The last decade has seen a marked increase in the use of the external approach for primary and secondary rhinoplasties. As a consequence, endonasal techniques are taught less and the external approach is increasingly being used for minor corrections. We review the infracartilaginous approach as an elegant variant of the endonasal approach and, for many procedures, a suitable alternative to the external approach and describe the technique of the infracartilaginous approach and illustrate its options with cases that, for the majority of rhinoplasty surgeons, would call for an external approach. We adopted the infracartilaginous approach as the preferred technique for most tip sculpting and repositioning procedures. The infracartilaginous approach is technically more challenging compared with the open approach in teaching situations. This, however, does not imply that the technique should therefore be abandoned. On the contrary, we are convinced that the technique can and should be taught and learned.
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The infracartilaginous incision follows the caudal border of the intermediate crus, the dome, and the lateral crus of the alar cartilage and gives access to the interdomal space, the cartilaginous and bony dorsum, and the piriform crest (A); the approach lends itself to tip modifying techniques such as transdomal sutures (B) and lateral crural overlay (C).
This figure illustrates the incision and dissection of the infracartilaginous approach. The infracartilaginous incision may be passed from medial to lateral, or vice versa, extending several millimeters into the columella (A) and following the inferior margin of the lateral crus, which is palpated with the side of a number 15 blade (B). A fine-pointed scissors will find a bloodless dissection plane directly over the thin perichondrium, which is left on the cartilage (C and D). Gentle countertraction with a single hook helps in dissecting the intermediate and lateral crus and the dome (D). Cephalic resection of the lateral crus with intact vestibular lining (E) and elevation of the vestibular skin lining from the lateral crus (F) can be performed without intercartilaginous incision. The degree of exposure is sufficient for modifications of the alar cartilages, such as shortening of the lateral crus by a lateral crural overlay (G) and domal sutures (H). Symmetric placement of transdomal sutures may be verified by exposing both domes through 1 nostril (I).
Illustration of a complex nasal tip plasty through a bilateral infracartilaginous approach. A 24-year-old patient before (A, C, E, and G) and 8 months after rhinoplasty (B, D, F, and H). Marked inspiratory alar collapse, a nasal hump, overprojection of the dorsum and tip, and a hanging tip were corrected. A deprojection and rotation of the tip were achieved through a transfixion incision (I), resection of a skin and cartilage wedge from the caudal septum (J), an infracartilaginous approach to the lateral crus (K) with resection of the cephalic half of the lateral crus, excision of the middle segment of the remaining lateral crus (L), rotation of this segment by 180°, and fixation to the ventral (M) and dorsal (N [repositioned segment held with forceps and lateral segment held with single hook]) segment of the lateral crus with mattress sutures. The steps in panels L, M, and N shortened the lateral crus by approximately 10 mm and corrected the concavity of the ala (O [right alar cartilage corrected]). After shortening of both lateral crura, the defect of the caudal septum from the wedge excision (J) is closed by the upward rotation of the tip (P). Fine-tuning of tip projection and rotation completes the tip plasty by anchoring the columella to the caudal septum in the desired position.
Illustration of a revision nasal tip plasty to correct iatrogenic tip asymmetry and bossae of the alar cartilage domes. Tip deformity after a transcartilaginous resection of the cephalic portions of the lateral crus and persistent deviation of the cartilaginous dorsum (A and C). A revision septoplasty and tip plasty through an infracartilaginous approach corrected these deformities (B and D [6 months after surgery]). The displaced and malformed domes were exposed as described in Figure 2 (E and F). Previous surgery resulted in an asymmetric cephalic resection of the domes and lateral crura with kinking of the left dome. Symmetry of the tip was restored by a cephalic resection of the right dome with a single interdomal suture (G).
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