Correspondence: Fernando Pedroza, MD, Department of Facial Plastic Surgery, CES University, Carrera 16, 86a-32, Bogotá, Colombia (email@example.com).
Objectives To present and evaluate outcomes with the seagull wing technique, which was designed to replace the lower lateral cartilages and to reconstruct the nasal tip.
Methods The seagull wing technique is illustrated and described in detail. Sixty patients who underwent surgery 1981 and 2002 were retrospectively evaluated. A preoperative diagnosis of tip deformities was made based on photographs, which were compared with the postoperative results. Patient satisfaction was subjectively evaluated.
Results The postoperative results showed a significant statistical improvement in the following tip deformities: underprojected tip (P<.001), poorly defined tip (P<.001), alar retraction (P<.001), alar pinch (P<.001), overrotated tip (P<.001), and tip ptosis (P<.01). The average follow-up period was 14.6 months. Fifty-five patients (92%) stated that they were very satisfied with the surgical results; they required no additional revision surgery.
Conclusions The seagull wing technique is a safe and efficient reconstructive treatment for the aesthetic and functional problems that were caused by the overresection of the nasal tip cartilaginous framework. The outcomes were pleasing, and the results were stable during the follow-up period. Patient satisfaction was high.
The iatrogenic deformities of the nasal tip represent a great challenge to the surgeon who specializes in nasal surgery. Because of the technical difficulties involved in the aesthetic and functional restoration of the nasal tip, there is a frequent need for revision in such cases. According to Kamer and McQuown,1 23% of the patients who undergo revision rhinoplasty will require a third intervention.
In revision of the nasal tip, various aesthetic and functional deformities caused by overresection of the alar cartilaginous framework are frequently observed. Some of the most commonly used techniques for tip reconstruction partially address these problems. It is well known that the optimal anatomical shape and function of the lower lateral cartilages are rarely, if ever, achieved with these techniques.
We describe our 20-year experience with the seagull wing technique, which is designed to replace the lower lateral cartilages and to reconstruct the nasal tip. This technique has the advantages of almost completely rebuilding the structure of the nasal tip, restoring the function of the external nasal valve, and effectively correcting a great variety of aesthetic deformities.
From 1981 to 2002, the senior author (F.P.) performed 2482 rhinoplasties, 573 (23.08%) of which were secondary rhinoplasties; the seagull wing technique was used in 127 (22.16%) of them. The charts of all 127 patients were retrospectively examined for 1 or more of the following indications: dysfunction of external nasal valve, alar pinch, and previous surgical procedure with an intraoperative diagnosis of overresected lower lateral cartilages. Patients were excluded if they had no preoperative or postoperative photographs and if they had less than 2 months of follow-up. Sixty patients met the study criteria.
All patients were evaluated and questioned about clinical symptoms (especially nasal obstruction), medical history, and social habits. Physical examination was performed to evaluate the external and internal structure of the nose. Diagnosis of alar pinch, lack of tip definition, and tip asymmetry was made on asubjective basis. Diagnosis of columellar show and alar retraction was based on the Gunter classification.2 The ideal tip projection was accessed based on the Byrd coefficient.3 The ideal tip rotation was defined as previously described by Powell and Humphreys.4
Outcomes were assessed based on comparison of the preoperative photographs with the last postoperative photographs and on the subjective evaluation of the patients' overall satisfaction (functional and aesthetic). The χ2 test with Yates correction and the Fisher exact test were used to analyze the data with Epi Info software (version 6.04). Ethical approval was obtained from the Committee on Ethics.
The seagull wing technique consists of the 5 following steps: (1) marking the nasal tip; (2) harvesting the ear cartilage graft; (3) sculpturing and molding the graft; (4) accessing the nasal tip; and (5) fixating the graft (Figure 1). Complementary techniques can be performed as needed.
Seagull wing technique. A through D, Conchal cartilage graft harvesting. E through G, Graft sculpturing and molding. H through K, Placement and fixation of the graft.
