You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > COSMETIC SURGERY Rhinoplasty, Broad Nasal TipArticle Last Updated: Jul 8, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 6
  Author: J Charlie Finn, MD, Assistant Consulting Professor of Surgery, Department of Surgery, Duke University J Charlie Finn is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery and American Academy of Otolaryngology-Head and Neck Surgery Editors: Daniel G Becker, MD, Clinical Associate Professor, Department of Otorhinolaryngology-Head and Neck Surgery, Division of Facial Plastics and Reconstructive Surgery, University of Pennsylvania; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Dean Toriumi, MD, Department of Otolaryngology, Associate Professor, University of Illinois Medical Center; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: rhinoplasty, broad nasal tip, nose job, nasal surgery, bulbous nasal tip, rhinoplasty, narrowing of the nasal tip INTRODUCTIONSection 2 of 6
  History of the ProcedureRefinement of broad nasal tip has been a challenge since the first rhinoplasty was performed. Successful narrowing of the nasal tip requires a thorough understanding of the causes of broad nasal tip and the different tools available to address each cause. Skill in a variety of approaches and procedures is required to properly address the diverse anatomy encountered in treating broad nasal tip. ProblemBroad nasal tip refers to the appearance resulting from excessively wide tip defining points or from a disproportion in width between the dorsum and the tip. Other important factors to consider in assessment include skin thickness, racial origins and patterns, and cartilage strength. FrequencyAlthough prevalence has not been studied, broad nasal tip is a common reason of patients seeking rhinoplasty. Broad nasal tip is the dominant problem in many rhinoplasties, while in others it may be a secondary concern. EtiologyMultiple anatomic causes for broad nasal tip exist. The bulbous nasal tip appears as a broad rounding of the area of the lateral crura of the lower lateral cartilages. Commonly, the broad nasal tip has strong and broad lower lateral cartilages. A bulbous nasal tip appearance results when lower lateral cartilages have strong bidomal configurations. Excessive divergence of length of the middle crura can also contribute to a wide, boxy tip appearance. From the basal view, a trapezoidal or rectangular configuration to the tip may occur due to an increased angle of divergence of the middle crura. A weak cartilaginous structure and thickened nasal tip skin create a broad nasal tip with poor definition in some patients. This is common in patients of Asian or African descent and can be very difficult to correct. At times, a combination of thick skin and strong cartilage may contribute to broad nasal tip. The triad of thin skin, strong cartilage, and lower lateral cartilage bifidity is important (see Image 1). Special care must be taken to avoid overexcision of lateral crura in patients with a bulbous tip with this anatomic triad; dome-binding sutures should be applied during rhinoplasty. Great care should be taken to achieve a smooth cartilage result. Otherwise, patients with this triad are at special risk for bossa formation. TREATMENTSection 3 of 6
Surgical therapyRegardless of the surgical approach, the underlying guiding principle in correcting broad nasal tip is to maintain and increase the structural integrity of the tip. Surgical treatment can be divided into 3 categories. First, suture reshaping of the domes is a commonly used approach to achieve significant long-lasting tip narrowing. Dome division is another method used to narrow the bulbous nasal tip. Cartilage grafting offers a third approach that can give the appearance of a narrowed nasal tip. Aside from narrowing the dome, these approaches have other predictable effects that must be anticipated for best results. In all techniques, "the devil is in the details," and careful application of each technique is mandatory for optimal outcomes. The tripod concept is a simplified explanation of tip dynamics that can facilitate understanding of possible effects of the above-mentioned approaches. In the tripod conceptualization, the lateral crura constitute the superior limbs of a tripod, and the combined mesial crura act as the third limb of a tripod. Lengthening the inferior limb causes upward tip rotation and increased projection. Shortening the inferior limb causes counter-rotation and deprojection. Conversely, increasing the length of the superior limbs causes increased projection and counter-rotation. Decreasing the length of the superior limbs causes increased rotation and deprojection. An understanding of the complexities of tip dynamics and a careful consideration of the patient's overall anatomy and specific surgical goals will lead to the appropriate choice of tip-modifying techniques. The effective surgeon will carry a fluid arsenal of tools into each rhinoplasty, to use as each case requires. Preoperative detailsPlanning is key to successful rhinoplasty. The surgeon should undertake a careful and methodical preoperative anatomic analysis. Each nose should be carefully evaluated. Nasal analysis is not the subject of this chapter; the reader is advised to undertake appropriate study of methods and approaches to nasal analysis. The surgeon should carefully examine the bulbous tip, both visually and manually, to gain a detailed knowledge of the skin-soft tissue envelope and the underlying lower lateral cartilages (see Image 2). An intranasal examination is also a requisite part of any complete preoperative assessment. In this preoperative physical examination, the surgeon must visualize the underlying anatomy a structure. The surgeon should also examine the availability and quality of available cartilage grafting sources. A list of problems should be outlined in order of priority following a thorough examination. The steps of surgery are carefully planned based on the surgeon’s examination. The surgical plan may be modified during the procedure, but an organized approach is critical. Intraoperative detailsSuture control Dome-binding sutures can be used to narrow a bulbous tip. A conservative resection of the cephalic edge of the lower lateral cartilages (see Image 3) may be undertaken with dome-binding suture and other approaches. This is commonly