Vertical Dome Division Rhinoplasty 

Updated: Oct 31, 2018
Author: John M Hilinski, MD; Chief Editor: Arlen D Meyers, MD, MBA 

Overview

History of the Procedure

Safian originally alluded to the philosophy and technique of vertical dome division (VDD) in the 1930s.[1] In 1957, Goldman popularized vertical dome division (VDD) as a method of refining tip position without the use of columellar grafts.[2] Despite its initial acceptance, the technique was later stigmatized because of the postoperative sequelae associated with it. Once the dynamics of nasal tip surgery were better realized, the technique regained a degree of popularity and acceptance with modified techniques offered by Simons and Adamson. The indications and applications for vertical dome division (VDD) are now much broader; some surgeons continue to embrace its application, although others strictly avoid it.[3]

Problem

Nasal tip surgery is among the most complex and difficult tasks in rhinoplasty surgery. Vertical dome division (VDD) is one of a variety of techniques that may be used in refining nasal tip appearance.[4] Collectively, vertical dome division (VDD) refers to one of many methods of vertically dividing the lower alar cartilage at or near the dome to modify nasal tip aesthetics. The technique was originally recommended as an alternative in altering tip projection and appearance while minimizing use of implants and the degree of postoperative tip ptosis. Vertical dome division (VDD) targets various nasal deformities, including overprojection or underprojection, suboptimal rotation, disproportionate lobule ratios, and broad or asymmetric tip.[5] The surgeon must strive to achieve an aesthetically pleasing nasal tip that is in balance with the remainder of the nose without compromising nasal airway function.

Epidemiology

Frequency

Although the exact frequency of vertical dome division (VDD) is unknown, the technique is used quite commonly by a variety of plastic and reconstructive surgeons.

Presentation

Candidates for vertical dome division (VDD) typically present for rhinoplasty evaluation with a desire to correct an unfavorable nasal tip appearance. The typical patient presenting for vertical dome division (VDD) usually has a poorly defined or malpositioned tip with a combination of abnormal projection/rotation, broad or amorphous lobule, asymmetric tip defining points, and/or boxy, trapezoidal base.

Indications

Selection principles

Vertical dome division (VDD) is a philosophical and technical approach to management of the nasal tip. This philosophy is based on the belief that vertical dome division (VDD) is a more conservative maneuver than horizontal excisional techniques traditionally used in tip refinement surgery. Adherents to this principle argue that horizontal excisional techniques rely too heavily on unpredictable and uncontrollable postoperative scarring to produce desired tip results. Proponents of vertical dome division (VDD) believe that vertical incisional and excisional techniques, on the other hand, offer a more definitive and reliable means to achieve desired tip changes.

Goldman originally described this technique in 1957, although he never used the term vertical dome division (VDD).[2] In this landmark paper, he attempted to highlight the significance of the medial crura in nasal tip projection. Transecting the domes across the apex, as he described it, was a novel alternative technique intended to help refine and maintain nasal tip appearance without the requirement of grafts or implants. Since this first description, newer insight into nasal tip dynamics has broadened the application and use of vertical dome division (VDD) as an adjunctive tool in rhinoplasty.

In principle, the technique of vertical dome division (VDD) separates the medial and lateral crura into 2 independent units. By transecting the dome, the inherent spring within the arch is released and allows realignment of the newly divided medial and lateral segments to reconstruct the nasal tip.

In general, techniques that preserve the integrity of the alar cartilage anatomy and minimize excision should be considered as first-line methods of modifying the nasal tip. Vertical dome division (VDD) is typically reserved for more complicated cases that require greater changes to effect tip refinement than could be achieved using other techniques. Nearly all variations of vertical dome division (VDD) used today involve some modification of the original Goldman technique. These numerous versions of vertical dome division (VDD) make it a versatile technique that may be applied in patients requiring alterations or corrections in tip projection, tip rotation, infratip lobule abnormality, domal width, and tip asymmetry.

