You are in: eMedicine Specialties > Plastic Surgery > NOSE Rhinoplasty, Tip SurgeryArticle Last Updated: Apr 26, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Arian Mowlavi, MD, Consulting Staff, Department of Plastic Surgery, Cosmetic Surgery Clinics of Laguna Beach, CA Arian Mowlavi is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons, Phi Beta Kappa, and Plastic Surgery Research Council Coauthor(s): Bradon J Wilhelmi, MD, Endowed Leonard Weiner, MD, Professor and Chief of Division of Plastic Surgery, Residency Program Director, University of Louisville School of Medicine 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; George Peck, Jr, MD, Consulting Staff, Department of Plastic Surgery, St Barnabas Hospital of New Jersey; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Al Aly, MD, FACS, Consulting Surgeon, Iowa City Plastic Surgery Author and Editor Disclosure Synonyms and related keywords: reconstructive surgery, nose surgery, nose job, cosmetic surgery, nose reconstruction, nasal reconstruction, nose tip surgery, nose-tip surgery, facial surgery cosmetic facial surgery, nasal surgery, nose surgery, nasal tip reconstruction, nose tip reconstruction, reconstructive rhinoplasty, rhinoplasties, tip rhinoplasty INTRODUCTIONSection 2 of 10
  History of the ProcedureSushruta introduced reconstructive rhinoplasty in India as early as 800 BCE. However, not until the late 1800s was rhinoplasty described as a cosmetic procedure. In 1891, John O. Roe, an American otolaryngologist, presented a reduction procedure that included removing the nasal dorsal hump. In 1898, Jacques Joseph, a German surgeon, described nasal tip alteration with partial excision of the alar cartilage and a wedge from the lower portion of the septum. In current practice, tip rhinoplasty remains one of the most intricate procedures and has inspired copious descriptive reports. ClinicalPatients being evaluated for tip rhinoplasty must undergo a thorough history and physical examination. Clinicians must acknowledge the concerns of patients and document the specific areas of nasal tip shape that they want altered. Recent emphasis has been placed on psychological screening of patients as early as the first consultation visit. The clinician must differentiate patients with realistic, healthy reasons for seeking rhinoplasty from patients with reasons stemming from personal conflicts such as major losses, feelings of inadequacy, marital difficulties, or immaturity. Gourney introduced the acronym SIMON, which is a red flag for potentially problematic patients. It refers to single, immature, male, overly expectant, and narcissistic patients. Regardless, Daniel cautions that only 15% of single male patients fall into this category. Clinicians must clearly understand patient expectations if they are to achieve success. Surgical planning, especially that which entails nasal tip modification, requires several prerequisites. The surgeon must appreciate the presenting nasal deformity and understand the anatomic deviations leading to the deformity. Standardized photographs obtained from a camera equipped with a 105-mm lens, including 2 anteroposterior and 2 lateral profiles and worm's eye views, are critical for a thorough evaluation and planning. These requirements can be satisfied only if one has a complete knowledge of the underlying nasal tip anatomy. INDICATIONSSection 3 of 10
Tip rhinoplasty may be used to change the tip projection, alter the tip rotation, decrease the distance between the tip-defining points (TDPs), reduce tip fullness, create a supratip break, and alter the relationship between the columella and the alar rims. Tip projection may be either excessive or inadequate. Decreased tip rotation, which is typically associated with inadequate tip projection, manifests as a drooping nasal tip and acute nasolabial angle. Nasal tip shape alterations may be detected based on spread TDPs and on increased and ill-defined tip fullness. Various nomenclature has been introduced to characterize these changes, based on outward nasal tip appearance. For example, the trapezoidal nose, otherwise known as the bulbous nose, is caused by overly widened lateral alar crura. The square nose results from a lengthened middle crus. In contrast, a shortened middle crus may manifest as inadequate tip projection. The broad tip results from an increased angle of divergence between the bilateral middle crura (normal angle of divergence is approximately 60°). The parenthesis nose is due to a lateral crus cephalic slant of up to 60°, versus the normal angulation of 15°. Other factors critical to nasal tip rhinoplasty involve the contour definition of the nasal tip and its alar lobules. An ideal nasal tip is described as having highlights related to the shadow created by nasal surface depressions and extensions (eg, the alar groove) and the shine provided by the TDPs, which represent the junction of the middle and medial crura, termed the dome. In fact, patients may present with satisfactory leg placement of their nasal tripod infrastructure yet maintain an ill-defined nasal tip. These patients typically demonstrate either excess subcutaneous fat or thickened skin that obliterates contour subtleties created by the underlying cartilaginous infrastructure. RELEVANT ANATOMYSection 4 of 10
