Vertical Dome Division Rhinoplasty Treatment & Management

Updated: Jul 22, 2015
  • Author: John M Hilinski, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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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. [4] 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. [5] Brennan describes using a complete transfixion incision and sculpting the lateral crural flap by resection of an elliptical area of the caudal-most border. [6] 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. [7] 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. [8] Wise described intermediate crural overlay and how it had minimal effects on nasolabial angle. [9]

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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.

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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.

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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. [10]

Adamson reported that approximately 5% of patients required revision surgery for postoperative tip abnormalities and irregularities attributed to use of vertical dome division (VDD). [11] 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.

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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. [12] 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.

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