Alteration of tip projection

The underprojected tip

Most cases in which vertical dome division (VDD) is used patients presenting with an underprojected nasal tip. By essentially borrowing from the lateral crus, the length of the medial crura can be augmented to provide an increase in tip projection. The Simons method of vertical dome division (VDD) is a common technique used when mild-to-moderate changes are required. In cases for which more dramatic changes in tip alignment and projection are desired, the classic Goldman procedure is recommended over the modified techniques.

The overprojected tip

Retroactive tip displacement can be accomplished with vertical dome division (VDD) in patients with marked overprojection. In patients with less severe overprojection, more conservative techniques, such as repositioning the medial crural footplates closer to the facial plane, may suffice. By dividing the lower alar cartilage medial to the dome, the medial crus can be overlapped and shortened to drop the anterior projection of the nasal tip complex.

Alteration of tip rotation

The underrotated tip

Vertical dome division (VDD) may also be indicated in patients requiring increased tip rotation. First-line techniques for increasing rotation include simple domal suturing, cephalic trimming of the lateral crura, and cutback of the lateral crural hinge region. Vertical dome division (VDD) can be used to further rotate the nasal tip by dividing the lobule medial to the dome. The lateral crural segments then can be rotated superiorly and repositioned along the caudal septum in a more cephalic orientation relative to the medial segments. This aids in widening the nasolabial angle and, as a result, increases tip rotation.[6]

The overrotated tip

Vertical dome division (VDD) can also be used to decrease tip rotation (counter-rotation). After dividing the alar cartilage medial to the dome, the cut edge of the lateral segment can be overlapped on the remaining medial crus, in a similar fashion to vertical dome division (VDD) for the overprojected nose. By realigning the lateral segment in a more caudal orientation, counter-rotation of the tip is achieved in addition to a decrease in tip projection.

Alteration of other abnormalities

Lobule abnormalities

Many patients presenting with an underprojected tip also have a noticeably short or hypoplastic infratip lobule as observed on base view. Vertical dome division (VDD) is a reliable technique to help lengthen this lobule while providing an increase in tip projection.

The relationship between the infratip lobule and the surrounding tip structures (nasal tip lobule, columella, soft tissue triangles) is complex. The infratip lobule is located between the nasal lobule and the columella and is most typically lunate (crescent moon) shaped in appearance. The structure primarily responsible for the prominent infratip lobule length is the overly long intermediate crus.

Other patients present for nasal tip modification with a disproportionately elongated lobule. Many other techniques used to shorten this lobular region reduce the length of the lateral legs of the nasal tripod; however, they do little for the remaining medial tripod leg. Using these techniques in this situation only serves to further shorten the columellar and overall nostril dimensions, leaving a lobule that is even more disproportionately long. Vertical dome division (VDD) medial to the domes, with overlapping of the medial crural segments, aids in shortening the lobule as well as in correcting overprojection in these patients.

Other patients may present with a hanging infratip lobule abnormality as a secondary indication for vertical dome division (VDD). Ideally, the infratip lobule is observed on lateral view as a subtle break in the columellar profile, with slight cephalic angulation. Patients with a hanging infratip lobule, instead, demonstrate a pronounced inferior curvature or droop in this region. This irregularity must be distinguished from a hanging columella, since techniques intended to correct these deformities are different.

Widened dome

Patients with a widened domal arch present with a relatively broad, amorphous nasal tip with a trapezoidal appearance noted on base view. As the width of the arch increases, definition in the lobule region decreases. Vertical dome division (VDD) may be indicated to help correct this abnormality by narrowing the convergence of the apex and arch, thus increasing projection and restoring a more triangular base appearance.

Tip asymmetries

Asymmetries of the nasal tip and lobule are a frequent and challenging problem for the rhinoplasty surgeon. Vertical dome division (VDD) is a particularly useful technique for managing these asymmetries. Each dome is addressed individually and is divided vertically to achieve a more balanced tip with symmetric domal highlights. Redundant or knuckled cartilage may be excised either unilaterally or bilaterally, and tip rotation or narrowing may be addressed as needed for each side.

