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Research
Original Investigation
The Tripod Graft
Nasal Tip Cartilage Reconstruction During Revision Rhinoplasty
Fernando Pedroza, MD; Luis Fernando Pedroza, MD; Maria Teresa Achiques, MD;
Edgar Felipe, MD; Felix Becerra, MD
IMPORTANCE Nasal tip revision remains one of the most challenging surgical procedures for
facial plastic surgeons to perform.
OBJECTIVE To describe preoperative and postoperative findings related to nasal tip
functional and aesthetic aspects following revision rhinoplasty using the “tripod” technique.
DESIGN, SETTING, AND PARTICIPANTS A retrospective descriptive study was performed in
patients who underwent revision rhinoplasty between 2007 and 2012 at a clinic in Bogota,
Colombia. A preoperative diagnosis of nasal tip deformity was made on the basis of
photographic records and compared with postoperative nasal tip findings in patients who
required the tripod technique. Photographs were evaluated before and after surgery every
month for the first 3 months, and after 6, 9, and 12 months postoperatively.
MAIN OUTCOMES AND MEASURES Nasal projection, tip rotation, columellar and alar retraction,
alar pinch, lack of tip definition, and nasal tip asymmetry.
RESULTS Sixty-four of the 69 patients who received revision rhinoplasty using the tripod
technique during the study period were enrolled in the study. The tripod technique improved
all of the following aesthetic and functional parameters (all P < .001). Nasal tip definition
improved in 43 of 49 patients (88%). After surgery, projection was normal in 28 of 40
patients (70%) who had underprojection and overprojection preoperatively, and rotation
improved in 29 of 38 patients (76%) who had overrotation or underrotation preoperatively.
Columellar retraction improved after surgery in 18 of 24 patients (75%). The alar region
improved in 41 of 52 patients (79%) who had alar retraction and/or pinch preoperatively, and
inspiratory collapse improved in 49 of 50 patients (98%).
CONCLUSIONS AND RELEVANCE The tripod technique is an efficient surgical alternative for
nasal tip reconstruction during revision rhinoplasty. This technique allows the destroyed
cartilaginous framework to be recreated and returns original nasal tip appearance with stable
results.
LEVEL OF EVIDENCE 4
Author Affiliations: Clínica La Font,
Bogota, Colombia.
JAMA Facial Plast Surg. 2014;16(2):93-101. doi:10.1001/jamafacial.2013.2348
Published online January 23, 2014.
Corresponding Author: Fernando
Pedroza, MD, Clínica La Font, Carrera
16 No. 86 A-32, Bogota, Colombia
(fpedroza@lafont.com.co).
93
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ by Fernando Pedroza Campo on 04/29/2014
Research Original Investigation
The Tripod Graft
N
asal tip revision remains one of the most challenging
surgical procedures for facial plastic surgeons to perform. Changes in the support mechanisms, which are
commonly disrupted by previous operations, and alterations
in normal anatomical structures make this procedure difficult for many surgeons. Manipulation of the nasal tip to restore tip contour and nose function is one of the most difficult tasks to achieve.
The deformities that most frequently occur are external
valve dysfunction, alar pinch, alar retraction, and lack of tip
definition and projection, due to overresected lower lateral cartilages. To correct these deformities, the surgeon must not only
restore but also replace the tip framework.
Toriumi1 reported the importance of reestablishing tip support by stabilizing the nasal base with a columellar strut, suturing the medial crura to the caudal septum, or using a caudal extension graft to maintain projection postoperatively.
Alar and tip asymmetries and contour deformities have
been addressed with multiple graft types, for example, batten grafts,2 lateral crural strut grafts,3 composite grafts,4 alar
rim grafts,1 shield grafts,5 and suture techniques.6,7
Although numerous techniques to restore nasal tip structure have been proposed, to our knowledge, no single structured
graft that is capable of solving all of these major problems simultaneously has been described. The “seagull wings” technique8
described previously by one of us (F.P.) and colleagues is designed to replace the lower lateral cartilages and restore nasal
tip contour. This graft technique has been found to improve tip
projection, tip rotation, alar pinch, alar collapse, and alar retraction, but less improvement has been observed for columellar retraction. According to our results,8 columellar retraction was still
present in 64% of the patients after surgery.
In search of a graft structure that corrects major aesthetic
aspects of the nasal tip contour, including columellar retraction, we propose the creation of a structured graft that we have
named the “tripod.”