Using violet dye, 2 dots are drawn on the nasal skin to demarcate the location of the patient's own domes and vertical lines and to identify the level of the new domes. To aid in defining the level of the new domes, the inferior nasal tip is pressed with the index finger, rotating it cephalically to the desired position. Then, the correct graft place is outlined.
The chosen ear is usually opposite to the side that the patient uses to talk on the telephone. One ear provides sufficient cartilage for a complete reconstruction of the nasal tip. The external acoustic meatus is occluded with a piece of cotton moistened with a povidone-iodine solution. The anterior surface of the concha cymba and the concha cavum is infiltrated with 1% lidocaine and 1:100 000 epinephrine in a subperichondrial plane until hydrodissection is achieved.
The incision,which is made with a No. 15 blade, initially addresses only the skin and the perichondrium. The incision line runs 2 to 3 mm anterior to and below the antihelix, from the antitragus to the most anterior part of the inferior crus of the antihelix. A skin-perichondrium flap is elevated from the anterior surface of the concha.
The cartilage incision is made 1 mm below the skin incision, thus providing a better wound closure. The posterior perichondrium is left attached to the cartilage when it is removed. Removal of the concha cymba provides a cartilage block of approximately 15 × 30 mm. A 3- to 4-mm strip of cartilage is left intact between the concha cymba and the concha cavum if the latter is removed to use in complementary techniques (eg, strut and shield). This strip provides support to the ear and avoids postsurgical deformities.
Complete hemostasis is achieved before skin closure. One tiny retroauricular incision is made for the drain, which is left in place for 1 day. The skin is closed with an interrupted 6-0 polypropylene (Prolene) suture. The concha is packed under pressure with moistened cotton and draped with micropore strips (Figure 2).
Ear graft harvesting. A, Skin incision. B, Skin-perichondrium flap elevation. C, Cartilage withdrawal. D, Skin suture with drain in place.
The concha cymba is divided into 2 equal parts along its longer axis. The place of the new domes is marked to create 1 cm of medial crus and 2 cm of lateral crus. A double-mattress, 910 polyglactin mesh (Vicryl 5-0; Ethicon Inc, Somerville, NJ) suture is used to shape the new domes in the graft, 2 mm below the marking of the new domes. The final molded width of the lower lateral cartilage is 7 mm in the larger portion of the lateral crus and 5 mm in the dome region.
The 2 grafts are then sutured together through their medial crura with the polyglactin mesh. The intercrural stitches are first placed posteriorly, 2 to 3 mm below the domes, and then anteriorly, 6 to 8 mm below the domes. This configuration allows the creation of the aesthetic triangle of Sheen and Sheen5 (Figure 3).
Seagull wing graft sculpturing and molding. A, Shape of the ear cartilage graft harvested from the cymba concha. B, Cartilage division. C, Transdomal suture. D, Bilateral untied grafts. E, Intercrural suture. F, Final shape of the graft.
There are 3 possible approaches to insert the seagull wing graft: via external rhinoplasty, via a marginal incision, and via a delivery approach. The whole graft can be inserted as 1 piece or as individual pieces. The senior author has successfully used both endonasal and external access for the placement of the seagull wing graft. In the last years, only the endonasal approach is been used. When the endonasal approach is chosen, there are 2 options.The first option involves a marginal incision, which is used in patients with a symmetrical but poorly defined and projected tip. Bilateral marginal incisions are performed. A pocket is created over the remaining alar cartilage (lateral crura) and between the medial crura, with the correct size to perfectly fit the graft. In marginal incision cases, the graft should be inserted as 1 piece (Figure 4A and B; video available here). The precartilaginous incision runs along the anterior edge of the alar cartilage. As is frequently seen in revision cases, the alar cartilage may not be present, so the incision should be made in an imaginary line that corresponds to the original border of the alar cartilage. If the surgeon wishes to increase the length of the nose, the graft can be placed anterior to the remaining alar cartilage. The second option involves alar delivery, which is suitable in patients with an asymmetrical and/or a wide tip. In these cases, the graft can be placed as 1 piece, or each alar graft can be placed independently (Figure 4C and D).