Relevant Anatomy

Successful application of vertical dome division (VDD) requires a fundamental understanding of the anatomic components and dynamics of the nasal tip. The most anterior projecting point of the nasal tip is considered the tip defining point. The nasal tip is characterized by the shape of the lobule, which is formed by the contour of the underlying alar cartilage.

The lobule is defined as the portion of the nasal tip complex that is situated anterior to the nostrils; it extends from the tip defining point to the junction with the columella, as observed on base view. The alar cartilage (lower lateral cartilage) is C-shaped and can be divided into the medial, middle, and lateral crus. The middle (intermediate) crus comprises the domal segment and largely influences the shape of the lobule and, therefore, the form and definition of the nasal tip. The dome is considered the highest arching segment within the nasal vestibule.

Important parameters to consider in vertical dome division (VDD) include tip projection and rotation, lobule size, and nasal length. Projection of the tip refers to the posterior-to-anterior distance that the tip extends from the alar-facial groove. Rotation can be defined in terms of relative tip position along a circular arc, with the radius centered at the nasolabial angle and extending toward the tip defining point.

Nasal length is simply the distance from the nasion to the tip defining point. Several methods of calculating tip projection have been developed. The simplest method, as described by Simons, defines projection as the distance from the subnasale to the tip defining point as seen on a profile view, with an ideal distance equal to the height of the upper lip. Tip rotation can be referenced as a function of the nasolabial angle, with ideal rotation measuring 90-100° in males and 95-105° in females. The lobule size can be assessed in comparison to the columellar length. If the base view demonstrates a columellar-to-lobule ratio of approximately 2:1, the structural support and configuration of the nasal tip is considered adequate. A long nasal length reflects an acute nasolabial angle; a short length reflects an obtuse nasolabial angle.

The anatomy of the nasal tip is often described using the tripod concept to facilitate understanding of the key structural components and to provide a simple explanation of tip dynamics. According to this analogy, the cartilaginous framework of the lower third of the nose is compared to a tripod that is attached to the facial frontal plane. The 2 individual lateral crura represent 2 legs of the tripod, and the conjoined medial crura and caudal septal attachments correspond to the third leg.

By lengthening or shortening any or all legs of the tripod, the changes that will be effected in tip projection and rotation can be predicted. For instance, techniques that augment or lengthen the medial crural segment enhance projection. Shortening the medial crura or disrupting their septal attachments without reduction of lateral crural length decreases projection and rotation of the nasal tip. Shortening the lateral crura and maintaining or lengthening the medial crural segment would be expected to increase rotation.

Essentially, 4 major mechanisms contribute to nasal tip support as follows:

  • The overlap (scroll) of the caudal border of the lower lateral cartilage overlapping the cephalic margin of the upper lateral cartilage

  • The membranous attachment between the anterior septal angle and the interdomal ligament

  • The membranous attachment of the medial crural footplates to the caudal septal margin

  • The length, width, orientation, and inherent strength of the lateral crura

In most rhinoplasty procedures, violation of these support mechanisms is avoided or countered using augmentation or reinforcement techniques. By respecting these major mechanisms and by understanding their role in tip projection, potential postoperative complications and tip irregularities can be minimized.

Contraindications

Vertical dome division (VDD) is predominantly contraindicated in patients with relatively thin skin. These patients are particularly prone to developing visible cartilage edges along the nasal tip region. This results from contraction of the thin overlying skin and soft tissue envelope around the new and more prominent medial cartilaginous strut. A thick overlying skin and soft tissue envelope is better able to cushion the appearance of prominent cartilaginous structures, such as those in vertical dome division (VDD).

Avoid classic vertical dome division (VDD) in patients who show evidence of already weakened lateral nasal walls. Dividing the domal region without reapproximation of the cartilage segments disrupts the integrity and continuity of the lower lateral cartilage. The lateral nasal wall is more susceptible to structural collapse than the newly reinforced medial footplates. As a result, lateral wall weakening and collapse are further potentiated.

