs) antagonizes the rhinoplasty nasal tip support maneuvers and favors scarring forces' pulling the nasal tip in a less projecting vector. The NTDs' disinsertion is feasible through the open rhinoplasty approach. Yet, the reliability of the open approach to manipulate all NTD attachments is still questionable. The upper buccal sulcus approach (UBSA) is a reliable approach to manipulate variable anatomy of the NTDs.

Methods: Thirty-two patients had primary open rhinoplasty between 2016 and 2020. All patients showed hyperactive NTDs during smile preoperatively. Through UBSA, disruption of NTDs was done. Aesthetic outcome was evaluated by comparing the pre/postoperative nasal tip projection (NTP) and nasolabial angle (NLA) in lateral views.

Results: The sample included 28 women and four men, and the mean age was 30.7 years. The mean follow-up period was 23.8 months. Preoperatively, 53% (n = 17) of patients showed normal NTP measurements; this percentage increased to 87.5% (n = 28) postoperatively. The mean NLA for the 32 patients was 91.0 degrees preoperatively' which was increased to 102.5 degrees postoperatively. These aesthetic results were maintained throughout the follow-up period' with no significant increase in the incidence of complications.

Conclusions: The combination of the UBSA with open rhinoplasty resulted in objective visualization and manipulation of the NTDs. This was proven by the maintained NTP and NLA in aesthetic optimum values throughout the follow-up period. We believe that UBSA can be safely combined with open rhinoplasty as a reliable hidden approach to manipulate hyperactive NTD cases.

Fig. 1.

A 34-year-old female patient presented with hyperactive NTDs, causing significant upper lip vertical height reduction with smiling. A, The patient in normal anterior view. B, The same patient in a full smiling anterior view.

Fig. 2.

A 23-year-old male patient with hyperactive NTDs. A, An inverted V-shaped incision in the upper buccal sulcus. B, Intraoperative view showing the DSNm just before surgical disruption of its columellar attachment.

Fig. 3.

A 34-year-old-year old female patient presented with nasal dorsal hump. A, NTP was calculated to be 50%. B, NLA was measured to be 92 degrees.

Fig. 4.

NTP before and after surgery. Rounded markers (gray) represent individual observations. Squared markers (black) with traversing horizontal lines represent the mean. Error bars represent the 95% confidence limits. Preoperatively, 53% (n = 17) of patients showed normal NTP measurements, and this percentage increased to 87.5% (n = 28) postoperatively.

Fig. 5.

NLA before and after surgery. Rounded markers (gray) represent individual observations. Squared markers (black) with traversing horizontal lines represent the mean. Error bars represent the 95% confidence limits.

Fig. 6.

A 44-year-old woman presented with an under-rotated and under-projecting nasal tip. During smiling, the patient complained of nasal tip depression and upper lip creasing‚ causing social embarrassment. A, Preoperative lateral view; the NTP was 45%. B, Postoperative lateral view; the NTP was more aesthetically optimized to be 50%. C, Preoperative lateral view showing under rotated nasal tip; the NLA was 75.5 degrees. D, Postoperative lateral view showing corrected nasal tip rotation; NLA was 97.4 degrees.

Fig. 7.

A 25-year-old woman presented with a long‚ humpy nose and hyperactive NTDs during smiling. A, Preoperative lateral view showing NTP within normal range (59%). B, Postoperative lateral view. The aesthetic complaints of the patient were managed successfully while the NTP was maintained within the normal range (57%). C, Preoperative lateral view showing under rotated nasal tip. The NLA was 92 degrees. D, Postoperative lateral view showing corrected nasal tip rotation. NLA was 103.7 degrees.

Fig. 8.

A 23-year-old man presented with a long‚ humpy nose and hyperactive NTDs during smiling. A, Preoperative lateral view; the NTP was within normal range (58%). B, Postoperative lateral view; the aesthetic complaints of the patient were managed successfully while the NTP was maintained within the normal range (53%). C, Preoperative lateral view showing under rotated nasal tip. The NLA was 83 degrees. D, Postoperative lateral view showing corrected nasal tip rotation. NLA was 92 degrees.