Graft placement through marginal incision (A and B) and through delivery approach (C and D).
With both options, the graft is sutured to the remaining lower lateral cartilages and through the vestibule skin with a 5-0 polyglactin mattress interrupted suture. The skin incisions must be completely and meticulously closed with the same suture.
When the surgeon desires a greater increase in tip support and/or projection, a columellar strut can be placed. In the same way, the shield graft of Sheen and Sheen5 can be used to increase tip definition and projection. The shield graft is sutured to the seagull wing graft to avoid further displacement. Before the graft is placed, tip rotation can also be corrected with the “new domes” technique previously described by the senior author.6
Of the 60 study patients, 49 (82%) were female and 12 (18%) were male (age range, 15-58 years [mean ± SD age, 33.4 ± 9.8 years]). Follow-up ranged from 2 months to 13 years (average, 14.6 months). All 60 patients had undergone a previous rhinoplasty procedure; 55 (92%) had undergone 2 or more previous rhinoplasties at other institutions. Article
The most frequently diagnosed nasal tip deformities were poor tip definition (45 cases [75%]), poor tip projection (37 cases [62%]), and alar pinch (34 cases [57%]) (Table 1). Improvement of the poorly defined tip and alar pinch was accomplished in all patients (100%). Improvement of the underprojected tip was observed in 34 patients (92%). Improvement of the nasolabial angle was accomplished in 13 patients (87%) with an overrotated tip, changing from an average of 120° to 104° and elongating the nose 5.5 mm on average. The patients with tip ptosis had an average nasolabial angle of 80° before surgery and achieved an average of 100° degrees afterward. Such enhancement was observed in 13 (88%) of the patients with tip ptosis. All the patients with other diagnosed deformities showed a significant statistical improvement after the use of seagull wing graft; the only exception was observed in those with columellar retraction (P = .13) (Table 1).
Thirty-six patients (60%) presented with obstructive symptoms due to insufficiency of the external nasal valve. All the patients reported improvement of obstructive symptoms. When questioned about their satisfaction with the surgical outcomes, the patients reported that they were very satisfied in 55 cases (95%), satisfied in 3 cases (5%), and not satisfied in 2 cases (3%) (Figures 5-Article7). Complications were not observed.
Preoperative photographs show a poorly projected and defined nasal tip and a slight alar pinch and retraction (A, C, E, and G); photographs taken I year after surgery show clear improvement of tip projection, tip definition, and alar pinch and retraction (B, D, F, and H).
Preoperative photographs show a poorly projected and defined nasal tip and a severe alar pinch (A, C, E, and G); photographs taken I year after surgery show clear improvement of tip projection, tip definition, and alar pinch and great improvement in the nasal base view (B, D, F, and H).
Preoperative photographs show a poorly defined tip and a small supratip deformity (A and B); photographs taken I year after surgery show clear improvement of tip projection and tip definition (C and D); and photographs taken 13 years after surgery show that the outcomes are long lasting (E and F) .
The seagull wing technique, which was created in 1981, has been used by the senior author over the last 25 years. It provides anatomical and physiological reconstruction of the structure of the nasal tip and helps to correct most deformities that have resulted from previous rhinoplasties.
Most of our patients present with the “mestizo nose,” as described by Ortiz-Monasterio and Olmedo.7 The mestizo nose is characterized by thick skin and usually weak lower lateral cartilages. Overresection of the tip framework to achieve refinement is the most common mistake that is made in such cases. Resection of the subcutaneous tissue of the tip (“defatting of the nasal skin”) is considered another mistake. Lack of an underlying structure, severe damage to the soft tissues, thick skin, and vascular insufficiency can lead to unpredictable results. The deformities that most frequently occur are external valve dysfunction, alar pinch, and lack of tip definition and projection due to overresected lower lateral cartilages. To correct these deformities, the surgeon must not only restore but also replace the tip framework. Improving tip definition and projection in a patient with thick skin, which is already very difficult, is much more challenging in revision rhinoplasty cases that involve deformities.