 

Treatment

Surgical Therapy

The Goldman technique and several modifications are discussed below. The table summarizes some of the key discussion points.

Table. Summary of VDD Techniques (Open Table in a new window)

Technique

Summary

Goldman

Excise vestibular skin

Divide dome at apex

Reapproximate medial crura with horizontal mattress suture

Trim ventral margin of repositioned medial crura

Excise cephalic margin for bulbosity

Lipsett

Divide domes after caudal septum trimmed

and new anterior septal angle set

Divide dome medial to apex

Reposition tip in desired location with compression (no sutures)

Simons

Preserve vestibular skin

Divide dome 2-3 mm lateral to apex with excision of "v" triangle

Superior vector on suturing medial crura

Adamson

Proponent of open approach

Overlap medial and lateral crura cut edges

and stabilize with nonabsorbable suture

Requires tip grafting for increased projection

 

Goldman technique

The vertical dome division (VDD) prototype is the classic Goldman technique, which originally used an endonasal delivery approach. The Goldman technique begins with a transfixion incision and elevation of the soft tissue skin envelope through marginal incisions. Then, the caudal margin of the septum is resected a short distance. The lower lateral cartilages are exposed and delivered with an intercartilaginous incision. A hook serves to identify the apex of the dome. The dome is sharply divided through the apex, including division of the underlying vestibular mucosa and skin. Vertical division in this manner disrupts the contour of the dome and allows the new medial segment to straighten and spring anteriorly (see image below). By borrowing from the lateral crus, the medial crus length is augmented and provides additional structural support for increased tip projection and support.

Goldman technique. Goldman technique.

After resection of the interdomal soft tissue, a midline chondrocutaneous strut is fashioned by reapproximating the medial crural segments with a 4-0 absorbable horizontal mattress suture. The ventral (anterior) margins of the repositioned medial crura then are trimmed a certain distance, depending on the desired final projection of the nasal tip. Goldman specifically recommended ventral trimming such that the caudal margin would be left higher than the cephalic margin. This creates a medial crura strut that is not in direct line with the lateral nasal profile, instead allowing more tilt and upward rotation.

The middle and posterior aspect of both medial crura then are sewn together with 2 additional 4-0 absorbable horizontal mattress sutures. Once the desired tip projection is achieved, an absorbable septocolumellar suture is placed through the chondrocutaneous strut and high along the caudal septum. Cephalic margin trimming is performed along the remaining lateral segments as indicated for residual bulbosity. The soft tissue and skin envelope is then redraped, intranasal packing is performed, and tape is placed across the nasal tip.

Since the original Goldman vertical dome division (VDD) was introduced, an array of technical modifications has evolved to help avoid some of the earlier pitfalls. These variations consist primarily of changes in the location of the vertical incision. By varying the position of the vertical dome division (VDD), the degree and direction of tip projection and rotation can be controlled. For example, vertical division of the dome just at or lateral to the apex results in medial crural lengthening with an increase in tip projection. If vertical division is performed medial to the apex of the dome, less disruption of the natural tip contour occurs and the alar orientation can be altered to decrease tip projection and rotation.

Lipsett modification

Shortly after Goldman's description, Lipsett advocated his variation of the vertical dome division (VDD) technique. Lipsett argued that incising the dome at the apex resulted in an unpredictable postoperative result. The disparity in height between the position of the midline chondrocutaneous strut and the dorsal septal plane, he claimed, predisposed patients to uncontrolled scar contracture. In addition, Lipsett was concerned about the potential for increased infectious complications within the voided supratip region. To avoid these adverse results, he recommended dividing the lower alar cartilage at the level of the desired dorsal cartilaginous plane.