The tripod graft is made by adding a complementary
shield graft5 to the seagull wing graft,8 giving it the appearance of a tripod like those used in photography; just as
Anderson9 explained, it has the most similar structure to the
normal cartilaginous nasal tip.10 The tripod graft replaces the
total cartilaginous structure of the nasal tip in patients who
lack support mechanisms because of overresection of nasal
cartilages in previous rhinoplasties.
The aim of this study was to assess the results of the tripod
technique in terms of improvement of nasal tip projection, tip
rotation, alar pinch, alar retraction, and columellar retraction.
Methods
Medical Record Review
A retrospective medical record analysis was performed in patients who required revision rhinoplasty between January 2007
and March 2012, using the tripod technique. One investigator
(F.P.) performed 465 revision rhinoplasties during that time; the
tripod technique was performed in 69 patients, 64 of whom were
included in this study. The remaining 5 patients did not meet the
94
inclusion criteria, either because they did not agree to participate (3 patients) or because they could not complete a minimum
follow-up period (2 patients who lived outside the country). All
patients included in the study completed follow-up of up to 1
year postoperatively. Institutional review board approval and
informed consent were waived because of the study design.
Three specialists (E.F., M.T.A., F.B.) reviewed all medical
records from patients in whom the tripod technique was used
for revision rhinoplasty. Data regarding age, sex, and number
of previous operations were collected. Patient measurements were obtained by photographic analysis to compare aesthetic parameters before and after surgery. The same photographer photographed all patients before and after surgery.
Outcomes and Measures
The following measures were considered in the frontal and lateral photographs and analyzed with specialized software. Nasal projection was based on the Byrd coefficient11; tip rotation, as defined by Powell and Humphreys12; and columellar
and alar retraction, based on the Gunter classification.13 Alar
pinch, lack of tip definition, and nasal tip asymmetry were assessed subjectively.
Photographs were evaluated before and after surgery every month for the first 3 months, and after 6, 9, and 12 months
postoperatively. All measurements were taken in the same way
every time.
Outcomes were assessed by comparing the different measures before and after the tripod technique surgery. The 12month postoperative photograph was used for analysis, and
different aesthetic parameters were compared objectively. A
qualitative comparison was made to address improvements.
Surgical Technique
The tripod technique consists of 4 steps: (1) marking the nasal tip, (2) harvesting the ear cartilage grafts, (3) sculpting and
molding the grafts, and (4) placing the tripod graft as a single
block or as independent grafts (Figure 1).
Marking the Nasal Tip
The first step during the operation consists of marking the nasal tip. Determining a patient’s domes and the location of the remaining alar cartilages is essential for surgical planning. The inferior nasal tip is pressed upward to rotate it cephalically to the
desired position to define the level of the new dome,7 and the new
dome position is marked. The positions of cartilage grafts and
additional rhinoplasty techniques for the patient are also marked.
Harvesting the Ear Cartilage Grafts
The anterior surface of the concha cymba and the concha cavum are infiltrated with lidocaine, 1%, and 1:100 000 epinephrine. An incision is made with a No. 15 blade 2 to 3 mm below
and anterior to the antihelix, from the anterior crus of the antihelix to the antitragus. A skin-perichondrium flap is elevated on the anterior surface of the concha.
The cartilage incision is made 1 mm below the skin incision to improve wound closure. The posterior perichondrium
is harvested together with the cartilage. Removing the concha cymba usually provides a cartilage strip of approximately
JAMA Facial Plastic Surgery March/April 2014 Volume 16, Number 2
jamafacialplasticsurgery.com
The Tripod Graft
Original Investigation Research
Figure 1. The Tripod Technique in Revision Rhinoplasty
A Conchal Cartilage Harvest
Skin incision
B
Cartilage for the seagull wing
Cartilage for the shield
Graft Sculpting and Molding
30 mm
22 mm
7 mm
Measuring and sculpting the shield
C
Sculpting the seagull wing graft
Independent grafts
Tripod graft in block
Tripod Placement as 1 Block
Precartilaginous incision
Pocket dissection
Placement into the pocket
Fixation of the tripod graft
D Tripod Placement as Independent Grafts
Suture of the seagull wing
to the cartilage remnant
Fixation of the
right seagull wing
Fixation of the
left seagull wing
15 × 30 mm. The concha cavum is always removed with the tripod technique to shape the frontal shield graft. A 3-mm-wide
cartilage bridge is left between the concha cymba and the conjamafacialplasticsurgery.com
Suturing the shield
Finalized tripod graft
cha cavum to maintain good support to the ear. Two small
drains are left in the field. The concha is packed with moistened cotton and draped with micropore strips.
