Building infra tip lobule and columella - options for grafts and pros and cons

Question

Hello, I had interdormal suturing an a Tongue and groove Procedure which really changed my nose. I have a retracted collumella and a flat infra tip lobule. My tip shape prior was more of a diamond shape.I want to reverse the TIG and also add these pieces back. I heard that it is possible but I'll need a columella strut to do this. I don't believe I have any septum left and heard that ear is not strong enough for the job. I hear that rib likes to absorb? Any advice, thank you?

Alejandro Nogueira, MD · Answer

The tongue in groove technique is indicated when the surgeon deems it is unsafe, unstable, unpredictable or unlikely successful letting the tip, the columella and the nasolabial angle float free to acquire their shape, position, projection and angle; it is one of the most if not the most powerful and versatile multipurpose maneuvers you can perform on a nose, since it affects, may affect or you can freely design to affect the following nasal parameters:
-tip / medial cruras / columellar projection and length: to project or deproject
-tip rotation / nasolabial angle: you can make the tip rotate, derotate, affecting part of the columella or all of it including the domes
-columellar protrusion / visibility: you can make it show, hide, sink in, part or all if its length
For its performance you need a non-short septum or, alternatively, rebuild the septum length with caudal septal extension grafts and assemble the tongue in groove on them, with or without an associated strut to form an L shape scaffold. 
Its technical reshaping power comes from the securization and firm fixation of the medial cruras and tip  against or towards the caudal septum (a very firm fixation point), septum which plays a beyond-the-strut role, inserting it between the medial cruras and suturing. Normally the caudal septum and the medial cruras are separated, floating free and forming the frontier between the mobile (tip and alae) and the stable (soft and hard pyramid) parts of the nose, with the mere separation of the subseptum soft areolar tissue. The tongue in groove eliminates such freefloat and makes the tip, or at least the medial cruras and the tip solidary and firmly cojoined to the pyramid.
Any of the above listed modifications achievable by means of spontaneous phenomena with traditional rhinoplasty techniques, based on the free float principle, which fails or is presummably unpredictable or unsafe can be equally achieved in a totally predictable manner and stable form by the tongue in groove.
Reasons to fail or of failure prognosis factors are, among other, flaccid skin-mucosa contraction to pull up
 the tip, skin too thick or non elastic, nose with strong ethnicity shape, etc; or alternatively there are no failure prognosis elements but the graduation of the case is so accurately required that no random factors are acceptable; finally, some very specific effects, shapes or graduations are totally impossible with traditional freefloat gestures, needing also securization with tongue in groove; that is the technique (do google it and also research my 
profile of Q&A) which secures the medial cruras to the caudal septum
 in order to calibrate a certain projection and rotation angle of the 
tip, among other effects.
However, the most remarkable power source of this maneuver is it follows the WYSIWYG principle, this means... there is no secondary adjustement or expectation of spontaneous correction adjustement, the effect created and its graduation stay like you leave them in the OR, this means... 
should be used only by very judicious and well experienced surgeons; 
needless to say I do use it in my own patients with certain regularity 
(whenever exists a clear indication).
If used non judiciously, in a non indicated case, overcorrected or poorly graduated... may end in a situation like the one you describe, its power makes it an essential tool in very well chosen cases but also that same power and stability brings its risk, poor results and revisions.
With that said, the good point is it is preservative with the original anatomy and can be reverted if the surgeon is fine, meticulous and well skilled, experience in tongue in groove is a must as well, restoring to before surgery state the original anatomy, grades, angles and lengths of the cruras and other structures once the adhesions and surrounding fibrosis have been released; furthermore... it can be fully reverted and in the same procedure re-performed under a better calibration! if deemed necessary of course, keep this in mind, I am not sure if you have received the best advice: a tongue in groove might have been well indicated for your nose but poorly calibrated or graduated, so you might not need reversion but re-calibration (I did not see your images, just theorization).
More concepts: the sunken columella and the absence of infratip lobule are well likely due to the overcorrected or wrongly indicated (unclear so far) tongue in groove, but other deformities are due to the domal plication / suturing... and this is sometimes impossible to reverse due to the necrotic damage, specially if permanent non resorbable sutures have been employed, becoming a more tedious repair with grafting and so on, feasible but not as easy to reverse as the tongue in groove. As per your description I am convinced a large part of your deformities arise from the interdomal plications and other (unknown so far) maneuvers.
More: I don't see the point why you might not have any septum left, the tongue in groove does NOT harvest or modify the septum, which is actually its support; unless, of course, the septum had been harvested or a septoplasty applied for breathing issues.
Wrong concept: rib cartilage is NOT more likely to resorb, the same successful rate if well thinned down; any thick cartilage graft, of any origin, may undergo vascular issues.
It is unclear if you need reversion of tongue in groove, re-calibration / re-design, or replacement by other maneuvers like struts or etc, but it is not true you necessarily need a columellar strut instead the tongue in groove; actually you might well need nothing instead but letting the tip float free.
I very hope my advice sheds solid and clear pillar to your deep understanding and therefore ease your concerns.
I'd be very proud to see your actual and current nasal shape to provide better advice. I do perform quite often tongue in groove and other high-end procedures on noses, I know well what I am telling you. I disagree adding a shield graft under the columella is the best solution, could be a solution but not the best, more anatomical and restoring one, it is best to meticulously release the tongue in groove and then reassess the options to achive the right shape.
If you wish better grounded opinion please do post or send privately well lit, focused and standard images: frontal, both lateral and both oblique views, also underneath the nostrils.
Feel free to request any additional information from me.

