This article presents a contemporary overview of tip suturing and tip structural grafting techniques used to refine the wide nasal tip. Previous reductive techniques have proved to produce unnatural results over time. It is imperative to correctly evaluate the nose and assess all possible pitfalls during the preoperative period before outlining a surgical plan. Intraoperatively, an algorithmic approach helps obtain a reproducible and refined yet properly narrowed domal tip region with graceful contours that extend laterally to the alar lobule with proper shadowing.
Key points
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The ideal nasal tip is achieved when there is a balanced interaction between the soft tissue covering and underlying nasal framework.
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Contouring maneuvers that establish, and maintain, aesthetically pleasing highlights and shadowing around the nasal tip region are mandatory for the overall balance of a truly refined nasal appearance.
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Comprehensive management of the broad nasal tip requires maneuvers that allow for a favorable contour extending from the lateral dome region to the alar margins.
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Surgical changes to the nasal framework dynamically alter the relationship between the tip structures, dorsum, and overlying soft tissues and must be evaluated preoperatively and intraoperatively to direct surgical maneuvers.
Introduction
Obtaining an aesthetically harmonized nasal tip complex remains one of the most challenging aspects of both primary and revision rhinoplasty. The ideal nasal tip is achieved when there is a balanced interaction between the soft tissue covering and underlying nasal skeleton. It has been well described that contouring maneuvers that establish, and maintain, aesthetically pleasing highlights and shadowing around the nasal tip region are mandatory for an overall balance of a truly refined nasal appearance. These expectations are exponentially challenged by nasal tips that are broad or bulbous/boxy. The skin envelope in the nasal tip region can further frustrate even the most experienced surgeon in its unpredictable long-term behavior.
During the perioperative planning period, it is important not only to design a surgical plan to obtain the desired result but also to recognize and document potential difficulties that may arise, because surgical changes to the nasal skeleton dynamically alter the relationship between the tip structures, dorsum, and overlying soft tissue. In dealing with a broad nasal tip, it is imperative to use maneuvers that allow for a favorable contour extending from the lateral dome region to the alar margins bilaterally to prevent undertreatment as well as an overly narrowed/artificial tip appearance.
Factors that inhibit this balance include skin thickness (thick or thin), lower lateral cartilage inherent strength and position, retracted soft tissue triangle facet, tip support, sufficient caudal septal support, domal architecture, and contractile forces that occur during the healing process.
For example, a retracted soft tissue triangle facet may necessitate additional rim grafting or direct soft triangle support at the marginal incision once the necessary tip projection and refinement are attained.
The contribution of the lower lateral crura to the projection, position, and contour flow from the paradomal region to the more lateral alar rim region is often underestimated. The orientation, strength, and position of the lower lateral crura have a direct impact on the limitations and successes in overall tip shaping. For example, cephalic orientation of the lateral crura is defined as lateral crura that are positioned 30° or less from the midline. This creates a vertical fullness of the nasal tip that interrupts the brow-tip aesthetic line. Once the domal architecture is surgically manipulated with proper suturing techniques, lateral crural repositioning/reshaping with or without lateral crural strut grafts can improve cephalically malpositioned lower lateral cartilages, retracted alae, and a pinched nasal tip.
The broad, bulbous, or wide nasal tip continues to challenge the most proficient rhinoplasty surgeon. Central to this inherent dilemma is that there may be a tendency to sacrifice tip-to-alar rim balance and support at the expense of excessive or poorly supported nasal tip narrowing. Conceptually, this is an operation of contour and reshaping to exploit proper nasal tip visible aesthetics—not simply narrowing of a wide tip. If surgical approaches take into account the appropriate magnitude of nasal tip narrowing balanced with alar rim support and soft tissue contributions, then outcomes are improved and revision rates reduced. With proper planning during preoperative assessment and a comprehensive understanding of structural rhinoplasty maneuvers, surgeons can effectively treat the wide array of broad nasal tips in a reproducible and predictable fashion.
Introduction
Obtaining an aesthetically harmonized nasal tip complex remains one of the most challenging aspects of both primary and revision rhinoplasty. The ideal nasal tip is achieved when there is a balanced interaction between the soft tissue covering and underlying nasal skeleton. It has been well described that contouring maneuvers that establish, and maintain, aesthetically pleasing highlights and shadowing around the nasal tip region are mandatory for an overall balance of a truly refined nasal appearance. These expectations are exponentially challenged by nasal tips that are broad or bulbous/boxy. The skin envelope in the nasal tip region can further frustrate even the most experienced surgeon in its unpredictable long-term behavior.
During the perioperative planning period, it is important not only to design a surgical plan to obtain the desired result but also to recognize and document potential difficulties that may arise, because surgical changes to the nasal skeleton dynamically alter the relationship between the tip structures, dorsum, and overlying soft tissue. In dealing with a broad nasal tip, it is imperative to use maneuvers that allow for a favorable contour extending from the lateral dome region to the alar margins bilaterally to prevent undertreatment as well as an overly narrowed/artificial tip appearance.