Tip anatomy must account for the cartilaginous framework and the soft tissues that contribute to the external appearance of the nasal tip. The lower lateral cartilage, ie, alar cartilage, is large and skew-shaped and has been further characterized by its divisions into the medial, middle, and lateral crura. The accessory cartilages are small, sesamoid cartilaginous particles that extend from the lateral crural end to the pyriform aperture. The size and shape of these cartilages and their 3-dimensional positioning, which is dependent on various fibrous attachments, determine the overall shape of the nasal tip. These attachments include the suspensory ligament, which spans the anterior septal angle between the bilateral middle crus; the fibrous connections between the lower lateral crus and the upper lateral cartilages; the fibrous attachments spanning the lateral crural ends onto the pyriform aperture; and the elastic fibers joining the medial crural footplates to the caudal septum. The infrastructure support for the tip has been best characterized by Anderson with the tripod principle. The tripod is defined by the 2 upper legs created by each of the lateral crura and a single lower leg defined by the bilateral medial crural footplates. The nasal tip is thus defined by the tripod tip, ie, the nasal tip. In theory, any alteration to the above structures results in an alteration of the tripod tip. Ideally, the tip projection leads the nasal dorsum by 1-2 mm. The refined tip is described by the double-break appearance, which is associated with a supratip and infratip break. The supratip is defined by the junction of the nasal dorsum and the nasal tip, and the infratip is defined by the junction of the tip and columella. The span between the supratip and infratip is subsequently called the infratip lobule and is composed of the middle crura. Finally, in order to link the nasal tip to the upper lip, the aesthetic nasolabial angle has been defined. The ideal nasolabial angle for males is 90-105°. For females, it is 95-110°. As such, tip rotation, defined by caudal versus cephalad rotation, affects both nasal tip projection and the nasolabial angle. CONTRAINDICATIONSSection 5 of 10
Contraindications to rhinoplastic nasal tip surgery are based on the patient's comorbidities and his or her ability to tolerate surgery. Coexisting medical conditions may put the patient at risk during anesthesia. Additionally, patients with unrealistic expectations probably should not undergo surgical correction. Gourney's acronym SIMON spells out warning signs that may indicate a patient is not a good candidate for nasal tip surgery. SIMON refers to single, immature, male, overly expectant, and narcissistic patients. However, note that only 15% of single male patients fall into this category. Finally, patient refusal is an obvious contraindication. TREATMENTSection 6 of 10
Surgical therapySurgical maneuvers must be implemented based on thorough preoperative plans designed to treat specific nasal tip deformities. These deformities most often include excessive tip projection, decreased or increased tip rotation, displeasing tip shape, and lack of tip definition. Excess tip projection is diagnosed after observing a tip that is extended disproportionately beyond the nasal dorsum. Importantly, rule out a low radix disproportion prior to engaging in nasal tip reduction because this low radix disproportion requires radix augmentation instead of tip reduction. Once the diagnosis of excess tip projection is made, assess the contribution of the various tip-supporting structures. The model for the aforementioned tripod theory includes the lateral crus, caudal septum, and medial crus. In this model, altering one leg of the tripod directly affects the other 2 legs. Thus, cartilage shortening by either excision or transection and repair of overlapped cartilage at the bases is used to differentially affect the tripod legs. Resection of the alar mid portion, ie, the dome, is discouraged in order to attempt to preserve the tip shape. Also, grafting with morselized cartilages overlying areas of cartilage transection is encouraged to avoid sharp edges and resultant