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Editor's Correspondence |

The Nasal Tripod Revisited

George L. Murrell, MD
Arch Facial Plast Surg. 2007;9(2):141-142. doi:10.1001/archfaci.9.2.141.
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I wish to comment on the recent article by Wise et al.1 The authors of this article present their experience with a technique involving division of the medial leg of the nasal tip tripod, with subsequent overlapping of the edges. This technique, intermediate crural overlay (ICO), was used in 11 cases. In these cases, the preoperative and postoperative nasolabial angles were measured by an observer who was blinded to the study objectives. It is stated that nasal tip deprojection was achieved in all patients, although no objective measurements are reported. Counterrotation of the nasal tip, ranging from 1° to 4°, was noted in 3 of the 11 cases. This is what would be predicted by the tripod concept.2 In 7 of the 11 cases, however, nasal tip rotation increased, in 1 case by 9°. No anatomic explanation is given for this finding. The thesis of the article is that ICO results in deprojection of the nasal tip “without significant changes in tip rotation.”1(p244) The authors acknowledge that this proposal, in part, contradicts the tripod concept, which would predict deprojection and counterrotation of the nasal tip with a shortening of the medial leg of the tripod. An increase in nasal tip rotation is opposite from what would be predicted by the tripod concept. The authors stress that although all of the patients underwent domal and interdomal suturing, the “sutures were centered over the dome, and were specifically placed so as not to achieve rotation or counterrotation.”1(p241) However, rather than the tripod concept not being fully applied in these cases, it is plausible that the other nasal tip maneuvers (ie, domal and interdomal sutures) rather than ICO could have contributed to the changes in the nasolabial angle.

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Figure 1.

The intermediate crural overlay (ICO) and lower lateral cartilage overlay techniques. A, On lateral view, the nasal tripod is represented as a triangle. Changes to the triangle limb lengths will affect nasal tip position and therefore projection and rotation. B, The ICO technique and lower lateral cartilage overlay are identical, with division, overlapping, and suturing of the intermediate crura. C, The ICO technique, depending on the amount of the overlap (ie, how much the medial leg of the tripod is shortened), results in an arc of possible tip positions, all of which exhibit both deprojection and counterrotation.

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Figure 2.

Lateral views of a patient who underwent intermediate crural overlay as well as domal sutures centered lateral to the existing tip defining points. A, Preoperative view; B, 3-year postoperative view.

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