Bahman Guyuron, MD · Answer

Unfortunately this is one of the ill effects of the tongue and groove technique. Often a simple combined columella and lobule only graft using septal or ear cartilage may correct this flaw. You can post or e-mail front, profile and head tilted back views of your face to one of us for a more meaningful advice.

Eric M. Joseph, MD · Answer

Consider consulting with several reputable rhinoplasty specialists with your operative report and preoperative photos so you could see what might be best for your condition. Releasing the suturing from your medial crura to your septum (TIG) may be helpful, along with columellar plumping grafts. We do not utilize rib cartilage in our practice, and ear cartilage has been found to be adequate for nasal reconstruction when there is insufficient septal cartilage available. Hope this helps! Dr Joseph

Sergio Pasquale Maggi, MD, FACS · Answer

Hello,Thank you for your question, and details of your procedure.  It is my impression that you are dissatisfied with your outcome, and require a Revision Tip Rhinoplasty.  I have seen similar complaints with this technique.  Please forward images to any one of us answering your inquiry and more details can be discussed.  Best,Sergio Maggi, MD, FACSdrmaggi.com

Steven Wallach, MD · Answer

Cartilage is often the best way to go. This can be obtained from your nose, ear, or ribs. Cadaver graft is also an option.

Victor Chung, MD · Answer

Revision rhinoplasty is a surgery to improve the shape of the nose for breathing or appearance after a previous nose surgery. A retracted columella can be improved with cartilage grafting. Cartilage may be harvested from the nose, ear, or rib. Septal cartilage from the nose is ideal, but there may not be enough. Ear cartilage is thick, curved, and weak. Rib is strong, thin, but can warp. I would discuss this with a revision rhinoplasty surgeon who understands the pros and cons of each rib. They can recommend techniques appropriate and safe for your nose. Safety comes first.

Jarrod Little, MD · Answer

The concerns that you have can be addressed by a revision procedure, but probably best performed atleast one year from previous surgery. If a strut is needed, rib can can successfully used, but is rarely needed.  If support is needed, a resorbable strut can be used.  This allows for tissue to form and can provide long-term support.  Alternatively, the cartilage that is already present can often be manipulated to give the needed tip support.  In terms of the tip grafts, ear cartilage is often the best option in your situation.  As always, it is important to personally consult with a board-certified Plastic Surgeon who specializes in rhinoplasty

Building infra tip lobule and columella - options for grafts and pros and cons

Answers (7)

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