undertaken to address bulbous deformity in the horizontal dimension, and in certain cases, it may allow an arched cartilage to bend without buckling. Preservation of a significant complete strip of cartilage is critical. Leaving at least an 8-10 mm width of cartilage is recommended. Careful mattress sutures are placed to narrow the dome area (see Image 4). If this is undertaken via an external rhinoplasty approach, a mattress suture is placed on each dome and progressively tightened until the desired configuration is obtained (see Image 5). The sutures are joined to create a double-dome suture (see Image 6). Typically, these sutures are clear and nonabsorbable with buried knots. An interdomal suture then can be placed to secure the individual cartilages in close approximation. Care must be taken to avoid overtightening of the interdomal suture. Alternatively, a single transdomal suture that acts as a horizontal mattress suture can be placed through both domes such that the knot will be buried between the domes. This approach is commonly undertaken when dome-binding sutures are placed via an endonasal approach. These sutures may be placed through a delivery technique, but some surgeons feel that increased ease and precision is obtained with the external approach. These techniques have been described in detail by a number of authors, including Tardy, Tebbetts, Johnson, Toriumi, and others. Suture control of the nasal tip is a reversible technique. Vertical dome division Vertical dome division (and preferably reconstitution; see Picture 7) can be performed via an endonasal approach (eg, Goldman tip technique, methods described by Simons and others) or alternatively via an external rhinoplasty approach.1, 2, 3 By vertically dividing the dome, the vertical spring of the cartilage is broken and lateral crus repositions in a narrowed configuration. Suture reconstitution of the divided segments provides improved control of healing and improved stability of long-term structure. By altering the location of the lower lateral cartilage division, tip projection and rotation can be altered simultaneously with tip narrowing. According to the tripod concept discussed earlier, by dividing the dome toward the medial crura (and reconstituting the segments), the tip can be counter-rotated and deprojected. By dividing the lower lateral cartilage lateral to the tip defining point (and then reconstituting the segments), rotation and projection can be achieved. At times, a small segment of cartilage may be excised from the lateral crura, or the cartilage may be overlapped and sutured. This provides added control over projection and rotation while simultaneously achieving nasal tip refinement. Cartilage grafting A number of grafts may be applied in the nasal tip, depending upon the anatomy and goals of surgery. Advantages of cartilage grafting techniques include strengthening of the tip and reversibility of techniques. Autologous cartilage is generally the preferred grafting material. Septal cartilage is the most commonly used autologous grafting material in the nasal tip. Conchal cartilage is frequently used when its shape is preferred or when septal cartilage is unavailable. Rib cartilage is another autologous grafting alternative. Irradiated rib cartilage is a nonautologous alternative. Irradiated rib has a tendency to resorb over time and to occasionally warp. Alloplastic materials should be avoided in the nasal tip because the nasal tip is too mobile and too exposed to reliably tolerate artificial materials for a lifetime. Lateral crural strut grafts, as described by Gunter, are underlay grafts placed beneath the lateral crus.4 Lateral crural strut grafts can flatten the bulbous lateral crus and refine the bulbous tip. This technique is best undertaken via the external rhinoplasty approach. Cartilage applied as a tip onlay graft can help create the illusion of a narrowed nasal tip and increase definition. Multiple layers of cartilage may be required. In the endonasal approach, a precise pocket is created in the nasal tip, and the graft is carefully placed. Grafts may also be crushed to camouflage edges. In the external rhinoplasty approach, a sutured-in-place shield graft can define the tip defining points. Tip grafting is a useful technique, especially when thicker skin is involved (see Image 8, Image 9, Image 10). With all grafting techniques, special caution should be used in patients with thin skin, as an increased risk of visible edges and bossa formation exists. Combined techniques Typically, rhinoplasty does not conform to simplified rules. A sophisticated approach and an ability to use multiple techniques are critical. A single technique may be employed with a mildly bulbous nose. However, a number of techniques may be necessary with a more dramatic bulbous shape. Selection of appropriate techniques relies on a detailed preoperative understanding of the patient's anatomy. Postoperative detailsManeuvers performed are carefully documented in operative dictation and in pictorial form immediately following surgery. A diagram provides the surgeon with at-a-glance recall, means for self-evaluation, and a learning tool. Edema of the nasal tip may camouflage the underlying changes to the nasal tip cartilages, especially with an open approach or patients with thick skin. Patients need careful preoperative counseling that final results may not be visible for 1-2 years. In patients with excessive swelling, subdermal injections of a dilute steroid solution may accelerate resolution. COMPLICATIONSSection 4 of 6
Risks of tip refining techniques include tip asymmetry and bossa formation. Development of a polly beak deformity can appear with excessive deprojection, inadequate caudal dorsal resection, or persistent supra-tip edema. In rare cases, suture extrusion or infection can develop, but this can be minimized by carefully concealing knots in deeper tissues, avoiding vestibular exposure of sutures, and avoiding permanent sutures. Nasal valve collapse can occur with excessive tip narrowing, decreasing the nasal airway. This may be treated with lateral crural grafts. Care must be taken with each technique to assess the functional effects of each maneuver. MULTIMEDIASection 5 of 6
REFERENCESSection 6 of 6
Rhinoplasty, Broad Nasal Tip excerpt Article Last Updated: Jul 8, 2008 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