Several authors have described techniques to address specific problems, such as correcting dysfunction of the external nasal valve. The alar spreader graft is a single bar that bridges the intercrural space, with the ends of the grafts placed in an undermined pocket between the lateral crura and the vestibular skin.8 The anchor graft is an anchor-shaped graft whose shaft is sutured to the caudal margin of the medial crura, and the transverse components may replace the lateral crura, but not completely.9 The alar batten grafts are nonanatomical grafts that are placed in a pocket extending from the piriform aperture to a paramedian position in the alar sidewall to correct external nasal dysfunction and can be placed cephalad to the lateral crus for internal valve collapse. The alar batten graft can improve the insufficiency of the external and internal valve as well as the appearance of the nasal pinch deformity, but it fails to improve tip support10 (Table 2).
Other grafts mainly address aesthetic issues, such as the tip support problem, to improve projection or definition. The subdomal graft is a bar-shaped graft that is placed in a pocket under the domes, and although it is suitable for correcting dome asymmetry, it does not correct severe external valve dysfunction.11 The lateral crural onlay graft is placed over the existing lateral crus to correct alar contour irregularities that are caused by a deformed, intact lateral crus, but it may be visible as a “step-off” at the anterior end and cephalic margin of the graft.12 The composite skin-cartilage ear graft is very effective for improving the appearance of the alar retraction, lowering the alar rim.13
Most techniques for revision rhinoplasties assume that useful residual remnants of the tip cartilages are present,14 but there is often a partial or complete absence of the alar cartilaginous framework. To treat severely overresected cases that present several tip deformities, an association of partial or nonanatomical grafts will probably be necessary. The risk of an unnatural look increases as the number of grafts that are used increases. The main advantage of the seagull wing graft is that it is an anatomical graft that totally replaces the lower lateral cartilages and provides the subsurface framework that creates support, nasal projection, airway patency, and the expected nasal contour.
To achieve the desired results, we believe that the conchal cartilage has the sufficient strength and flexibility to be the graft of choice. Its natural shape facilitates the task of sculpting and molding the graft so that it will be similar to the original alar anatomy. Preserving 1 layer of perichondrium over the graft offers better nutrition to the cartilage and decreases graft absorption. Effective correction of the insufficiency of the external nasal valve will ensure the anatomical function of the graft.
The seagull wing technique is indicated in cases in which there are severe signs of overresection of the lower lateral cartilages. Usually, it is recommended for patients who present with a variety of aesthetic and functional complaints, eg, insufficiency of the external nasal valve, alar pinch, or an an intraoperative diagnosis of overresected lower lateral cartilages. In most cases, these indications are associated with poor tip definition and projection and alar retraction. The techique can also be used to lengthen an overrotated and short nose. There are risks involved in the use of technique, however; therefore, carefully molding and suturing the graft, especially in thin-skinned patients, is extremely important to avoid complications such as graft displacement and visualization.
In summary, photographic evaluation showed that the seagull wing technique consistently improved the alar pinch, overrotated tip, alar retraction, tip asymmetry, tip ptosis, tip deviation, and poorly projected and defined tip in our patients. The favorable aesthetic outcomes were confirmed by the excellent rate of patient satisfaction. A great functional improvement was achieved and long-lasting results can be expected. Article
Accepted for Publication: September 1, 2006.
Financial Disclosure: None reported.
Additional Information: A video of the seagull wing technique is available here.
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Seagull Wing Graft: A Technique for the Replacement of Lower Lateral Cartilages
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