The tongue-in-groove technique

What repeats

Four findings that hold across the literature.

The angle it sets holds better than the angle a columellar strut sets

In 237 open rhinoplasties split three ways, the flexible tongue-in-groove group of 53 and the classic tongue-in-groove group of 107 lost significantly less nasolabial angle between month one and month twelve than the columellar strut group of 77, and both tongue-in-groove groups held higher Goode ratios at one, six and twelve months. The strut works by unifying the tip cartilages rather than by anchoring them, and its effect on raising projection is limited.

Rests on: Erdal et al., 237 cases · Rohrich et al., strut versus extension graft · and the columellar strut.

Some of the rotation gained at surgery goes back in the first year

Fifty-two closed rhinoplasties measured rotation at four points. Mean values ran 100.58 degrees before surgery, 116.19 on the operating table, 113.73 in the short term and 108.49 in the long term. The Goode ratio ran 0.61, 0.77, 0.68 and 0.64 across the same points. Projection settles early and rotation keeps settling, which is why surgeons set the tip slightly higher than the target.

Rests on: Celikal et al., membranous tongue-in-groove · Kocak and Gokler.

The alar-columellar relationship changes in a measurable direction

Ninety-four lateral views from 20 patients were scaled and compared. Exposed lateral nostril area fell at every time point, alar-columellar disproportion fell at every time point, nostril height and nostril length fell, and the nasolabial angle rose. The same stitch is used through the closed approach for a hanging columella.

Rests on: Shah et al., morphometric analysis · Williams, endonasal approach · and open versus closed rhinoplasty.

After open rhinoplasty, rotation is the commonest reason to operate again

A single practice reviewed 252 revisions and put its revision rate at 10.8 percent. The three leading reasons were insufficient tip rotation at 37.7 percent, hanging columella at 30.2 percent and supratip deformity at 28.6 percent. Against the tongue-in-groove, using a strut raised the risk of inadequate rotation 5.3-fold, of hanging columella 5.9-fold and of supratip deformity 2.2-fold. Age over 40 raised the hanging columella risk 6.8-fold.

Rests on: Sibar et al., 252 revisions · and the polly beak.

By what the surgeon is trying to change

One stitch, five different jobs.

Rotation of a tip that points down

Forty-two primary open cases treated for a drooping tip moved the mean nasolabial angle from 85.7 degrees to 99.3 degrees and the tip projection ratio from 0.60 to 0.64, at a mean 17.3 months.

Rests on: Kocak and Gokler · Schertzer et al., tip tensioning.

Projection, raised or lowered

Sliding the crura back along the septum lowers a tip that projects too far. Twenty-two patients had the setback combined with footplate resection or medial crural overlay, and 19 of them, 86.4 percent, were measurably deprojected, at a mean deprojection ratio of 0.06.

Rests on: Datema and Lohuis, deprojection · Spataro and Most.

A front septum that sits off the midline

Kridel and colleagues described the technique across 287 patients treated in two practices, and held it up as the way to keep a corrected caudal septum on the midline. Of the 108 patients whose caudal septum was deviated before surgery, none needed further surgery for it. Suturing the crura onto the caudal septum holds the septum where the surgeon has put it. The technique is used in primary cases and in most revision cases, and it is combined with septal work rather than replacing it.

Rests on: Kridel et al., the original description · Datema and Lohuis, primary and revision · and the caudal septum.

A septum with no usable front edge

When the caudal septum is too short, too soft or already harvested, a septal extension graft is built first and the crura are set onto that. This is the standard route in Asian rhinoplasty, where the septum is often small and the soft tissue thick.

Rests on: Hwang and Dhong · Rohrich et al. · and rib cartilage grafts.

The upper lip, which moves with the base of the nose

In 367 primary rhinoplasties, 209 with the tongue-in-groove alone and the rest with an extension graft under it, the upper lip angle changed significantly in both groups. The base of the columella shifts up and back, and the lip slope on the profile follows it.

Rests on: Sazgar et al., upper lip slope.

What to ask about a tongue-in-groove

Questions the evidence supports asking.

Will the tip feel stiff

Stiffness of the tip and retraction of the columella are the two standing criticisms of the technique, named by the surgeons who use it most. Ask how much of the septum the crura will be set against, and what the surgeon does when a patient reports a rigid tip.

Rests on: Spataro and Most, refinements and pitfalls · Datema and Lohuis.

How much rotation will I lose by a year

Ask for the surgeon's own before and after profiles at twelve months, not at six weeks. The measured pattern is a large gain on the table, a smaller gain in the first months, and a further loss of rotation after that.

Rests on: Celikal et al. · Bellamy and Rohrich · and the tip in the journal archive.

Why this rather than a columellar strut

In 133 primary rhinoplasties by one surgeon, 40 with a strut and 37 with a septal extension graft, projection loss at one year was 4.7 percent for the strut and 0.2 percent for the graft, and mean rotation loss was 4.9 degrees against 1.3 degrees. A meta-analysis of 8 studies covering 256 strut and 371 extension graft patients found long-term nasolabial angle favouring the extension graft.

Rests on: Bellamy and Rohrich · Ozgenc et al., meta-analysis.

What happens to my upper lip and my smile

The profile of the upper lip is part of the result, not a side note. Ask to see profile photographs of patients whose starting nasolabial angle matched yours.

Rests on: Sazgar et al..

The terms, defined

The words used about this technique.

• Tongue-in-groove: setting the medial crura back onto the caudal septum and suturing them there, so the septum fixes tip rotation and projection. [10937111] [27494586]
• Medial crura: the paired cartilage struts inside the columella, the wall between the nostrils. [41349577]
• Caudal septum: the front edge of the septum, running from between the nostrils up to the tip. [27494586]
• Rotation: how far up or down the tip points, measured on the profile as the nasolabial angle. [33649928]
• Projection: how far the tip stands out from the face, measured as the Goode ratio. [40968171]
• Hanging columella: the wall between the nostrils sitting below the nostril rims on the profile view. [22801799]
• Septal extension graft: a piece of cartilage sewn to the caudal septum to lengthen it before the crura are set onto it. [30005789]
• Columellar strut: the alternative, a free piece of cartilage placed between the crura and not anchored to the septum. [32332531]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology published a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what a surgeon should assess and record before changing the tip, whichever technique is used.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries three chapters covering this stitch and the anatomy it acts on. They are written for surgeons.

• Tongue in groove technique for nasal tip positioning
• Supporting the Nasal Tip
• Treatment of the Caudal Septum

The reference summary

Rhinoplasty in StatPearls and Septoplasty in StatPearls, on the National Library of Medicine's Bookshelf, give the anatomy, the indications and the complication list in full text at no charge.

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.
• The Rhinoplasty Society, the surgeons' body, with its member directory.

The trials in progress

Caudal septal work is under test in registered trials, so the evidence base moves.

• Cartilaginous Batten Graft Septoplasty in Caudal Septal Deviation, completed, 20 participants.

What is not settled

• No randomised trial compares the tongue-in-groove with the columellar strut. The comparison rests on single-practice retrospective series and on photographic measurement. [34644278] [34550928]
• Reported rotation loss comes from photographs of series treated by one surgeon each. The four-point measurement that shows it exists in one closed-approach series. [40968171]
• Tip stiffness is named as a criticism in every review of the technique and measured in none of them. [30216946] [27494586]
• Whether the extension graft under the tongue-in-groove adds stability or only adds bulk is argued from cohort comparisons, not from a trial. [40854551] [36728586]
• The upper lip result is reported at one centre in 367 patients and has not been reproduced elsewhere. [35348827]