Nasal tip deformities after primary rhinoplasty may occur, including the formation of bossae, a pinched nasal tip, and nasal tip ischemia. Because of the central location in the midface, even minimal nasal tip deformities (small bossa) may be noticed and upsetting to the patient. This is in addition to more severe nasal tip deformities, including nasal tip ischemia, that are easily visible to any viewer. Prevention, early recognition, and, depending on the case, intervention are critical in minimizing these complications. If complications do occur, regular communication with the patient and follow-up are crucial.
Key points
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Because of the central location in the midface, even minimal nasal tip deformities may be noticed and upsetting to the patient.
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Prevention, early recognition, and, depending on the case, intervention are critical in minimizing these complications. If complications do occur, regular communication with the patient and follow-up are crucial.
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Secondary or revision rhinoplasties are not uncommon (5%–10%), and informing patients that future revision may be indicated should be a component of the informed consent process.
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Related to the nasal tip, deformities may include, but are not limited to, the presence of bossae, a pinched nasal tip, and an ischemic tip.
Introduction
Rhinoplasty is often considered the most challenging of all facial cosmetic procedures because of the central location of the nose in the midface making any deformity visible to the patient or viewer. In addition to being the most challenging, rhinoplasty is also one of the most popular facial cosmetic procedures, with an increasing number being performed annually. As the number of primary rhinoplasties performed continues to increase, one would expect that the number of patients seeking secondary or revision rhinoplasties would also increase. In the patient seeking secondary or revision rhinoplasty, deformities may be residual or iatrogenically induced. In a survey of surgeons, a self-reported revision rate of 0% to 5% was reported most commonly followed by a revision rate of 5% to 10%. The reported revision rate finding reminds us that secondary or revision rhinoplasties are not uncommon, and informing patients that future revision may be indicated should be a component of the informed consent process. Related to the nasal tip, deformities may include, but are not limited to, the presence of bossae, a pinched nasal tip, and an ischemic tip. In addition, an overresected nose can affect multiple nasal structures, including the nasal tip. In a review by Nassab and Matti, a large nasal tip was the chief complaint of 25% of patients presenting for evaluation for secondary or revision rhinoplasties. A large nasal tip was the second most common complaint after nasal asymmetry. A tip asymmetry was noted 26% of the time on clinical examination. A tip asymmetry was the third most common clinical finding after nostril asymmetry and septal deviation. Inadequate tip projection was present 20% of the time; an overprojected tip was present 14% of the time; and a pollybeak deformity was present 17% of the time. In addition to cosmetic deformities, a loss of function, such as difficulty with nasal breathing, was present in 22% of these patients. The diagnosis of nasal tip deformities will be discussed as well as remedies for treatment. Because of the proximity of the supratip to the nasal tip, the supratip deformity (pollybeak deformity) will also be discussed.
Anatomy
The terms nasal tip and nasal lobule are 2 terms used interchangeably to describe the most projected point of the nose. To avoid confusion, the term nasal tip will be used. Anatomically, the nasal tip is positioned between the 2 domes and between the supratip and infratip break. The nasal tip is often described as having 3 major tip supporters and 6 minor tip supporters. The major nasal tip supporters are the lower lateral cartilages, the attachment of the medial crura to the nasal septum, and the attachment of the lower and upper lateral cartilages. The minor tip supporters are the anterior nasal spine, the membranous nasal septum, the cartilaginous dorsal septum, the attachment of the soft tissue to the ala cartilages, the sesamoid cartilages, and the interdomal ligament between the lower lateral cartilages. The attachment of the lower and upper lateral cartilages, one of the major tip supporters, is termed the scroll area. The connection between the upper and lower lateral cartilages in the scroll has been described as interlocked, overlapping, end to end, or opposed. The lower lateral cartilages, one of the major tip supporters, are composed of the medial, intermediate, and lateral crus. The lower lateral cartilages also play an important role in supporting the external nasal valve. The left and right medial crus meet in the midline and attach to the nasal septum, making up the third major nasal tip support.
Patient evaluation
In evaluating the patient considering a rhinoplasty, the patient’s chief complaint should be carefully investigated as well as the patient’s motivators for seeking treatment. Treatment in patients with external motivators should be avoided. Related to the nasal tip, common complaints include a bulbous or boxy nasal tip. Photograph documentation is crucial to assist in treatment planning. Photographs should be taken in the frontal view, profile view, and the worm’s eye view. On clinical examination, the shape of the nasal tip should be evaluated. Nasal tip shapes include bulbous, pinched, twisted, asymmetric, and boxy. Nasal tip projection should also be evaluated. The Goode method is a commonly used method for evaluating nasal tip projection. In the Goode method, the nasal tip is measured from the alar point to the nasal tip (AP-NT). This is then divided by the distance from the nasion to the nasal tip (N-NT). (AP-NT)/(N-NT) should ideally be between 0.55 and 0.60. The Crumley method is another method for evaluating nasal tip projection, and ideal proportions are based on a 3-4-5 triangle composed of AP-NT, N line (perpendicular to Frankfort horizontal)-AP, and N-NT. The presence of a supratip and infratip break as well as the tip defining point should be documented. From a worm’s eye view, the ideal nasal base is triangular with alar margin support. The thickness of the skin overlying the nasal tip is important to evaluate. Changes in the underlying nasal tip anatomy are easily noticeable in patients with thin skin. Changes in the underlying nasal tip anatomy are less noticeable in patients with thick nasal skin.
Nasal tip deformities
Bossae
Bossae are knoblike protuberances of the lower lateral cartilages that can occur after primary rhinoplasty ( Fig. 1 ). Bossae is the plural of bossa, which is Latin for “bump.” Bossae are best categorized as either early bossae or late bossae. Early bossae are those that occur within 3 months of primary rhinoplasty, and late bossae are those that occur greater than 1 year after primary rhinoplasty. Early bossae are often caused by either an uncorrected or an iatrogenically induced asymmetry. Late bossae, on the other hand, are caused by fibrosis or scar contracture on a weakened or unreconstituted cartilaginous framework. Patients with thin skin and strong cartilages are more prone to bossae formation. In order to prevent the formation of bossae, vestibular skin should be well undermined from strong asymmetric cartilages to prevent irregularities in the overlying skin. In patients with strong lower lateral cartilages, after septum exposure, the lower lateral cartilages should be well approximated with suturing techniques to prevent widening of the medial crura, which may lead to bossae formation. Overresection of the cephalic margins of the lower lateral cartilages should also be minimized, as this can lead to weakening of the lower lateral cartilages, buckling, and the formation of bossae. The recommendation is to leave at least 6 mm of the lower lateral cartilage intact to prevent buckling and bossae formation. Treatment of bossae includes further stabilization of the cartilages with suturing techniques or grafting. Shaving of the bossae should be avoided, as this further weakens the cartilage, one of the causative factors in bossae formation.
