You are in: eMedicine Specialties > Plastic Surgery > NOSE Rhinoplasty, Tip ApproachesArticle Last Updated: Feb 11, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: George Peck, Jr, MD, Consulting Staff, Department of Plastic Surgery, St Barnabas Hospital of New Jersey George Peck is a member of the following medical societies: American Society for Aesthetic Plastic Surgery Coauthor(s): George C Peck, Sr, MD, Professor, Department of Plastic Surgery, University of Medicine and Dentistry of New Jersey; Richard E Peck, MD, Assistant Professor, Department of Plastic Surgery, University of Medicine and Dentistry of New Jersey ; Consulting Staff, The Peck Center Editors: Fred Menick, MD, Clinical Associate Professor, Department of Surgery, Division of Plastic Surgery, University of Arizona; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; R Edward Newsome, MD, Associate Professor, Program Director and Chief, Department of Surgery, Section of Plastic Surgery, Tulane University Health Sciences Center; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Deepak Narayan, MD, FRCS, Associate Professor of Surgery (Plastic), Yale University School of Medicine; Chief of Plastic Surgery, West Haven Veterans Affairs Medical Center Author and Editor Disclosure Synonyms and related keywords: Nasal tip, nasal tip correction, nasal tip approach, rhinoplasty, tip rhinoplasty, tip approach, nose tip, hump reduction, nasal hump, tip cartilage, intracartilaginous, infracartilaginous, endonasal, nasal tip definition, define nasal tip APPROACH TO NASAL TIPSection 2 of 11
  Correction of the nasal tip is one of the most challenging aspects of rhinoplasty surgery, requiring ingenuity and flexibility of the surgeon. Every surgeon should master several techniques to modify the nasal tip. The nasal tip should be modified before making alterations to the nasal hump. This sequence of surgery has been found to be advantageous because the removal of cartilage from the nasal tip that defines the tip also decreases nasal tip projection. Once the cephalad border of lower lateral cartilages is removed, the surgeon can perform nasal hump reduction by merely lowering the nasal dorsum to accommodate the new nasal tip projection. The 2 basic endonasal approaches to remodeling the tip cartilage are the intracartilaginous and infracartilaginous approaches. The intracartilaginous approach is the author's favored technique to produce a nasal profile in which the nasal tip stands out approximately 2 mm from the dorsal bridge line. This endonasal operation is unquestionably useful in managing the nasal tip in both primary and secondary rhinoplasty. The surgeon sees the result immediately. This approach involves no guesswork, excess edema, or flap issues that may interfere with the surgeon’s ability to evaluate the definition of the nasal tip. ANESTHESIA FOR TIP SURGERYSection 3 of 11
Local anesthesia for tip surgery is used more for the hemostatic effect (epinephrine) than the regional block (lidocaine) that circumferentially interrupts all the neural pathways to the nasal tip and bridge (see Image 1A). Most of the authors’ patients who have primary or secondary rhinoplasty undergo general anesthesia, making the need for local anesthesia much less necessary. For administration of the anesthetic, we use a 25-gauge needle and 5-mL syringe. Insert the needle until bone is felt and direct it cephalad (see Image 1B). The surgeon injects the local anesthesia as the needle is withdrawn. The needle is then directed caudally (see Image 1C) to inject the area of the infraorbital foramen (see Image 1D), the base of the alar rim, and the area of the piriform fossa (see Image 2B). Inject a very small amount of local anesthetic to the proposed intercartilaginous line intranasally (see Image 2C). Before beginning surgery, wait a minimum of 10 minutes for the local anesthesia to take its full effect. NASAL TIP SURGERYSection 4 of 11
The intracartilaginous technique is the most precise method to produce nasal tip definition and a profile in which the nasal tip stands out gracefully from the dorsal bridge line, with good nasal tip projection and sufficient supratip break. The nasal tip should project approximately 2-3 mm beyond the nasal bridge. Remember that the initial local infiltration of anesthesia does not distort the tip or the bridge; thus, the results of surgery on these areas are immediately observed. Examination of the patient should include profile and frontal views to determine the plan for surgery. The authors take 7 photographs for the operating room (2 frontal and 4 lateral in repose and smiling, with 1 worm’s eye view). Always mount the photographs in the operating room so that they can be used for reference during the procedure. PREPARATION AND MARKING FOR TIP SURGERYSection 5 of 11
