Cosmetic rhinoplasty involves surgical manipulation of the nasal cartilages, nasal bones, lining mucosa and extracartilaginous soft. The nasal tip is a complex composite arrangement of tissues. These structures are responsible for creating individuality and asymmetries and for controlling nasal air entry and valving. Medical aesthetics involves filling relevant areas of the tip with hyaluronic acid to disguise grooves or soft defect contour defects. Standard tip surgery involves an open or closed approach. Manipulation of the flexible alar cartilage using intracartilaginous and interartilaginous sutures is preferable to resection, and alar base reduction is becoming more prevalent.
Key points
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Medical nasal tip rhinoplasty can reduce the bulk of soft tissue either via superficial epidermolysis using abrasion, lasers or plasma, or via deep dermis using radiofrequency. Hyaluronic fillers have become a mainstay in managing tip asymmetry and contour defects.
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Understanding the anatomy of nasal superficial muscular aponeurotic system, distribution of fat within the nose tip, and sebaceous thickness of nasal tip skin gives a clearer understanding of expected outcomes and duration of postoperative swelling.
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Alar base wedge excisions are becoming more popular and avoid nasal flare, especially when reducing forward projection and narrowing the tip via an open approach.
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Nasal tip narrowing is done best using internasal and intranasal sutures rather than resection of alar cartilages. Soft tissue relocation may be necessary.
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Onlay cartilage tip grafts are advised only when necessary, and the skin is relatively thick to avoid spiking and visible displacement. Inlay grafts are preferable to support the nose tip, to fill in contour defects medially, and as spreaders in the treatment of valving.
In a majority of cases, tip rhinoplasty is included as an integral part within a general rhinoplasty and may involve profile augmentation or reduction and infracture. There are many cases where tip surgery alone can suffice to meet the patients’ needs and less aggressive mobilization of the tissues is of benefit, but the best exposure always is through an open approach.
A closed approach is perfectly feasible provided that adequate exposure to the middle, medial, and lateral crura can be identified preoperatively. These patients tend to have flared nostrils and larger apertures.
Increasingly, the modern tip rhinoplasty surgeon includes the use of hyaluronic acid (HA) fillers (liquid rhinoplasty) in the armamentarium as a simple and rapid means of correcting grooves and asymmetries around the rim, lateral crus, alar dome, supratip, and medial crura. With an immediate visible result, little downtime, and with little risk, it gives the patient a chance to see if major surgery actually is necessary. The plane for HA injection and the plane of dissection must be understood, and these are explained herein. In a competitive market, the rhinoplasty surgeon has to offer all modalities of treatment.
Surgical anatomy
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The natural nose tip has an intricate anatomic architecture and shape specific to the individual and is composed of skin, fat, superficial muscular aponeurotic system (SMAS), muscle, cartilage, and mucosa. Essentially, the nose tip is a composite of all these connective and epithelial tissues that are mobile and free to glide over the lateral cartilages cranially and are pegged medially by the loose attachment of each alar cartilage adjacent to the caudal septum ( Figs. 1 and 2 ).
Fig. 1 Front-view drawing of nasal architecture showing overlap of the nasal tip alar cartilages over the lateral cartilages and implicating the relationship to nasal valving. The medial crus and foot process on each side is important in stabilizing the nose into a central position, but this centrality varies according to the axis of the septal cartilage. The arch of the middle alar crus, therefore, will be asymmetric if there is any septal angulation against which the medial crus is loosely attached.
Fig. 2 Side-view drawing of nose showing overlap of the lower lateral cartilage by the lateral crura. To reduce the vertical height of the nose, the septum must be reduced in height and each of the lateral and medial crura also must be reduced in height. It is important to avoid intranasal soft tissue contracture by limiting unnecessary intranasal submucosal dissection of cartilages and to stabilize the nose tip against the septum at the time of surgery to prevent pollybeak deformity. - •
Traditionally, the alar cartilages are manipulated surgically to change the shape of the nose tip using either intracartilaginous or extracartilaginous sutures and by inlay or onlay cartilage grafts harvested from cephalad alar cartilage, nasal septum, ear, or costal cartilage.
