Rhinoplasty, Supratip Deformity Treatment & Management

Proper preoperative surgical planning and identification of those patients at highest risk for the deformity are the hallmarks for prevention of supratip deformity. Though many patients demonstrate mild degrees of supratip prominence following removal of the dorsal splint and dressings, aside from supratip taping, immediate intervention generally is not recommended.

To address supratip prominence, Gruber advises waiting 4-6 weeks after surgery, at which time he injects 1-2 mg of triamcinolone (0.1-0.2 mL of 10 mg/mL triamcinolone) into the supratip with an equal volume of lidocaine.^[19] The patient is evaluated the following week and the dose repeated as necessary. This regimen then is repeated for several weeks as needed.

Guyuron stresses the importance of preoperative identification of those patients at risk.^[4] For patients with a history of prior hypertrophic or keloid scarring and those with noticeably sebaceous oily skin, he suggests prophylactic Kenalog injection into the supratip region at the time of surgery, emphasizing the need for deep injection and avoidance of dermal instillation. In patients who develop noticeable supratip fullness within 1-3 months after surgery, he recommends early aggressive taping (1-3 mo postoperatively) of the supratip region for as many hours as the patient tolerates. If this proves unsuccessful, he proceeds with steroid injection (0.1-0.2 mL of triamcinolone 40 mg/mL or 0.2-0.4 mL of 20 mg/mL) into the supratip swelling. If no improvement is noted after 3 injections, he suggests waiting for at least 1 year before attempting surgical intervention.

Although subcutaneous steroid injection may prove effective at resolving or at least minimizing the appearance of the postoperative supratip deformity, it must be used with caution to avoid associated stigmata. Local complications including telangiectasias, thinning of the skin, and poor healing can result from local installation, and the patient should be warned of these potential adverse events before proceeding with therapy.

The newest medical treatment for supratip deformity involves injection of calcium hydroxylapatite into the deep dermis or dermal-subcutaneous junction above the affected area. The injected substance can then effectively be molded to shape and used to build up and diminish the lower prominence by creating a continuous nasal dorsal profile. Treatment can be performed using topical numbing cream and takes as little as 15 minutes. The result can then be expected to last 8-12 months or longer.

Timing of surgical intervention to address the supratip deformity is equally as important as the overall approach. Although early revision may be tempting, it also may prove disastrous. Nonoperative measures should be exercised and exhausted before surgical plans are made, and these plans should not be pursued before 12 months following the initial surgery. Prior to surgical revision, the nose should be analyzed through a systematic approach focusing on all aspects of its architecture. If possible, obtain old operative records or notes in the planning of this procedure.

The deformity first is defined through a detailed history and complete aesthetic facial and nasal analysis. Next, its etiology is identified. Are displaced anatomic structures present? Have structural components been underresected (incomplete surgery) or overresected (overzealous surgery), or has a combination thereof occurred? From here, surgical goals are established. Finally, a treatment plan is formulated. Displaced anatomic structures must be repositioned appropriately. Areas of underresection should be identified and the proper amount and location determined. Likewise, in areas of overresection, missing tissue should be identified and replaced as needed. Finally, the optimal method of approach (closed vs open) is determined based on the overall findings and the deformity itself.^[20]

In addressing the deformity, Sheen suggested making a proper diagnosis of the abnormality, limiting dissection, using only autogenous graft material, and designing a well-defined preoperative concept of the aesthetic goal. Although he acknowledged that the deformity can reflect local underresection or overresection, in his experience, most were the end result of overzealous resection and inadequate tip support. For these, he advocated autologous augmentation of the dorsal septum and proper tip grafting.

For those patients in whom underresection was the culprit, Rees et al suggest trimming the high dorsum, excising scar tissue, and lowering the upper lateral cartilages, as necessary.^[15] Although he recognized the effectiveness of increasing tip projection through columellar advancement and alar cartilage modification, he advised against the use of alloplastic materials or autogenous grafts to achieve this end, warning of the risk of extrusion or resorption. He also argued against overresection of the upper lateral cartilages, the end result of which can be "...unsightly grooves on either side of the midline of the nasal dorsum below the nasal lines..." that he said are "...almost impossible to correct...."^[15]

In an analysis of the deformity, Guyuron suggested that "...the simplest type of secondary supratip deformity is an overprojected caudal dorsum...."^[4] He believed this can be corrected by resection of excessive cartilage. In patients with thick skin, he advocated placing a supratip stitch to optimize coaptation of the dorsal skin envelope over the modified cartilaginous framework, adding that the goal should be to create a 6- to 8-mm differential between the tip and supratip apices to achieve aesthetically pleasing supratip definition.

For the underprojected tip, he recommended tip grafts if the lobule is small or columellar struts if the lobule is of adequate size. For the underprojected mid vault, he proposed the use of septal, costochondral, or conchal cartilage grafts. For the cephalically oriented lower lateral cartilages, he suggested simply repositioning them to address supratip prominence. Finally, he supported Sheen's conclusion that most supratip deformities are the result of overzealous resection and that the deformity is the end product of scar tissue formed in response to overresection and creation of dead space.^[4]

Review of the comprehensive literature describing both the supratip deformity and its correction suggests an approach tailored not only to diagnosing the problem but also, of equal importance, to identifying its etiology. In the end, the best method for preventing the secondary supratip is to avoid it altogether. This can be accomplished only through a systemic preoperative analysis of the nasal architecture and a focused surgical plan.

In the case of a supratip deformity caused by a previous attempt at a rhinoplasty, a detailed discussion must be carried out with the patient. One feature that is worth emphasizing is that in a secondary or tertiary procedure, the resolution of edema may be slower than in the primary procedure.

While a close follow-up is important in all rhinoplasty patients, it is of particular import in patients who have undergone previous attempts at correction of the deformity. Because of their past experience, they may be significantly more anxious or demanding than "routine" rhinoplasty (ie, patients undergoing their first procedure).