When the patient has been prepared for surgery, examine the nose carefully. Palpate the cartilaginous structures. As Gustav Aufricht once told the author, "not only must we study the nasal and facial lines, we must feel the nose and put the feel of the nose into our fingers." Palpate the caudal borders of the lower lateral cartilage, and use a skin marking pencil to outline those borders on the external skin (see Image 3). The intracartilaginous incision (see Image 4B), which resembles a gull's wing, is next outlined on the external skin (see Image 4A). In most patients, the author elects to leave a caudal margin of lower lateral cartilage that measures approximately 4-5 mm. Precisely how much cartilage is removed is not important; the amount of remaining cartilage is important. The integrity of the lower later cartilage must remain intact to prevent notching or nasal wall collapse. The surgeon must remove enough cephalad lower lateral cartilage to create nasal tip definition while maintaining the integrity of the lower lateral cartilages. LOWER LATERAL CARTILAGE SURGERYSection 6 of 11
Nasal tip technique Place the suction tip intranasally in the dome area beneath the sculpturing line that has been drawn on the external skin (see Images 5A-5B). An imprint is created by applying pressure with the middle finger of the opposite hand against the tip of the suction (see Image 5C). This imprint, which is merely a guide, marks the intracartilaginous (sculpturing) line that initially had been drawn on the external skin. Using a No. 15 blade scalpel, begin the incision at the imprint and extend it laterally, always parallel to the alar rim margin (see Images 5D-6A). As the alar rim edge is everted with the double hook, always identify the caudal border of the lower lateral cartilage to be sure that sufficient width of cartilage is left. The lower edge of the cartilage is easy to see because it bulges through the vestibular skin as the alar rim is everted. This edge also serves as a guide for the removal of lower lateral cartilage. Leaving a generous width of cartilage is always better than removing too much cartilage, as it is easy to trim more cartilage, if necessary. Carry the incision medially and laterally, always staying parallel to the alar rim (see Image 6B). Image 6C diagrammatically shows the extent of the sculpturing incision. A mosquito hemostat is used to grasp the vestibular skin. Pulling downward exposes the cephalad portion of lower lateral cartilage and the contiguous fibroadipose tissue between the skin and the cartilage (see Image 6D). This exposed area represents the cartilage and fat that will be removed (see Image 6E). After the incision has been made, undermine the skin from the fibroadipose tissue and cartilage, especially in the central supratip area (see Image 7A). As the skin circumferentially contracts, the fat forms a ball, and supratip fullness appears 2-3 weeks postoperatively. Attempts to reduce this fullness with steroids are risky, as steroids can produce subcutaneous soft tissue atrophy, creating a depression. Holding the vestibular skin with a hemostat, separate the vestibular skin from the intranasal side of the lower intranasal cartilage with sharp dissecting scissors (see Image 7D-7E). (In Image 7C, the hemostat grasping the vestibular skin is hidden by the sharp pointed scissors. The point of the hemostat is visible through the opened tip of the scissors in Image 7F.) Using the tips of the sharp pointed scissors, peel the vestibular skin from the lateral intranasal side of the lower lateral cartilage (see Image 8C). Image 8D shows the scissors inserted to transect the lateral portion of the lower lateral cartilage. The maneuver is shown in simplified form in Image 9A. The lower lateral cartilage is then transected (see Image 9A) and removed (see Image 9C-9D). The lateral most extent of the lower lateral cartilage is maintained to prevent nasal wall collapse and a depression. The specimens of cartilage that are removed are shown in Image 10A). The attached fibroadipose tissue can be seen at the lower edge of the lower segment of cartilage and the upper edge of the other specimen. Examine the nasal tip externally and note the highlighting that has developed at the intracartilaginous line (see Image 10B). The sculpturing technique produces a level discrepancy. As light hits the line of demarcation, it creates highlighting at the tip, the highest point, and a shadow or definition in the supratip. If the "gull's wing" sculpturing line has been properly placed, the resulting shadow imparts to the nasal tip the desired aesthetic qualities. A gull wing highlight is a distinguishing characteristic of all defined nasal tips and can be readily appreciated by looking at pictures of models in fashion magazines. At this time, it is of primary importance to understand what has been achieved. The nasal tip has been modified but the continuity of the dome (arch) of the lower lateral cartilage has been preserved. The structural support and skeletal framework of the nasal tip have been left intact. Joseph technique and derivatives In contrast to the procedures presented