95
The Tripod Graft
Figure 2. The Tripod Graft Unit (Seagull Wing Graft + Shield Graft)
A
B
C
A, Frontal view. B, Lateral view. C, Rear view.
Figure 3. Tripod Technique as Independent Grafts
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
A-D, Preoperative photographs. E-H, Photographs taken 1 year after surgery. I
and J, Nasal surgical markings. K, Independent seagull wing grafts.8 L, Suturing
96
the right seagull wing. M, Suturing the shield. N, Finalized independent tripod
graft. O, Spreader grafts.17 P, Cartilage grafts over the upper lateral cartilages.
The Tripod Graft
Figure 4. Tripod Technique as Independent Grafts
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
A-D, Preoperative photographs. E-H, Photographs taken 1 year after surgery.
I, Nasal surgical markings. J, Conchal cartilage harvest. K and L, Sculpting and
molding the seagull wings8 and shield5 grafts. Ruler in K is in millimeters.
M-P, Placing the independent grafts as the tripod graft.
Sculpting and Molding the Grafts
After the ear cartilage is harvested, the concha cymba is divided into 2 equal parts along its longer axis. The domes are
marked and sutured with 910 polyglactin mesh (Vicryl 5-0,
Ethicon). The final size of this graft, which represents the
alar cartilage, has approximately 10 mm of medial crura and
20 mm of lateral crura. The lateral crura is 7 mm wide in the
central part and 5 mm at the dome area. Each part of this
graft constitutes 1 lower lateral cartilage. The parts are
sutured together with 910 polyglactin to form the seagull
wing graft.8
Then the shield graft is sculpted from the concha cavum. The
approximate measurements depend on the individual patient
but usually range from 15 to 20 mm long and from 7 to 8 mm wide
at the superior border. Once the shield has been shaped, it is sutured to the anterior part of the seagull wings to form a single
block cartilage graft, called the tripod graft (Figure 2).
Placing the Tripod Graft
The whole graft can be inserted via an endonasal or external
approach. The usual approach used for patients in this study
was endonasal via the precartilaginous or marginal incision.
Bilateral precartilaginous incisions were made, and pockets
above the remaining alar cartilages were formed. Then the graft
was inserted through the incision and fitted into the pockets.
The graft was placed anterior and superior to the patient’s own
alar cartilages to increase the length of the nose and to improve columellar retraction.
97
The Tripod Graft
Figure 5. Tripod Technique in 1 Block
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
A-D, Preoperative photographs. E-H, Photographs taken 1 year after surgery.
I, Nasal surgical markings. J, Bilateral conchal and tragal cartilage grafts. Ruler is
in millimeters. K and L, Sculpting and molding the seagull wings8 and shield
grafts. M and N, Finalized tripod graft in 1 block. O and P, Butterfly graft.18
The graft was sutured to the remaining lower lateral cartilages and to the anterior skin of the precartilaginous incision with 5-0 polyglactin sutures. The skin incisions were
closed meticulously. If needed, the tripod can be assembled
separately; the seagull wing graft can be independently added
over the remaining alar cartilages, and then the shield is placed
and sutured to the seagull wings (see Figures 3, 4, and 5).
Definition
A poorly defined nasal tip was the deformity diagnosed
most frequently. Forty-nine of the 64 patients (77%) presented with poor nasal tip definition; this characteristic
improved in 88% of patients. Only 6 patients had similar
preoperative nasal tip definition after surgery. Success was
estimated at 78% to 97%.
Projection
Results
A total of 64 patients were included (55 women [86%] and 9
men [14%]). The mean (SD; range) age was 32.5 (9.6; 19-59)
years. All patients had undergone at least 1 previous rhinoplasty elsewhere (Table 1). Results for aesthetic parameters are
as follows (Table 2).
98
Underprojection was the second most frequently altered
parameter; 38 of the patients (59%) had an underprojected
nasal tip, and only 2 (3%) had an overprojected tip. We
observed improvement in this parameter in 28 patients
(70%). The mean projection was 24.7 mm preoperatively
and 27.6 mm postoperatively, which was considered a statistically significant improvement.
The Tripod Graft
Rotation
Inspiratory Collapse
We observed that 76% of the patients with altered rotation,
either overrotation (48%) or underrotation (11%), improved
compared with their preoperative analysis. Twenty-nine of 38
patients with rotation problems showed a better nasolabial
angle postoperatively. Surgical success was estimated at 64%
to 88%. The mean underrotation angle was 87° before surgery and 97° after surgery, whereas the mean overrotation angle
was 119° preoperatively and 108° postoperatively.
