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Template Rhinoplasty

Paul O'Keeffe developed this operation after years of dissatisfaction with the traditional rhinoplasty operation and a study of fresh cadaver nasal anatomy. It is a closed rhinoplasty so there is no external scarring.

Experience with traditional rhinoplasty procedures highlighted the problem of the unstable nose tip, most commonly a drooping and settling back of the tip. A relationship between the amount of shortening of the length of the nose and the amount of settling back of the nose tip was noticed. A possible explanation for this was presence of muscle in the columella  1  base, particularly a muscle connecting the columella cartilage to the front of the upper lip. A study was carried out to investigate the anatomy. Illustration of relationship between nose shortening and tip position

Muscle was found in the columella base that acts like a tether, pulling the columella backwards when the columella is made to sit higher on the face by nasal shortening.

Apart from the muscle in the columella base, which could be called the superficial depressor septi muscle, plentiful elastic tissue was found in the mucous membrane above the columella, which pushes the columella forward. Thus, there are balancing forces controlling projection of the nose tip.

Illustration of tip tilt factors The tilt of the nose tip was considered to be due to the balance of nose tip projection (9) and length of the alar complex (10). The alar complex length would be shortened when a more upwards tilt was required. This was initially done by excising a portion of the alar cartilage at the middle of the alar cartilage  7  and suturing the fragments together. Later, the alar complex was shortened in the ligamentous portion. Illustration of lateral alar ligament

There is, in Template Rhinoplasty, a complete elevation of the skin and soft tissue from the nasal pyramid that facilitates its redistribution so thickening of the tissue is hardly ever seen. Thus, accurate pre-op planning becomes an option.

Illustration of nose tip cartilages The template rhinoplasty takes these three factors (tether effect, columella projection and alar complex length) into account when planning the changes to the nose. During the planning the nose tip is repositioned first and then the rest of the nose is changed to fit in with the new tip position. Illustration of nose tip dynamics

Planning is done on clinical photographs and when a pleasing change is worked out it is duplicated on life-sized photographs. Usually there will be a shortening of the lateral alar ligament and the exact amount of shortening to produce the desired changes can be measured on the life-size photograph. A template is made by tracing on polycarbonate sheet over the life-size profile photograph. The template is cut out and is used during the operation to guide the surgical reduction of the nose.

A prominent nose Masking to show desired change Life-size photograph with proposed profile change    6 weeks post-operation
Point to photos for descriptions
The template is used post-operatively to check on the changes to the profile, that is, the overall projection of the tip, the tilt of the tip and the reduction of the bridge line. Experience has shown that the nose tip is now more stable in position and drooping is rarely seen for primary rhinoplasty.

A further benefit for patients having this type of rhinoplasty has been noted: the airway is usually clearer. This is due to increased tension in the lateral wall of the nose, at the lateral alar ligament.

Slackness of the lateral alar ligament can be assessed by pulling the cheeks laterally, tensioning the sides of the nose. If this makes the airway is clearer it is likely that the template rhinoplasty will improve the function of the nose.

Illustration of Lateral alar ligament

A disadvantage of template rhinoplasty is the longer time required for planning and for doing the operation and the corresponding greater expense.

There is a more detailed description of this operation in the Template Rhinoplasty section of this site.

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