above, in the Joseph technique and in techniques that have evolved from that procedure, the philosophy of shaping the nasal tip is based on removal of a portion of lower lateral cartilage and transection of the dome, with a geometric resection in the remaining rim of the lower lateral cartilage. The desired and expected result in the Joseph procedure is the remodeling of the nasal tip when the transected medial and lateral crucial components come together and head into the modified shape. The problem inherent in this technique is that the union between the transected crura is scar tissue, which does not have the rigidity of cartilage. Consequently, in many cases, the procedure resulted in a kinking at the scar and a boxy, asymmetric tip. Occasionally, one or the other of the transected ends of the crura would curl, producing sharp points in the skin. The variables in the Joseph technique are many and unpredictable. The fundamental shortcoming in the Joseph procedure lies in the surgeon's failure to realize the reduction in tip height and the overall reduction in nasal tip pyramid size that occur after reducing volume in the lower lateral cartilages. By preserving the lower lateral domes, the author does not burn any bridges. If a tip is wide or high, the operation can be modified and continued with other techniques that are described later in this article. INTRANASAL VALVESection 7 of 11
Once the surgery of the lower lateral cartilages has been completed, an intranasal examination reveals an intact, preserved internal nasal valve (see Image 10C). This structure is essential to normal nasal physiology. Destruction of the intranasal valve leads to symptoms of obstructed breathing in an otherwise clear airway as a direct result of scarring from an intercartilaginous incision. After using this kind of incision for many years, the author has now almost totally replaced it with a more anatomically conforming and less destructive intracartilaginous incision. All surgery on the lower and upper lateral cartilages and bridge can be performed using this simple incision, thus avoiding any intercartilaginous incision. Another view of the intranasal valve can be seen in Image 10D. This suction tip has been placed under the valve tenting it, and preservation of nasal anatomy is evident. Image 11A shows the transcartilaginous incision and the nasal valve. Images 11B-11E show examples of the terribly scarred intranasal valves. INTRANASAL VESTIBULAR INCISIONSSection 8 of 11
Three vestibular incisions (from cephalad to caudal) are commonly used.
The intercartilaginous incision (see Image 11F, incision 1) is positioned at the red-white line where the vestibular skin meets the mucosal lining at the intranasal side of the upper lateral cartilage. It opens the nasal valve area, leading to postoperative scarring and symptoms of obstructive bleeding. This author rarely trims the caudal ends of the upper lateral cartilages; thus, this incision, exposing the cartilage, is unnecessary. The intracartilaginous incision (see Image 11F, incision 2) preserves the integrity of the nasal valve while allowing excellent exposure. In the Joseph technique, this incision was made following the intercartilaginous incision and resulted in a bipedicle vestibular skin flap that could easily be torn or destroyed, causing additional scarring in the valve area. The author thoroughly believes that everything that was done in the past through the 2 incisions (intercartilaginous and transcartilaginous) can be effectively done through an intracartilaginous incision. This involves less surgery and better preserves the normal anatomy of the area. The third incision is the infracartilaginous, or rimming, incision (see Image 11F, incision 3). This incision must hug the caudal edge of the lower lateral cartilage. If the incision is made below the caudal edge of the cartilage, it may violate the alar rim. The author uses this incision to deliver the lower lateral cartilages. The delivery technique is very useful in a patient with a broad nasal tip. The infracartilaginous incision, usually in conjunction with the intercartilaginous incision, is used by some surgeons to approach the lower lateral cartilage and to produce adequate exposure. However, this technique produces a bilateral pedicle flap and exposes all of the lower lateral cartilage, which means more scarring and a greater possibility of postoperative healing complications. The delineation and removal of the supratip fibroadipose tissue also becomes more difficult. Problems also can arise when an augmentation of the nasal tip projection is attempted in a patient with a short tip. Once an infracartilaginous incision has been made, placing an onlay graft over the dome becomes more difficult. ELEVATION OF THE COLUMELLA AND/OR NASAL TIPSection 9 of 11