Also, an endonasal delivery approach is used with the Lipsett technique. After the caudal septum has been trimmed and the anterior septal angle height has been reset, the new dorsal cartilaginous plane is established and vertical dome division (VDD) is performed. The apex and most of the domal contour ideally will be situated on a slightly higher plane than the dorsum; therefore, dividing the domes at the level of the new dorsal cartilaginous plane will invariably result in placement of the incision medial to the apex, along the medial crural segment. Thus, division of the dome medial to the apex creates a laterally based chondrocutaneous flap consisting of part of the medial crus, the dome, and all of the lateral crus with the underlying mucosa and vestibular skin coverage.

By carefully repositioning and/or overlapping the chondrocutaneous flaps along the remaining medial crura, Lipsett reports that the tip can be refined as indicated for that particular patient.[7] In repositioning the medial edge of the chondrocutaneous flap more posteriorly, the overprojected, acutely angled nasal tip may be retroactively displaced and reshaped.

Similarly, repositioning the chondrocutaneous flap more anteriorly may provide additional projection and narrowing of the excessively broad nasal tip, although no mention of suture stabilization was made in the original article describing this technique. (The chondrocutaneous flap and skin were reported to be "already adhered" after 10-12 h using tape and a compression sling; however, the durability of this reconstructive technique must be questioned.)

Excess spring within the chondrocutaneous strut then can be addressed with partial thickness cuts (scoring) along the dorsal convexity. If further reduction in the domal height is indicated, excising additional cartilage along the cut medial edge of the chondrocutaneous flap will accomplish this.

Simons modification

The Simons modification to the Goldman technique was borne of the desire to retain favorable effects of vertical dome division (VDD) while maintaining better control of the transected cartilages during the healing process. The Simons technique is also performed via the endonasal approach.

After completion of the marginal incisions and delivery of the alar cartilages, the interdomal region is defatted. As with the Goldman vertical dome division (VDD), precise position of the apex is confirmed by placement of a right angle hook at the highest point within the dome. Accurate identification of these apices ensures symmetric vertical division on both sides. Vertical dome division (VDD) is then performed 2-3 mm lateral to the apex. Unlike the Goldman technique, careful attention is paid to cut through cartilage only, leaving the underlying vestibular mucosa and skin intact (see below). A V-shaped segment of cartilage is excised across the domal region, with the apex pointing toward the caudal margin. To help maintain support, Simons recommends preservation of a lateral crural segment at least 6-8 mm wide. It is suggested that less than 2-3 mm of cartilage be resected along the caudal border to minimize risks of postoperative alar notching.

Simons modification. Simons modification.

The remaining medial crural segments are then reapproximated and fixed with suture. Just as it is important to incise the domes at similar positions, it is equally critical that suture placement in the domal region result in symmetric tip appearance. A 5-0 nonabsorbable suture is placed in a buried, horizontal mattress fashion with the superior bite closer to the transected edge and the inferior bite more medially. With knotting of the suture, Simons also recommends an inferior-to-superior vector of pull to afford better tip rotation.

Adamson modification

Adamson later reported his variation of the Goldman vertical dome division (VDD). He pointed out that an essential factor in reducing many of the postoperative complications seen in vertical dome division (VDD) is restoration of the integrity of the lower alar anatomy. Adamson initially used an excisional technique with suturing but without overlap of the cartilage. Although this provided adequate stability, subsequent alterations of his own technique evolved into new methods that provided more tip support with fewer tip irregularities. The latest technique focuses more on a cartilage incision rather than excision, and overlap with suture stabilization of the divided segments. This modification essentially reconstitutes and maintains much of the integrity of the lower alar cartilage complex. This translates into a more durable structural framework for maintenance of tip support, with reduced aesthetic complications and scarring.

An external rhinoplasty approach is recommended with use of this form of vertical dome division (VDD). Some argue that the external approach offers optimal exposure and assessment of the underlying tip deformities. In addition, this approach also facilitates more precise, symmetric suture approximation, without the inherent distortion that accompanies cartilage delivery techniques.

