Clinical Review & Education

Surgical Pearls

The Protection of Augmented Tip (PAT) Flap Technique

for Tip Camouflage
Tomas Gomes Patrocínio, MD; Lucas Gomes Patrocínio, MD, PhD; Jose Antonio Patrocínio, MD, PhD

Two of the most tricky rhinoplasty complications are tip irregu-

Figure. Intraoperative Photograph of the Protection
larities and tip graft visibility. In thin-skinned patients, even regular of Augmented Tip (PAT) Flap Technique
dome sutures can create visible tip irregularities. In thick-skinned pa-
tients, strong tip grafts to achieve projection and definition can be-
come visible in long-term follow-
Video
up. Common tip camouflage
materials are crushed cartilage,
temporalis fascia, dorsal rasp leftovers, and acellular dermis, but an
ideal graft is still yet to be described.
Recently, Courson and Adamson1 described the intercrural fas-
cia graft, the soft tissue between the medial crura and the domes
of the lower lateral cartilages, as a graft to camouflage small irregu-
larities at the end of the rhinoplasty.
During the past 3 years, we have been systematically using
the same fibrous tissue between the medial crura to cover and
camouflage tip grafts as a vascularized advancement flap (not as
a graft), as earlier described by Adamson and McGraw2 for pre-
maxillary augmentation. We call this technique the PAT flap (pro-
tection of augmented tip) and use it to prevent tip grafts from
creating irregularities in the long term and to smooth the infratip
lobule transition. preservation of the tissue to be used afterward do not add time to
the overall procedure.
Surgical Technique Thick-skinned patients tend to have a thicker intercrural
After the tip cartilage is exposed by an open approach, the inter- fibrous tissue, favoring its use to cover the strong grafts used to
crural soft tissue is identified. Laterally retracting the lower lateral achieve tip projection and definition. However, thinner PAT flaps
cartilages with a single hook, the dissection begins at the domes are available in thin-skinned patients; the use of this technique is
and is directed posteriorly to the anterior septal angle at an avas- essential to cover dome sutures or even small tip graft
cular plane up to the anterior nasal spine, releasing the soft tissue irregularities.
of the intermediate and medial crura. The blood supply is pre- We have previously published a graduated approach to refine-
served and the flap, now totally freed from the lower lateral carti- ment of the nasal lobule.3 In our group 4, patients with thin skin and
lages and caudal septum, is hidden at a premaxilla pocket. After dome suture maneuvers only, we have been using the same graft
the insertion of the tip grafts, the flap is advanced, covering the to camouflage small tip irregularities. In group 5, patients with thick
graft’s edges and giving a smooth contour to the tip and infratip skin or who require strong tip grafts, we used to use the same graft;
transition. A 5-0 polydioxanone suture is used to secure the vas- however, during the past 3 years, we have been using the PAT flap
cularized flap to the grafts. The technique is shown in the Figure, instead of a free graft.
Video 1, and Video 2. We used the PAT flap in 35 patients. In 23 (66%) patients, the
flap was used to cover tip grafts, and in 12 (34%), to cover newly cre-
Discussion ated domes in thin-skinned patients. We have not identified com-
We present a procedure in which a flap is created dissecting be- plications such as resorption, graft visibility, or prolonged edema in
tween the medial crura fibrous tissue and then sutured over the tip 1-year follow-up.
grafts, protecting the augmented tip, to protect from long-term ir- We present a vascularized flap to prevent tip irregularities and
regularities. The dissection of the intercrural soft tissue is a neces- smooth infratip lobule transition. The PAT flap has become a com-
sary step to refine the nasal tip and to allow maneuvers to struc- mon step of our primary rhinoplasty when the use of tip augmen-
ture the tip as the tongue-in-groove. Therefore, the manufacture and tation grafts is planned.

ARTICLE INFORMATION (T. G. Patrocínio, L. G. Patrocínio); Department of Corresponding Author: Tomas Gomes Patrocínio,
Author Affiliations: Division of Facial Plastic, Otolaryngology, Medical School, Federal University MD, Division of Facial Plastic, Department of
Department of Otolaryngology, Medical School, of Uberlândia, Uberlândia, Brazil (J. A. Patrocínio). Otolaryngology, Medical School, Federal University
Federal University of Uberlândia, Uberlândia, Brazil

jamafacialplasticsurgery.com (Reprinted) JAMA Facial Plastic Surgery Published online April 12, 2018 E1

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 Clinical Review & Education Surgical Pearls

of Uberlandia, Rua Arthur Bernardes, 555, First
Floor, Uberlândia, Minas Gerais 38400-368, Brazil
(tomaspatrocinio@clinicaotoface.com.br).
Published Online: April 12, 2018.
doi:10.1001/jamafacial.2017.2459
Conflict of Interest Disclosures: None reported.
REFERENCES 3. Patrocínio LG, Patrocínio TG, Maniglia JV,
1. Courson AM, Adamson PA. The intercrural fascia Patrocínio JA. Graduated approach to refinement of
graft in primary rhinoplasty. JAMA Facial Plast Surg. the nasal lobule. Arch Facial Plast Surg. 2009;11(4):
2018;20(1):76-77. 221-229.
2. Adamson PA, McGraw BL. Soft-tissue
premaxillary augmentation flap. Laryngoscope.
1991;101(1, pt 1):86-88.

E2 JAMA Facial Plastic Surgery Published online April 12, 2018 (Reprinted) jamafacialplasticsurgery.com

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