Before surgery, 50 of the patients (78%) showed inspiratory
collapse, but only 1 did so after surgery. Improvements in
external valvular collapse were achieved in 98% of the
patients.
Table 1. Principal Characteristics of the Study Patients
Value
(N = 64)
Characteristic
Age
Columella
Columellar retraction was observed in 24 patients (38%). After
surgery with the tripod technique, 75% of these patients showed
substantial improvement. Although an objective measurement
was used to assess improvement, it was necessary to consider
cases with severe columellar retraction (>4 mm). These patients
had no normal measurements postoperatively but showed an
important improvement in columellar retraction when evaluated qualitatively. We found that all patients (100%) improved
after surgery on the basis of a qualitative assessment.
Mean (SD), y
32.5 (9.6)
No. (%)
≤19 y
1 (2)
20-29 y
14 (22)
30-39 y
23 (36)
40-49 y
20 (31)
50-59 y
6 (9)
≥60 y
0
Sex, No. (%)
Male
Alar Region
9 (14)
Female
Alterations in the alar region were classified as alar retraction, pinched ala, or both. We found alar retraction in 10 patients (16%), a pinched ala in 12 (19%), and both in 30 (47%).
We observed an overall improvement in 79% of patients for this
parameter. Of the 30 patients who presented both deformities simultaneously, only 1 did not show major improvements after surgery.
55 (86)
Previous rhinoplasties, No. (%)
1
36 (56)
2
18 (28)
3
8 (12)
4
1 (2)
5
1 (2)
Table 2. Prevalence of Tip Deformities During the Preoperative and Postoperative Periods
Prevalence, No. (%)
(N = 64)
Deformity
Preoperative
Postoperative
Defined
15 (23)
58 (90)
Not defined
49 (77)
6 (9)
Success Rate,
Proportion (% [95% CI])
P Value
43/49 (88 [78-97])
<.001
28/40 (70 [57-83])
<.001
29/38 (76 [64-88])
<.001
18/24 (75 [60-85])
<.001
41/52 (79 [67-90])
<.001
49/50 (98 [94-100])
<.001
Nasal tip definition
Projection
Normal
24 (38)
52 (81)
Overprojected
2 (3)
3 (5)
Underprojected
38 (59)
9 (14)
Normal
26 (41)
55 (86)
Overrotated
31 (48)
9 (14)
Underrotated
7 (11)
Rotation
0
Columella
Normal
40 (62)
58 (91)
Retraction
24 (38)
6 (9)
Normal
12 (19)
53 (83)
Retraction
10 (16)
7 (11)
Pinch
12 (19)
3 (5)
Retraction and pinch
30 (47)
1 (2)
Alar region
Inspiratory collapse
Yes
50 (78)
1 (2)
No
14 (22)
63 (98)
99
The Tripod Graft
None of the 64 patients included in the study required
any further revision procedure; they were all satisfied with
the results.
Discussion
The tripod technique was designed by one of us (F.P.) to correct all nasal tip alterations derived from previous surgical
procedures, including poor nasal tip definition, tip underprojection, tip overrotation, alar retraction, pinched ala, alar
collapse, columellar retraction, and lack of support of the
nasal tip. The tripod graft replaces the total cartilaginous
structure of the nasal tip, and it therefore provides excellent
support to the nasal tip, as well as a pleasing aesthetic
appearance, and recovers the functional aspects of the nose.
The addition of the shield graft gives more support to the tip
by adding strength to the medial crura and columella. It also
improves nasal tip definition.
In our practice, of the 1453 rhinoplasties performed between January 2007 and March 2012, 32% were for patients undergoing revision rhinoplasty (n = 465) who had previous operations at other institutions and sought out one of us (F.P.)
to correct their defects. Sixty-nine (15%) of the patients undergoing revision rhinoplasty presented nasal tip deformities that required complete nasal tip reconstruction with the
tripod technique.
Lack of nasal tip structures, damage to soft tissues, and vascular supply alterations cause most of the problems observed
with the nasal tip, which include external valve dysfunction,
alar pinch, alar retraction, lack of definition, and columellar
retraction.8 Most revision rhinoplasty techniques promote an
open approach to correct these deformities, arguing for better visualization of the structures that must be corrected.14
However, the tripod technique addresses all nasal tip structural, functional, and aesthetic problems using an endonasal
approach, in which the graft can be correctly positioned and
sutured to the alar remnants.
