Bulbous Tip Correction in Asian Nose with Nasal SMAS Excision (Smasectomy)

1)     Introduction

: For the correction of a bulbous nasal tip, cartilage manipulation is a basic procedure, along with Skin & Soft Tissue Envelope (SSTE) reduction which may be an important limiting factor a, especially in Asians. There are many ways to reduce the lower lateral cartilage divergence angle but it is not easy to control thick SSTE. Thus, reduction of SSTE is a more important procedure for the correction of Asian bulbous tip. In this article, the author will introduce the usefulness of nasal SMAS excision(Smasectomy) technique for the correction of Asian bulbous tip with thick nasal SSTE.

2)     Methods

The author reviewed 316 cases of bulbous tip surgery between January 2000 and May 2013. In case of patients with a LLC lateral crus width of more than 10mm, the author classified it as a well developed cartilage framework, and for cases with a LLC lateral crus width of less than 10mm as poorly developed cartilage framework . The author classified patients with an SSTE of less than 3mm thickness as thin,and in cases with a thickness of more than 3mm as thick. The author divide bulbous tip patients into 3 categories as follows.

Category 1. Thin SSTE with well developed cartilage framework.

Category 2. Thick SSTE with well developed cartilage framework

Category 3. Thick SSTE with poorly developed cartilage framework

In case of category 1, cartilage excision of LLC cephalic portion, and lateral crural spanning suture or transdomal & interdomal sutures was performed for the reduction of LLC divergence angle. In case of category 2, cartilage excision of LLC cephalic portion, and cartilage manipulation was performed for the reduction of LLC divergence angle. And an additional procedure of nasal Smasectomy was performed for the reduction of thick nasal SSTE. In case of category 3, cartilage excision of LLC cephalic portion was not performed, but cartilage work was performed for the reduction of LLC divergence angle. And an additional procedure of nasal Smasectomy was done.

The boundary of nasal Smasectomy procedure starts from the supratip breakpoint cephalically to the distal portion of the pronasalae caudally and alar groove laterally. Because the nasal SMAS layer includes a superficial fatty layer, fibromuscular layer and deep fatty layer, Smasectomymay lead to significant bleeding. Therefore meticulous bleeding control is needed.

3)     Results

Of the 316 cases, Category 1 had 33 cases (10.5%), Category 2 had 92(29.1 %), and Category 3 had 191(60.4%). Along with cartilage work, an additional procedure of nasal Smasectomy is important for the reduction of Asian bulbous tip with thick SSTE. However, this procedure may sacrifice major blood supply to the lobular tip.The author experienced 1 case of nasal tip skin necrosis, 4 cases of columellar flap congestion as a complication.

 

4)     Conclusions

In Asian bulbous tip, well developed cartilage framework proportion (Category 1 & 2) was 39.6% and thick SSTE proportion(Category 2 & 3) was 90.5%. Thus, cartilage excision of LLC cephalic portion was performed in 40.6%. and nasal Smasectomy was performed in 90.5% of the patients. All cases need cartilage suture technique.

For the correction of Asian bulbous tip, not only cartilage work but also nasal Smasectomy is an important procedure for the reduction of Asian bulbous tip with thick SSTE. But because the nasal SMAS layer includes a fibromuscular layer, Smasectomy may sacrifice a major blood supply to the lobular tip such as the external nasal branch of anterior ethmoidal artery, lateral nasal artery, columellar artery. After Smasectomy, blood supply to the Smasectomy area is only dermal plexus remains, so nasal tip circulation surveillance is important during post operation period. The author experienced 1 case of nasal tip skin necrosis, 4 cases of colmellar flap congestion as a complication. These major complication occurred only at the early operation period, so this technique may need a certain amount of a learning curve. Another identifiable complication is recurrence of bulbous tip due to scar tissue formation. In this case, post operation triamcinolone with hyaluonidase injection is needed.

Fig. 1 : Total nasal Skin flap elevation

Fig. 2 : Nasal Smasectomy