Reply: Subnasal Lip Lifting in Aging Upper Lip: Combined Operation with Nasal Tip-Plasty in Asians.

Abstract

197e Reply: Subnasal Lip Lifting in Aging Upper Lip: Combined Operation with Nasal Tip-Plasty in Asians Sir: I thank Dr. Huan Wang for his interest in the article “Subnasal Lip Lifting in Aging Upper Lip: Combined Operation with Nasal Tip-Plasty in Asians.”1 The main focus of this technique is to make natural lip lifting with minimal scars. Therefore, we discussed specifically key suture methods under Surgical Technique in our article. First, too much excision without careful flap dissection may cause sill problems, as you mentioned. Therefore, less lip skin excision and more underdissection toward the Cupid’s bow help to reduce the skin tension. In addition, the balance between these is the main key to the result. As we mentioned in the article, the suture between the superior edge of the orbicular muscle and the base of the nose with interrupted absorbable 5-0 polydioxanone stitches (Ethicon, Inc., Somerville, N.J.) is the most important. Security of this suture helps to control the skin tension. Also, in some conditions, a strut graft also helps to make the nasal base stable. Second, it is crucial to pay utmost attention to the suture because the labial flap is longer than the nasal flap. Stitches taking the nasal flap perpendicular to the skin and the labial flap in parallel have to be placed. In this way, the length of the labial flap shortens and becomes as long as the nasal flap while the columellar skin can be redistributed without cutting this area. This technique is the most critical for minimizing sill deformity. Third, not all cases were successful with regard to scars, and we mentioned this in the Discussion section. In two of the 30 patients (6.7 percent), incisional scarring was noticeable from a conversational distance at the time of long-term follow-up. These patients underwent scar revision surgery and received comprehensive postoperative treatment to prevent additional scarring. Therefore, the surgeon must pay utmost attention to avoid scars with the exact procedure and even tension distribution. Fourth, our incision begins at the alar fold of the nose, enters the nostril, and rises medially on the lower margin of the medial crura of the alar cartilage. A separate incision begins at the other alar fold, enters the nostril, and rises medially, similar to the first incision. A vertical skin bridge is left intact between the left and right incisions. At first, this incision technique was planned because spare skin from lip lifting can be recruited to augment the nasal tip to solve the tip underprojection problem in an aging Asian nose. seemingly compromised or absent. This is somewhat apparent in the cases present in Figures 5 and 8. In addition, because the incision started inferiorly to the sill border, it is reasonable to speculate that tension, whether it is gravitational or dynamic from muscle movements, will be mounting on this structure. It might be especially significant when there are no accessory incisions around the nasal base that could delineate and, to some extent, divert the tension2 to prevent the sills from becoming deformed at long-term follow-up. Therefore, we wonder whether the authors’ team could provide more details on how the nasal sills were processed, protected, or preserved during the procedure. This is because, in our practice, we occasionally have some patients complain about the compromised sills when it comes to a running nose. Second, one apparent advantage of this technique is it avoids any transverse scar on the columella. However, such merit might become a hurdle when it comes to suture-based nasal tip-plasty. This is more difficult when combined with muscle reductions at the nasal base. In our practice, we have concerns on whether this technique could achieve symmetry between two nostrils, as the shape of each nostril is determined by the delicate balance of the incisions, the amount of tissue removed, and the location and tension that each suture undertakes. What are the authors’ experience and suggestions in this regard? Third, another concern of ours is with regard to the indication. This series excluded those who “needed to correct different nasal deformities with spreader grafting techniques, tissue resection, or osteotomy.” Because a successful rhinoplasty procedure could improve the nasolabial angle by increasing the nasal tip projection and height, and consequently elevate the lip, one might therefore wonder, in case when a patient requests, or rather, has the indications for a simultaneous costal cartilage–based rhinoplasty and lip elevation, what suggestions would the authors give? DOI: 10.1097/PRS.0000000000006332