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There are loose and tenuous supporting intercartilaginous ligaments that suspend the alar cartilage composite from the underlapping lateral nasal cartilages and help maintain the nose tip gravitationally in a static position yet allow the nose to laterally flare or slide superiorly or inferiorly when animating and expressing.
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The lateral, middle, and medial crura of each alar cartilage spread the nasal os laterally to the left and right and are responsible for nasal air entry and valving. The flexible external valve is influenced by voluntary movements of the small muscles attached to the lateral crus. These muscles are listed in Box 1 . There is also splinting of alar soft tissues by accessory cartilage at the alar bases. The nasal tip can passively and voluntarily glide smoothly into a tip ptosis, or pollybeak, shape over the caudal midline cartilaginous septum but variable degrees of static ptosis of the tip often are hereditary and genetically predetermined. Postrhinoplasty swelling of the nasal tip is a cause of morbidity and can be explained by understanding the tissue plane of dissection in relation to the nasal SMAS.
Box 1Muscles acting on the nose tip and valves- •
Levator nasii superioris alaeque nasi
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Alar nasalis
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Depressor septi
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Orbicularis oris
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Dilator naris anterior
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Compressor narium minor
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Transverse nasalis
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Accumulations of fat are present both superficial and deep to the alar SMAS layer, and a complex of lymphatics, blood vessels, and nerves is transmitted in the more superficial layers with more solitary perforating larger vessels in the sub-SMAS layer of fat. This is relevant as a potential embolic danger when injecting fillers and assessing the potential for postoperative swelling and deep scar formation. There also is an interdomal fat pad and, where less developed, presents as a supratip depression in the diamond space above the medial alar domes.
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The plane and extent of tissue dissection required to expose and mobilize the alar cartilages during tip reshaping contribute to postrhinoplasty tip swelling, which classically takes many months to settle. The thicker and more sebaceous the nasal skin ( Fig. 3 ), the worse the postoperative edema within the fat pad and the longer time to settle, concomitant with patient disappointment if not adequately explained prior to surgery. These fat pads are not present over the upper lateral cartilages, and hence, there is less swelling postoperatively in these areas. The fat pads superficial to the SMAS at the nasal tip are also more spongy and vascular than in the sub-SMAS layer and contain diffuse cutaneous sensory nerve fibers to the tip. The larger individual sensory nerves and vessels travel in the sub-SMAS tissues before perforating into the superficial spongy layer through the loose interdomal and intercartilaginous ligaments.
Fig. 3 Photograph to show thinning of thick sebaceous skin by superficial plasma energy treatment using Nebulaskin™ (manufactured by Fourth State Medicine). Left: Pretreatment. Right: Posttreatment with Nebulaskin™. - •
The fat compartments have no clearly defined borders and enable tissues to glide over a fixed point and within the limits of muscle and fascial attachments. The function of SMAS is to position skin by attachment to the dermis via perpendicular structural ligaments and to transmit, distribute, and amplify the effect of contracting muscles by superficial containment. The more powerful the action the less compliant the SMAS layer.
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Steroid injections and therapeutic ultrasound may improve the duration of inflammatory edema in the fat adjacent to the SMAS but should be reserved for the patient with swelling associated with thicker sebaceous skin, to avoid thinning or depigmentation.
The ideal nose tip
In essence, the nose, however attractive, is one that is somewhat unseen when observed at first frontal facial glance, especially when great eyes, smile, lips, and white teeth are more the usual center of immediate attention ( Fig. 4 ). High cheek bones and attractive nose are more obvious on profile view, but all assets are enhanced by hair color and hairstyle, skin quality, make-up, and clothes. The summation of all is beauty. There are many examples of high-profile attractive male and female celebrities who have attractive facial features yet ordinary noses.
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