contour abnormalities. Decreased tip rotation is best demonstrated by a drooping nasal tip with an acute nasolabial angle. Importantly, when a nasal dorsal hump is present, this may create an illusion of a decreased tip rotation; however, only a dorsal hump reduction is needed, not rotation. Various maneuvers have been described to increase tip rotation. First, one may excise a triangular piece of the caudal septum (ie, placing the base of the triangle at the cephalad edge). Cephalic trimming of the lateral crus gains some additional cephalad rotation. However, this may result in a decreased tip projection, which may necessitate placement of a shield graft. Finally, augmentation of the premaxilla with autogenous cartilage or polytetrafluoroethylene may be used to increase tip rotation. Increased tip rotation has been associated with hypertrophy of the caudal septum with a resultant increased nasolabial angle and a short upper lip. Treatment may include trimming of the caudal septum near the nasal spine, which results in a more obtuse nasolabial angle and decreased lip tension. Another option includes augmentation of the nasal dorsum, which creates a dynamic illusion of decreased tip rotation. Most patients are not concerned about excess tip projection or tip rotation; rather, they remark on the shape of their nose. As such, various nasal shape deformities have been characterized. A trapezoidal or bulbous nose can be corrected into a more triangular nose by excising the cephalic lateral crura. However, leave at least a 6-mm strip of cartilage or otherwise risk alar collapse and a resulting pinched nose deformity. A square nose is characterized by excessively long middle crura. In fact, the height of the middle crura defines the length of the lobule tip. The broad tip nose develops secondary to an increased angle of divergence between the middle crura. Treatment involves the use of sutures to narrow the interdomal distance. The parenthesis nose refers to excessive cephalic crura with a slant of up to 60° to the lobule, instead of the normal 15°. Treatment depends on the severity of the deformity. If mild, then tip grafting can be used to increase the highlight of the tip, thus disguising the misplaced crura. If moderate to severe, the lateral crura must be transected and placed back down into the alar rims. Often, the shape of the tip is adequate but lacks definition, which is referred to as highlights. Treatment may involve removal of excess subcutaneous fat. However, the surgeon must be cautioned against aggressive debulking, which may compromise vascular perfusion and result in skin sloughing. Thus, one may consider tip grafting instead of debulking, especially in thick-skinned individuals. Additional highlights can be gained by improving the definition of the alar groove by performing cephalic lateral crural trimming or even placing intercrural and intracrural stitches. Various stitching techniques have been described to effectively alter the structural support underlying the nasal tip. A transdomal stitch spans a single dome and, in effect, narrows the dome and improves nasal tip projection. Hyperinflation beneath the alar cartilage is recommended to avoid inadvertent stitching through the nasal mucosa. An interdomal suture brings the middle crural tips together and provides tip symmetry and strength. An intercrural stitch is placed through the caudal aspect of the medial crura; this horizontal mattress stitch is placed such that the columella is narrowed and the central tip support is augmented. The lateral crural spanning stitch spans the lateral crura and narrows the cephalad aspect of the tip (used for a bulbous tip), thus providing increased projection. More recently, the lateral crural mattress stitch has been reported as a replacement for the lateral crural spanning stitch. This horizontal mattress stitch is placed to allow for flattening of the lateral crus convexity. In general, for all the presented nasal tip stitches, 4-0 and 5-0 nylon clear sutures are used because they help maintain adequate and persistent strength. Various tip grafts have been described that can provide either increased tip contour definition or structural support. The shield graft (Peck or Sheen graft) is shaped like a tombstone and includes a score or break at the transverse midline. These grafts are typically 8 mm wide (ie, the aesthetic distance between TDPs), with the lower half of the graft creating the middle crus contour and the upper half of the graft creating the dome contour. A columellar strut graft has been described and is placed between the medial crura; it is intended to increase the structural support of the tip. Finally, an umbrella graft has been described, and it provides both structural and contour-enhancing functions. In general, tip grafts are secured with a single suture using 4-0 or 5-0 nylon clear suture. COMPLICATIONSSection 7 of 10