Once the lower third of the nose has been exposed and septal work has been completed, defatting of the interdomal region is accomplished. If indicated, resection of the medial crural footplate and/or lateral crural hinge region, as well as cephalic trimming, is completed. In many cases, these maneuvers, along with scoring and domal suturing, are adequate to achieve acceptable tip refinement. In cases with more exaggerated tip irregularities, vertical dome division (VDD) is then performed. The vestibular skin is preserved by use of wide undermining along the medial and lateral crura surfaces. The dome is then divided vertically at the targeted site. Any redundancy or knuckling in the cartilage is addressed to optimize tip symmetry. In patients with excessive overprojection or an unusually broad tip, a small segment of cartilage may require excision.

The hallmark of the Adamson technique is overlapping of the medial and lateral cut edges and suture stabilization. The edges can be overlapped approximately 2-4 mm and realigned to form the desired domal height and tip position. The overlapping cartilage is stabilized with placement of a 6-0 nonabsorbable horizontal mattress suture, taking care to bury the knot in the interdomal space. A 6-0 nonabsorbable interdomal suture is placed in similar fashion for added stability. Scoring along the dorsal convexity may be performed for further tip refinement.

Note that this incision and overlap technique result in a reduction of tip projection (see below). In cases for which retroactive tip displacement is not desired, Adamson recommends use of tip grafts, scoring of the new domes, and/or lateral crural overlap and advancement to "buy back" some lost projection. Therefore, the incision and overlap technique is not helpful in patients who require an increase in tip projection.

Adamson technique. Adamson technique.

Other modifications

Patients with a drooping nasal tip may benefit from the McLure modification, which adds a nasal septal strut between the medial crura and maintains a small amount of separation caudally of the repositioned lateral crura to create a new double nasal dome. Safian describes transecting the tip cartilage at the dome.[8] Brennan describes using a complete transfixion incision and sculpting the lateral crural flap by resection of an elliptical area of the caudal-most border.[9] The crural flap is then advanced medially over the medial crus. Finally, in excessively wide and overly projected nasal tips, a hockey-stick excisional extension to vertical dome division (VDD) may be used for excision of excess alar cartilage.

Recently, Bizrah described limiting the marginal incision to the junction of the intermediate and lateral crus.[10] With a limited marginal incision, Bizrah believes less alar retraction may be possible, but no long-term results are available. Shah and Constantinides described cartilage splitting techniques and discussed the specific application of each nasal deformity with the location of division and overlay.[11] Wise described intermediate crural overlay and how it had minimal effects on nasolabial angle.[12]

Preoperative Details

Methodical preoperative analysis and planning is imperative in rhinoplasty surgery. A complete physical examination and thorough consideration of both functional and cosmetic nasal abnormalities is obligatory. This examination includes both a visual survey and manual palpation of the individual nasal subunits. When considering use of vertical dome division (VDD), the overall balance of the nose is appraised, but nasal tip position and appearance become the focus. Agreement on what is and is not an acceptable, cosmetically pleasing nasal tip is somewhat difficult because of the highly subjective nature of aesthetic assessment. Despite this challenge, various methods of objective nasal analysis have been developed and are helpful in characterizing the ideal tip projection and rotation in terms of well-proportioned nasal-facial dimensions.

High-quality, consistent photographic documentation aids in preoperative nasal analysis of the potential impact that tip modification may have on overall harmony and balance. An aesthetically pleasing, well-balanced nasal tip is said to exist when adequate projection and rotation, symmetric tip highlights, and a naturally contoured domal arch transitioning into a slightly convex lateral crus are present. Base view should demonstrate an overall triangular or pyramidal configuration. The lobule length should be equal to a third of the nasal base, while the columella and adjacent nostril length should equal two thirds of the nasal base.

Obviously, nasal analysis of patients presenting for rhinoplasty and tip alteration will deviate from these ideals to a variable degree. This may manifest as an asymmetric, amorphous, boxy, bulbous, and/or bifid tip on frontal view. Lateral and oblique views may substantiate either an overprojected or an underprojected nose with irregularities in the infratip lobule or alar-columellar relationship. On base view of the nose, the overall appearance may confirm a more trapezoidal or rectangular shape, rather than triangularity, with possible evidence of an asymmetric tip. Alternatively, the patient may have a high, acutely angled dome requiring lowering and restructuring to a more graceful arch.

