Cupuloplasty for Mestizo Nose

Background: The rhinoplasty techniques which are described by most authors are applied on leptorrhine-type noses and have some or no success at all in platyrrhineand mesorrhine-type noses (Mestizo nose) as for the former reduction and removal techniques are used; whereas, in the latter, increase and elevation techniques are used. Objective. To provide an alternate surgical solution which offers proper results in patients with mesorrhineor platyrrhine-type nose. Materials and methods: Preand post-operative photographic records of 200 patients were utilized in this investigation. The same surgical technique was used in all cases, with variations related to the size and severity of the case. Results: In a case in which no cardinal points were set, some loss of the nasal tip and the natural luminous points in it, as well as some upper depression of lateral crura, were noted. In a case in which no anterior elongated trapezoidal graft was placed, there was no adequate definition of the nasal tip in the natural form of its characteristic double fold. Conclusion: Using this technique can help to define, thin, project and turn the nasal tip, give the height as desired, and lift the nasal dorsum when required. This is a highly accessible technique to lift the dorsum through osteo-cartilaginous or cartilaginous grafts with the anterior support (nasal tip) strengthened. This technique also works to increase the strength of tissue by providing an excellent structural support to the axis columella-alar-nose tip, without any elasticity or movement loss since the grafts are sufficiently thin.


Introduction
The rhinoplasty techniques, described by most authors, are applied on leptorrhine-type noses, and have some or no success at all in platyrrhine-and mesorrhine-type noses which are very frequent in and a characteristic of world miscegenation. In the former type, reduction and removal techniques are used; whereas in the latter type, augmentation and elevation techniques are applied. Therefore, we come up with a surgical technique to functionally and aesthetically correct the nose in patients whose characteristics are      The septoplasty was made, and deviations were corrected, efforts were made to take advantage of them and obtain a cartilage bar according to the height, which was planned from the anterior nasal spine to the nasal tip ( Figure 1) [1]. The shape of this cartilage was trapezoidal, very elongated, with blunt edges (Figure 2). When it was necessary to enlarge or make the dorsum regular, we took a bar of cartilage and bone with a strong supercut angled scissors in order to take the septum's basal region without separating the bone from the cartilage (ethmoid bone perpendicular plate (LP) of the quadrangular plate or quadrangular cartilage (LC)). The length of this graft must be the same as the length of the nasal dorsum, and its shape was like a very long, narrow and thin rectangle ( Figure   1). We then proceeded to valvuloplasty with resection of the return of the upper lateral cartilage and the cephalic border of lower lateral cartilage as required. It was extremely important that these dry fragments were kept separately in saline solution to use them afterwards as cardinal grafts. Once the lower lateral cartilage had been taken out and dried, we proceeded to identify with extreme care the dome which, in some cases, was non-existent, and must be assessed according to the desired height of the new nasal tip.
We then carried out a cupulotomy (with skin) making a diagonal cut so that its limits end as a point thus achieve a higher projection and height of the tip ( Figure 3) [2]. We then placeed a graft or cartilage bar (strut) between medial crura (Figure 4), we sutured with Dermalon 6-0 taking care of their stability in order to obtain satisfactory results. We then placed the elongated trapezoidal cartilage bar above the medial crura, taking care that it should be 2 mm higher than the height of medial crura which had been already sutured ( Figure 5) [3].    8). We proceeded to cut the thread without making a knot and leave a loose end of 3 cm approximately as a reference that cartilage remain in their place and are then fixed with tape (micro-pore) which was used to cover the nose at the end of the surgery. These stitches were cut seven or ten days in the postoperative period. If the anterior nasal spine is small or non-existent, we proceed to make a lateral incision and a blunt dissection in order to create a bag. All the remaining small fragments, including those of the bone, were placed as beads in a necklace in a Dermalon 5-0 suture with a large needle (Figure 9), and were inserted through the incision to be left in the desired area and give the volume required to the anterior nasal spine or subnasal expansion ( Figure 10).

Conclusion
Using this technique can help to define, thin, project and turn the nasal tip and, in cases so requiring it, to lift the nasal dorsum.
It is also useful to meaningfully increase the strength of tissue by providing an excellent structural support to the axis columellaalar-nasal tip and, since grafts are sufficiently thin, no elasticity or movement is lost, and we can prevent the effect of a "frozen" nose. Based on the observations and remarks made in relation to the patients referred to in this article, we are reporting a technique which meets many satisfaction requirements for both the patient and the doctor, which will always be influenced by the patient's expectations and by the doctor's skill to carry out the surgery. We make available to the otorhinolaryngologist an efficient and proven technique which will enable the doctor to decide how much he/ she wants to thin, sharpen, lift or turn the tip, or how much he/ she wants to lift the dorsum in relation to the doctor's sense of aesthetics and beauty and the doctor's knowledge and experience in the surgery of platyrrhine or mesorrhine nose.

Discussion
There is a number of techniques to lift the tip in nasal surgery.
Rather than a technique, Goldman's cupulotomy has become one This procedure provides additional support to the nasal tip, and it improves the shape of the columellar labial angle. Further, it makes rotation look controlled. Even with an excellent elevation of the tip of the mestizo nose, the width of nasal base is reduced, making the ratio dimensions of lobule and tip look proportionate because, when we make an elevation, we think the entire nasal lobule. The purpose of this procedure is to give a triangular shape from the basal view of the nose. In order to obtain the best result with this surgical technique, it is necessary the surgeon has a good aesthetic approach. We think this combination of various techniques is an excellent choice which must be included in the rhinoplasty procedures carried out in mesorrhine and platyrrhine noses.