Background: Reshaping of the central part of the face is done by changes to the nose and lips. Whether through a rhinoplasty or various lip augmentations or lifts, the shape of these two midline facial structures have a major influence on one’s appearance whether it is seen from the front or side views.
Rhinoplasty and lp enhancement procedures are not surprisingly requested and done during the same surgery. Normally combining changes to the nose and lips does not pose any adverse risks. The one exception is when an open rhinoplasty and a subnasal lip lift are desired. The proximity of the incisions needed for these operations raises concerns about whether the columellar skin between them would survive if done together. This is a well known debate and surgeons have opinions on both concomitant and staging the procedures.
Case Study: This young female wanted to change the shape of her nose to get rid of her small hump and narrow the tip. In addition she wanted a fuller upper lip and to decrease the vertical skin distance between the nose and the upper lip.
Under general anesthesia an open rhinoplasty was done to reduce the hump, narrow the tip and perform nasal osteotomies. No septal work done including shortening of the caudal septum or separation of the medial footplates. Once the nose was closed a subnasal lip lift was performed removing 4mms of skin at the central lip position.
After surgery she suffered no vascular compromise of the intervening skin segment between the incisions of the open rhinoplasty and the subnasal lip lift. Her aesthetic outcomes were acceptable with a more shapely nose, a shorter nose-lip distance and a fuller central upper lip.
If these two procedures are going to be performed together, maximal preservation of the vascular inflow to the lower columellar skin must be preserved. This requires non-disruption of the tissues that are on the backside of the columella, the septal mucosa and the anterior nasal spine area. This will be adequate for skin survival even with high and low skin incisions on its front surface. If a more extensive septorhinoplasty is to be performed then a subnasal lip lift should not be performed at the same time.
The alternative approach to a combined rhinoplasty lip lift procedure is to use just one incision at the base of the columella. This creates a longer superiorly-based skin flap but as long as excess tension is not placed on the tip skin due to increased projection this should not be a problem. This does, however, potentially create a downward tension the nasal tip which is avoided when a skin segment is maintained between them.
Highlights:
- 1) An open rhinoplasty uses a mid-columellar incision.
- 2) A subnasal lip lift uses an incision that crosses the base of the columella
- 3) Combining open rhinoplasty and a subnasal lip lift requires an appreciation for the integrity of the blood supply to the intervening columellar skin segment.
Dr. Barry Eppley
Indianapolis, Indiana