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Surgical Technique |

Alar-Columellar Disharmony Using the Tongue-in-Groove Maneuver in Primary Endonasal Rhinoplasty

Edwin F. Williams III, MD
Arch Facial Plast Surg. 2012;14(4):283-288. doi:10.1001/archfacial.2012.332.
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The correction of alar columellar disharmony can be very challenging and is often neglected during rhinoplasty. Failure to address alar columellar disharmony may adversely affect an otherwise satisfactory outcome. The tongue-in-groove suture technique has been described in the literature using an open approach as an effective surgical maneuver to assist in correcting this deformity. The endonasal approach in rhinoplasty has the advantage over the external approach of preserving greater nasal tip support. Herein, I highlight the tongue-in-groove suture technique using the endonasal approach in primary rhinoplasty as an effective long-term tool for correcting alar-columellar disharmony caused by the hanging columella in conjunction with other variant anatomy.

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Figure 1. Tongue-in-groove suture technique. A, A preoperative state of a columellar alar disharmony as a result of dependant intermediate and medial crus. B, Intraoperative illustration demonstrating suture placement with a cephalic and more interior position on the caudal septum using the endonasally placed tongue-in-groove suture. C, Suture tying the placed suture. D, Postplacement illustration of the tongue-in-groove suture.

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Figure 2. Left internal nasal valve illustrating the incision placement for access to the caudal septum and nasal dorsum.

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Figure 3. Intraoperative photographs. A, Cephalic dissection from left marginal incision to hemitransfixion incision. B, Tunnel from right marginal incision toward the left hemitransfixion. C, Suture 4-0 PDS placement in the caudal septum. D, The suture is passed anteriorly to the marginal incision on the right side. E, A small 1.0- to 1.5-mm bite of left medial crus cartilage and perichondrium is taken. F, The suture is passed back in a more cephalic direction to exit the left hemitransfixion incision. G, The suture is placed through the right previously developed tunnel to exit through the right marginal incision. H, A small 1.0- to 1.5-mm bite of right medial crus is taken. I, The suture is passed through for the final time in a more cephalic direction to exit the left hemitransfixion incision. J, The surgeon ties the knot while an assistant maintains gentle digital pressure in a more cephalic direction.

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Figure 4. A 35-year-old woman who desired septal rhinoplasty. On examination she was found to have an excess of caudal septum, cartilaginous septum, as well as a dependent intermediate crus. A rhinoplasty was performed, as can be seen in the schematic, and a tongue-in-groove suture was incorporated through a left hemitransfixion incision. These photographs demonstrate a 2-year result with good correction of the caudal excess septum and independent intermediate crus. Preoperative profile (A) and schematic (B). Preoperative (C) and postoperative (D) frontal views. Preoperative (E) and postoperative (F) base views. Preoperative (G) and postoperative (H) lateral views. Preoperative (I) and postoperative (J) oblique views.

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Figure 5. A 42-year-old woman who had nasal obstruction and who desired rhinoplasty. On examination, she was found to have an excess columellar show with dependent intermediate crus. She underwent a septal rhinoplasty as indicated in the schematic and incorporating a cephalic trim, radix graft, and tongue-in-groove suture placed in a left hemitransfixion incision. The 1-year postoperative photographs reveal a satisfactory result with a good correction of the dependent intermediate crus and preservation of nasal tip projection. Preoperative profile (A) and schematic (B). Preoperative (C) and postoperative (D) frontal views. Preoperative (E) and postoperative (F) base views. Preoperative (G) and postoperative (H) lateral views. Preoperative (I) and postoperative (J) oblique views.

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Figure 6. A 16-year-old girl who presented with nasal obstruction and who desired concurrent rhinoplasty. On examination she was found to have a dependent intermediate crus as well as excess of caudal septum in the anterior and posterior location. As seen in the schematic, a profile alignment was performed as well as resection of her anterior and posterior septum in conjunction with a tongue-in-groove suture placement through an endonasal approach. Postoperative photographs demonstrate a 15-year result when this patient presented for another procedure. Nasal tip preservation was maintained, and the intermedial crus has been corrected with long-term follow-up. Preoperative profile (A) and (B) schematic. Preoperative (C) and postoperative (D) frontal views. Preoperative (E) and postoperative (F) base views. Preoperative (G) and postoperative (H) lateral views. Preoperative (I) and postoperative (J) oblique views.

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