Complications

The classic Goldman vertical dome division (VDD) technique tends to work well in patients with thicker skin. However, vertical dome division (VDD) may result in a narrow, pinched tip in patients with thin skin. Goldman's intention, as stated in his original publication, was to avoid an "unduly pointed nasal tip."

The original technique is highly focused on manipulation and repositioning of only the medial crura, with no attempt made to reconstruct the remaining lateral crural segment and alar rim. Postoperatively, the medial crura and columella are sufficiently stable to resist loss of projection. Some loss of lateral support, which could result in lateral wall collapse and alar retraction, may occur. Vertical dome division (VDD) is also associated with bossae formation. This is most frequently seen in patients with thin skin and firm cartilages. Disruption of the underlying vestibular mucosa and skin, such as in the Goldman technique, also predisposes the patient to possible stenosis.

Beyond the major risks noted above, other postoperative complications associated with vertical dome division (VDD) include inadequate projection and rotation, infratip lobule irregularities, nasal tip asymmetry, and bossae formation.

With use of newer modified techniques and caution, vertical dome division (VDD) can be used successfully in nasal tip refinement with limited postoperative complications and reliable long-term results.

Outcome and Prognosis

Vertical dome division (VDD) can be a highly effective versatile alternative technique in nasal tip refinement. Great controversy still exists regarding the indications for vertical dome division (VDD) and the best type and extent of recommended dome division. Most practitioners using vertical dome division (VDD) today perform some modification of the original Goldman tip procedure. In the few studies available, reported patient and physician satisfaction rates are in the 90% range.

A study by Lavinsky-Wolff et al found that patients who underwent vertical dome division rhinoseptoplasty experienced improved postoperative quality of life, as based on the Rhinoplasty Outcome Evaluation (ROE) questionnaire, the Nasal Obstruction Symptom Evaluation (NOSE) scale, and a 100-mm visual analog scale (VAS). The study involved 44 patients and included a median follow-up period of 5 months, with the median postoperative ROE, NOSE, and VAS scores determined to be significantly better than the preoperative values.[13]

Adamson reported that approximately 5% of patients required revision surgery for postoperative tip abnormalities and irregularities attributed to use of vertical dome division (VDD).[14] These abnormalities were primarily nasal bossae and lobule asymmetries. Abnormalities were nearly 3 times as likely to occur in revision cases as in primary rhinoplasty; incidence was lower with use of the incision and overlap method.

Limited studies attempted to delineate the impact of vertical dome division (VDD) on nasal airflow with mixed and largely inconclusive results. However, this result is not surprising since rhinoplasty surgery typically involves numerous techniques to achieve its aesthetic goal, making it difficult to determine the impact of any single maneuver. Additionally, the known poor correlation between objective nasal resistance measurements and subjective assessment of nasal patency makes interpretation of results somewhat challenging.

Overall, most proponents of vertical dome division (VDD) agree that a more conservative approach with less excision yields better long-term results. With careful choice of technique and regard to tip support mechanisms, vertical dome division (VDD) often can predictably result in aesthetic enhancement and a positive outcome in most patients.

Future and Controversies

Vertical dome division (VDD) continues to be an effective nasal tip technique. Proper patient selection and use of modified vertical dome division (VDD) techniques provide the best long-term outcomes.

Vertical dome division (VDD) has been shown to have fewer complications when used properly. Many of the complications can be avoided if patients are properly selected. A study by Gillman et al demonstrated that vertical dome division (VDD) was 3.5 times less likely to result in bossae formation when used with suture uniting medial crura than with complete tip techniques.[15] Supporters of vertical dome division (VDD) state that healing is more predictable with less excision and more reorientation of the alar cartilages.

Vertical dome division (VDD) is likely to remain controversial in the future and should be undertaken with care. As knowledge of nasal tip surgery evolves, so too will further modifications of our existing tip techniques to attain more predictable outcomes.