See how Rhinoplasty can be used to correct an upturned, over-rotated nasal tip
Dr. Lamperti narrates an intra-operative video that shows how to carve rib cartilage into a caudal septal extension graft. He then illustrates how to use this graft to de-rotate an over-rotated, short nasal tip.
You can learn more about Short, Up-Turned Nose Repair here.
"This is Seattle Facial Plastic Surgeon, Dr. Thomas Lamperti. Today I'm going to show you how we can use rib cartilage to fix an over-rotated, short nose. The first step is to prepare the caudal septal extension graft using the rib cartilage. You can see here that I'm carving the rind or outer portions of the rib in order to obtain the central core which is the most stable portion of cartilage regarding staying straight and avoiding re-curvature. First we'll peel away these outer layers and then obtain the central portion. This rib cartilage carving is actually occurring over at least an hour or so. This is done to allow the various portions to bend and curve as they might occur as they settle. This is occurs as the various forces within the cartilage tissue become evident as it is trimmed. We're now further refining and thinning the central core to create a nice straight, but strong central strut for the caudal extension graft. Now you can see how the other portions of the rib cartilage have bent to various degrees. And these portions can be used for other maneuvers such as batten grafts, spreader grafts, and bridge augmentation grafts. So this rib cartilage isn't useless but just has to be used for various purposes. You can see the nice straight cartilage that I'll now further refine and trim. It is important to leave the strut relatively thin so as to not overly widen the tip as we will be sewing the tip cartilages to this strut in the middle. Now we'll further bevel the edges to then allow us to secure it to the caudal septum, the outer edge of the septum, to lengthen it.
Here we are now placing the graft into position between the medial crura. Now we are using a suture the graft to the septum itself. This is done in several different areas to create a nice bond between the graft itself and the septum. This becomes quite stable as it then heals over time. The movement of de-rotating the tip is quite difficult and we do need a nice strong support structure to maintain this position. Otherwise with scar contracture the tip cartilage unit will want to rotate back up again. I do actually use several sutures to secure the graft to the septum but I won't show you all of these steps but you do get the idea of the technique itself I think. Once I'm happy with the stability of the caudal septal extension graft I will then maneuver the tip dome defining points downward onto the graft. So here I am placing a suture through the right interdomal area -- I'll take a bite of that tissue -- and then carry it downward onto the extended septum itself allowing the placement of the tip in a more derotated position. I'm now aligning the area where I want to go through the graft itself and then enter the other side where we'll make a loop and secure the cartilage on this side down onto the extension graft as well. Obviously, symmetry and precise placement is very important here to create a symmetric tip and to make sure the position is even so we're placing it quite carefully and guiding the needle precisely where I want it to make sure the cartilage ends up precisely where I want it. Now I'll secure the cartilage and move to the next area and secure the cartilage in a different position. This is just a further interdomal stitch to bring the tip cartilages together. You can see that the caudal extension graft seems a bit long and you're right. I actually make it on purpose a little long and that allows me to then trim it to the exact height that I need rather than having it a little bit too short. I'd rather that it be a little long and then trim the graft after the fact once I know the exact length that I need. This is especially the case with rib cartilage where I have plenty of cartilage to work with. So I'm now trimming it to size -- a little bit of tailoring so to speak. I'm just making sure there are no portions of the graft that will stick up through the skin. Now that the graft is trimmed there I'm going to do additional interdomal sutures between the dome defining points to bring the tip defining points closer together to a more natural position to make sure that I'm not overly widening the tip. The goal with this patient wasn't to widen the tip at all as the tip width at the domes were perfect already so I didn't want to change those at all. So we're going to do an additional suture which allows us to bring the dome defining points of the tip just a little bit above the tip that will help to hide or obscure the graft to further ensure that it isn't palpable or visible through the skin at any point. Once we're happy with the tip position we can bring the skin of the tip back down over the tip to secure it and complete the case."