The surgical plan for the columella and nasal tip is formulated upon examination of the patient's profile. If the nose is too long with a hanging columella, the columella is shortened by removing the caudal septum from the nasal spine to the septal angle. If the nasal length is acceptable but the tip droops, only the outer third of the columella should be elevated. If the nasal spine is too prominent, it can be reduced with a bone rongeur. However, overcorrection and removal of too much nasal spine produces a recessed nasolabial angle and a poor aesthetic result. The nasolabial angle should always be approximately 90° or slightly greater; for this reason, the author always trims the caudal end of the septum first. After looking at the new profile line, the author decides whether any nasal spine surgery is necessary. Always look at the upper lip length before shortening the columella. An unfavorable postoperative result is a long upper lip as a consequence of overshortening the columellar septum. If a patient has a long upper lip and a long nose, a pleasing result can be achieved by elevating the nasal tip alone. This is accomplished by trimming and shortening the anterior 1/3 of the caudal septum. In elevating the nasal tip, one does not want to create a straight line from the nasal spine to the newly created septal angle, as illustrated by the dotted line in Image 12A). In too many patients, this straight-line technique produces a snub-nose look, with the columella sometimes hidden. Moreover, on the profile view the columella appears flat and straight. The surgeon should imagine the straight line that is desired in elevation and then create a line that lays caudal to the straight line. This second line forms an obtuse angle (see Image 12B), producing an aesthetic contour in the columella that is both attractive and surgically safe. If this obtuse angle is arbitrarily divided into thirds, it is the outer third that produces the tip elevation (see Image 12B, inset). This planning ensures that the posterior two thirds are lower and the nostril openings are kept more toward the horizontal plane. The nostrils are prevented from looking like gun barrels from the frontal view while the nasal tip is still adequately elevated. As the transfixion excision is made, it should hug the caudal end of the cartilaginous septum, and rarely should any of the membranous columella be excised (see Image 13A). As a rule, the transcartilaginous incision should not be connected to the transfixion incision. By not joining these lines, one can prevent the formation of a scar in which the circular incision of the combined transcartilaginous incision and transfixion contracts to produce a straight line. (All curved incisions tend to contract into straight lines.) The author has seen many contracture scars in the area of the septal angle in postoperative patients with combined transcartilaginous and transfixion incision. Therefore, the author believes that keeping the incisions separate with intact vestibular skin (at least 3-4 mm) between the two is important. One can visualize the result of a contracting circular scar as a lowering of nasal tip height. Remember, as the circular scar contracts, it exerts a posterior force on the soft tissue of the nasal tip. (This force is even more damaging in the old Joseph techniques, in which the domes were transected.) The transfixion incision is made (see Image 13B). This incision separates the membranous columella from the caudal end of the septum. If it is necessary to trim the cartilage from the nasal spine to the septal angle, the incision is carried down to the nasal spine (see Images 13C-13D). The elevation of the nasal tip begins by shaving the cartilage, starting at the nasal spine and extending the incision upward to the septal angle. In this patient, the nasal spine was not producing a deformity; thus, the nasal spine was left intact. However, in many severely crowded lips, the caudal end of the septal cartilage needs to be trimmed to the desired line and angle. In this patient, the entire caudal end of the septum had to be trimmed. The cartilage is cut at the spine with a No. 15 blade (see Image 14A), and the transection proceeds toward the septal angle (see Image 14B). The hemostat in Image 14C holds the segment of septal cartilage that is being excised. Although the segment of cartilage that has been removed appears to be straight (see Image 14D), it is not. The incision is always curved superiorly (see Image 12B), producing the obtuse angle. Image 15C shows the 3 segments of cartilage that have been removed: the lower lateral cartilages together with contiguous fat and the caudal end of the septal cartilage. By comparing the profile in Image 15A with the one in Image 15B, one can observe some decrease in the nasal tip height and that the dorsal hump appears to be larger. (The hump is only relatively larger; this apparent enlargement reflects the lowering of the nasal tip height.) MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Rhinoplasty, Tip Approaches excerpt Article Last Updated: Feb 11, 2008 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
