The tip of the nose is the most anatomically complex area manipulated in rhinoplasty and also one of the most visible. While it is the first area encountered in rhinoplasty surgery and often the last area of manipulation prior to closure, it is highly prone to irregularities. While they can be very subtle, if it is bothersome to the patient it will likely be a reason for revision rhinoplasty.
One such area of the tip that is often a problem is that of the soft triangle region. This area near the tip lacks cartilage support and is very prone to cause notching or retraction when the tip cartilages around it are manipulated. Nasal tip lengthening, transdomal suturing and cephalic lower alar cartilage trimming are all tip maneuvers that create a relative ‘cartilage-deficiency’ in the soft triangle regions. This combined with scar contracture can result in soft triangle recession, often referred to as the parentheses deformity.
Adding structural support with cartilage grafts that span across the soft triangle as alar contour grafts are the known key in both preventing such alar rim notching as well as in its secondary treatment.
In the March 2018 issue of the journal of Plastic and Reconstructive Surgery an article was published entitled ‘The Infratip Lobule Butterfly Graft: Balancing the Transition from the Tip Lobule to the Alar Lobule’. In this paper the authors describe their technique to provide volume to the soft tissue triangle as well as creating a smooth contour between the tip lobule and the alar lobule. Their preferred harvest site is the cartilage obtained from a cephalic trim with desired dimensions of 15mm long by 5mm side in a elliptical shape. It is fixed to the infratip lobule over the middle crura. Its wings then extend caudal to the domes out into the soft triangle area. The wings are not secured by sutures but allowed to act like springs that occupy the soft triangles. By its placement and with its ‘wings’ it gets the name of the butterfly graft.
In doing open rhinoplasty with any tip manipulation, it pays to be observant as to whether structural support is needed in the soft triangle area. This area is often compromised by other tip maneuvers and its natural lack of cartilage support can become magnified. (see attached) Notching of the alar rim in the soft tissue triangle area can mar an otherwise good rhinoplasty result.The butterfly graft is one technique to address this concern and may be a good source of cartilage recycling from cephalic trims of the lower alar cartilages. While some cartilage is always better than none, the butterfly graft provides the length needed to adequately span the tip to alar lobule distance as a single unit graft.
Dr. Barry Eppley
Indianapolis, Indiana