Tongue in groove securing of the medial cruras onto the caudal septum by means of sutures is a very powerful and at the same time, should the hands be wrong, dangerous maneuver which should not be applied flippantly since it is not of universal or generalized indication in rhinoplasty, but, should it be required, may be of paramount importance understanding its principles, the versatile effects that might be obtained with it and the delicate calibration required, as well as the risks of its use.
Normally the caudal septum and the medial cruras are separated, floating free and forming the frontier between the mobile tip and annexes unit and the stable immobile pyramid parts of the nose, with the mere separation of the subseptum soft areolar tissue. The tongue in groove eliminates such free float and makes the tip, or at least the medial cruras and the tip solidary and firmly conjoined to the pyramid.
The tongue in groove technical reshaping power comes from the securing and firm fixation of the medial cruras and tip against or towards the caudal septum, which is a very stable and firm fixation point, septum which plays a role beyond just a supportive strut, inserting it between the two medial cruras and suturing them three en bloc to act as a secure fixation point and columella strut at the same time.
The tongue in groove technique is indicated when it is deemed unsafe, unstable, unpredictable or unlikely successful letting the tip, the columella and the nasolabial angle float free to acquire their shape, position, projection and angle or alternatively when other less interventionist maneuvers with the same purpose are unreliable, unfeasible or have already failed, like columellar and tip grafting; it is one of the most powerful and versatile multipurpose maneuvers which can perform on a nose, since it affects, may affect or can freely designed to affect several critical nasal parameters; to project or deproject the tip, the medial cruras and the columella by modifying their support and length; to rotate or derotate the tip affecting part of the columella or all of it including the domes, and accordingly widening or narrowing the nasolabial angle; make the columellar protrusion and visibility show, hide, sink in or protrude partially or totally, etc.
For its performance a non short septum is required or, alternatively, rebuild the septum length with caudal septal extension grafts or septocolumella grafts and assemble the tongue in groove on them, with or without an associated strut to form an L shape scaffold called septocolumella graft.
With that said there are clear and necessary indications of the tongue in groove maneuver, in those noses with undoubted an undisputable requirement of extraordinarily firm positioning, projecting and angling of the tip, columella and nasolabial angle, as long as they are managed by highly experienced surgeons.
About its practical execution, it could not be easier and more accessible to anyone doing rhinoplasties, that is another reason why it is sadly over indicated and over executed, or too often well indicated but poorly executed due to lack of understanding or experience of the executing surgeon; the vast majority of cases it is practiced the tongue in groove was an unwise decision leading to serious structural nasal problems requiring extremely complex revision rhinoplasty procedures; access to the caudal septum is accomplished by means of a very short underneath the muchoperichondrium dissection via closed approach septal delivery or open approach intercrural access, then the medial cruras are partially freed and denuded, the positioning and angling set and the sutures applied.
It is considered a highly demanding technique of high difficulty of calibration but of low to medium difficulty in its execution, short time consuming in the operating room and pretty much artistic in terms of its versatility, allowing full deployment of creativity reshaping noses.
This gesture can be done by either closed or open approach rhinoplasties, notwithstanding the open approach is a must of safety, reliability and precision for its execution.
Patients warning: only highly experienced surgeons who have underwent optimal training and have performed already a large number of closed and open approach structure and non structure rhinoplasties should execute high end rhinoplasty cases, should they feel capable and comfortable with the challenge.