Various nasal tip complications have been described following tip rhinoplasty. These complications are more likely following an incorrect diagnosis of the tip defect, inadequate preoperative surgical planning, or improper surgical implementation. These complications may result in both functional compromise and cosmetic shortcomings. Functional compromise can develop if the patient develops a pinched nose deformity. This complication follows excessive reduction of tip and alar cartilages, resulting in alar collapse. Alar collapse, especially with deep forced inspiration, results in airflow obstruction at the external nasal valve. Most often, this follows overresected or malpositioned lateral alar crura, especially if the patient presents preoperatively with hypoplastic and weakened alar cartilages. Upon physical examination, one would observe voluntary flaring of the ala by the patient in an effort to resist inward collapse. This can be diagnosed by performing the Cottle test maneuver, which results in less impaired inspiration with retraction of the alar rim outward. Treatment of this complication involves repositioning of the lateral crura, improving structural support with a batten graft, or both. A less frequent functional complication of tip rhinoplasty involves exposure of the underlying cartilage from skin sloughing. This may result from inadequate perfusion to the tip following overly aggressive tip work in combination with soft tissue debulking. Following open rhinoplasty, the columellar branch of the superior labial artery is sacrificed, leaving only the lateral nasal artery and the external branch of the ethmoidal arteries to perfuse the tip. As such, aggressive debulking of the nasal skin may compromise the lateral nasal artery and aggressive septomucoperichondrial resection may compromise the external branch of the ethmoid arteries. Cosmetic complications following tip rhinoplasty are numerous and typically involve inadequate treatment of the presenting deformity. These include tip asymmetry, inadequate tip reduction or projection, improper tip rotation, and insufficient tip highlighting. Tip asymmetry is more likely to occur when cartilage grafts are used; these frameworks are prone to warping because of retained memory or they may migrate because inadequate fixation. One particular cosmetic deformity referred to as supratip deformity has been the topic of much controversy. Until recently, this deformity was presumed to occur secondary to underresection of the caudal end of the nasal dorsum, including the anterior septal dorsum, or overlapping of the upper lateral cartilages. This was argued to result in an inadequate void to allow spreading of the extraneous soft tissue and thickened skin. More recently, Sheen argues that this deformity is actually due to overresection of the nasal dorsum resulting in excessive noncontractile overlying skin that ends up draping over the arch of the nasal tip. Consequently, he advises surgeons to avoid the urge to reduce the anterior septum and instead to augment the nasal dorsum so that the overlying skin may drape over a larger construct and not droop over the nasal tip. OUTCOME AND PROGNOSISSection 8 of 10
Tip rhinoplasty involves subjective artistic maneuvers; therefore, objective studies of outcome are difficult. Reports suggest that satisfaction is observed in 80-90% of patients following primary tip rhinoplasty. As a general rule, patient dissatisfaction following rhinoplasty is likely to involve the lower third (ie, the tip) of the nose. The complication rate following rhinoplasty ranges from 1.7-18%. This includes patient dissatisfaction and frequent surgical complications such as infection and bleeding. Specifically, the rate of significant bleeding ranges from 0.7-3.6% and the rate of infections ranges from 1.7-2.8%. Outcome assessments that are more subjective involve surveys of patients following tip rhinoplasty. Interestingly, male patients are more likely to be dissatisfied (12.8%) than female patients (4.6%). This has led clinicians to recommend more conservative maneuvers when treating male patients. Patients must understand that although tip rhinoplasty can result in significant improvement in aesthetic nasal contour, a perfect result is not possible. As such, the goal of primary tip rhinoplasty is to reproduce consistent, long-lasting, and natural-appearing results that are in accord with patient desires. MULTIMEDIASection 9 of 10
REFERENCESSection 10 of 10
Rhinoplasty, Tip Surgery excerpt Article Last Updated: Apr 26, 2006 | ||||||||||||||||||||||||||