Some authors have described techniques intended to solve
specific problems, such as an alar spreader graft to address lat-
eral crura alterations15 or an alar batten graft to correct nasal
valve dysfunction.2 Other authors have suggested that the nasal tip consists of 3 segments: the columella, lobule, and ala,16
each of which must be addressed, as we also propose. They replaced the weakened lateral crura and sutured the replacement graft to the medial crura stubs and then used a tip graft
via an open approach. The tripod technique can be used as a
single framework to reproduce nasal tip structure and contour, correcting all the aesthetic deformities and functional
problems derived from previous operations, producing a natural-looking nasal tip.
Columellar retraction, which is a common problem in revision rhinoplasty cases, is difficult to correct, and retraction
improved in only 36% of cases when the seagull wing technique was used.8 Adding a shield graft5 to the seagull wing
graft8 (the tripod graft) corrected the columellar retraction in
75% of cases in the present study, in addition to correcting the
other aforementioned nasal deformities.
We believe that conchal cartilage is the best cartilage graft
for re-creation of the normal cartilage framework of the nasal
tip because of its flexibility and similar thickness to the alar
cartilages. It is also easy to sculpt, facilitating reproduction of
the shape of the alar cartilages.
The only limitation of the tripod graft technique is in patients who lack ear cartilage to harvest because of resection
in previous rhinoplasties.
Conclusions
The tripod technique has been demonstrated to be clinically
and statistically effective for correction of nasal tip rotation and
projection, improvement of nasal tip definition, and correction of columellar retraction and alar deformities such as pinching or retraction. It also corrects functional problems such as
valvular collapse. These results suggest that the tripod technique is a reliable method of repairing nasal tip alterations in
revision rhinoplasty cases in which cartilage overresection is
an issue or in which there is a combination of aesthetic and
functional problems that must be addressed.
ARTICLE INFORMATION
REFERENCES
Accepted for Publication: August 16, 2013.
1. Toriumi DM. New concepts in nasal tip
contouring. Arch Facial Plast Surg.
2006;8(3):156-185.
Published Online: January 23, 2014.
doi:10.1001/jamafacial.2013.2348.
Author Contributions: Drs L.F. Pedroza and
Becerra had full access to all of the data in the study
and take responsibility for the integrity of the data
and the accuracy of the data analysis.
Study concept and design: All authors.
Acquisition of data: All authors.
Analysis and interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: All authors.
Administrative, technical, or material support:
F. Pedroza, L.F. Pedroza, Becerra.
Study supervision: F. Pedroza, L.F. Pedroza, Becerra.
2. Toriumi DM, Josen J, Weinberger M, Tardy ME Jr.
Use of alar batten grafts for correction of nasal
valve collapse. Arch Otolaryngol Head Neck Surg.
1997;123(8):802-808.
3. Gunter JP, Friedman RM. Lateral crural strut
graft: technique and clinical applications in
rhinoplasty. Plast Reconstr Surg. 1997;99(4):
943-955.
4. Tardy ME Jr, Toriumi D. Alar retraction:
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5. Sheen JH. Tip graft: a 20-year retrospective.
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6. McCollough EG, English JL. A new twist in nasal
tip surgery: an alternative to the Goldman tip for
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7. Pedroza F. A 20-year review of the “new domes”
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9. Anderson JR. The dynamics of rhinoplasty. In:
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1969;206:708-710.
Conflict of Interest Disclosures: None reported.
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10. Larrabee WF Jr. The tripod concept. Arch
Otolaryngol Head Neck Surg. 1989;115(10):11681169.
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12. Powell N, Humphreys B. The Five Major
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1984:15-41.
13. Gunter JA, Rohrich RJ, Friedman RM, Hackney
FL. Importance of the alar-columellar relationship.
In: Gunter JP, Rohrich RJ, Adams WP, eds. Dallas
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14. Quatela VC, Jacono AA. Structural grafting in
rhinoplasty. Facial Plast Surg. 2002;18(4):223-232.
17. Sheen JH. Spreader graft: a method of
reconstructing the roof of the middle nasal vault
following rhinoplasty. Plast Reconstr Surg.
1984;73(2):230-239.
18. Clark JM, Cook TA. The ‘butterfly’ graft in
functional secondary rhinoplasty. Laryngoscope.
2002;112(11):1917-1925.
15. Gunter JP, Rohrich RJ. Correction of the
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Reconstr Surg. 1992;90(5):821-829.
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rhinoplasty: the 3-dimensional nasal tip. Arch Facial
Plast Surg. 2006;8(3):195-201.
101

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