Factors that inhibit this balance include skin thickness (thick or thin), lower lateral cartilage inherent strength and position, retracted soft tissue triangle facet, tip support, sufficient caudal septal support, domal architecture, and contractile forces that occur during the healing process.
For example, a retracted soft tissue triangle facet may necessitate additional rim grafting or direct soft triangle support at the marginal incision once the necessary tip projection and refinement are attained.
The contribution of the lower lateral crura to the projection, position, and contour flow from the paradomal region to the more lateral alar rim region is often underestimated. The orientation, strength, and position of the lower lateral crura have a direct impact on the limitations and successes in overall tip shaping. For example, cephalic orientation of the lateral crura is defined as lateral crura that are positioned 30° or less from the midline. This creates a vertical fullness of the nasal tip that interrupts the brow-tip aesthetic line. Once the domal architecture is surgically manipulated with proper suturing techniques, lateral crural repositioning/reshaping with or without lateral crural strut grafts can improve cephalically malpositioned lower lateral cartilages, retracted alae, and a pinched nasal tip.
The broad, bulbous, or wide nasal tip continues to challenge the most proficient rhinoplasty surgeon. Central to this inherent dilemma is that there may be a tendency to sacrifice tip-to-alar rim balance and support at the expense of excessive or poorly supported nasal tip narrowing. Conceptually, this is an operation of contour and reshaping to exploit proper nasal tip visible aesthetics—not simply narrowing of a wide tip. If surgical approaches take into account the appropriate magnitude of nasal tip narrowing balanced with alar rim support and soft tissue contributions, then outcomes are improved and revision rates reduced. With proper planning during preoperative assessment and a comprehensive understanding of structural rhinoplasty maneuvers, surgeons can effectively treat the wide array of broad nasal tips in a reproducible and predictable fashion.
Preoperative analysis
To harmonize nasal form with facial balance, the nose must be both analyzed and treated via multiple views. Although debatable, treating the primary and secondary nasal tip, with all its complexities, effectively may be best achieved via the open approach. Tip shape is best viewed from frontal and base views, whereas projection and tip position are viewed from the lateral and basal views. Dynamic (animated and inspiratory) views are also helpful in analyzing collapse of the nasal valve regions as well as noting active depressor septi nasi hyperactivity resulting in nasal tip ptosis.
Proper photography guidelines have been well described in the literature. On lateral view, the Frankfort horizontal plane that extends from the inferior margin of the bony orbit to the superior margin of the external auditory canal is used as the proper plane the parallels the Earth. This view is also important in establishing a nose-lip-chin plane (NLCP) for analysis and notation of chin and tip projection. A plumb line is drawn vertically (perpendicularly) from the Frankfort horizontal plane inferiorly extending adjacent to the most projecting portion of the upper lip. In women, the chin lies approximately 3 mm posterior to this vertical line. Tip projection can also be assessed with this method. Proper nasal tip projection is defined when 50% to 60% of the tip extends anterior to this vertical line. If the tip lacks proper projection, less than 50% of the tip extends to this line. Additionally, tip projection can successfully be measured as two-thirds (0.67 times) the ideal nasal length ( Fig. 1 ).
On basilar view, nostril aperture size and shape should also be considered. The ideal nostril/tip ratio has been described as 55:45 on lateral view. Studies using the basilar view to define a proportional aesthetic balance historically have described the infratip lobule to measure 33% of the columellar length. Recent observations regarding basilar view proportions mimic the lateral view findings and are consistent with a 60:40 to 55:45 ratio.
Also, some investigators stress importance of photographing patients twice, one with a single flash and the second with double light sources. This allows for proper analysis of highlights and shadows formed from the complex areas of convexities and concavities that surround the external nasal tip complex.
The nasolabial angle and alar-columellar balance should also be evaluated and noted. Maneuvers that increase tip projection intimately affect these angles, and other factors may be needed to take into consideration. By recognizing a premaxillary deficiency, proper tip projection may be achieved by simple premaxillary or caudal septal extension grafting and should be discussed in the surgical plan.
Tip balance relative to overall alar base width should be scrutinized relative to the alar base width. Although numeric values have been contemplated, the authors think it is best to evaluate on a case-by-case basis. Alar flaring and interalar width should be taken into account because these dimensions may require simultaneous modifications. Alar soft tissue modifications are performed at the end of the operation, mandating a keen understanding of the dynamic implications of alar width and nasal tip width. It is not uncommon for alar narrowing to be lessened or completely unnecessary as the medializing forces from tip complex narrowing and refinement may achieve this goal.
Skin and soft tissue
Evaluation of the overlying skin envelope assists in preoperative planning of the tip structure needed to appropriately drape the skin for an elegant tip. Fibrofatty tissue is found in the alar lobules and less in the nasal tip. The nasal tip and skin envelope should be examined, massaged, and palpated for proper evaluation. Medium skin thickness bodes well in the nasal tip region to successfully mask the underlying tip cartilaginous structure without hiding the provided definition form tip grafting.
In contrast, thick skin overtly conceals definition and can lead to an amorphous tip lacking refinement. A thick blanket of skin can hide the numerous tip-shaping maneuvers as well as creating a trapdoor-like effect with long-term dynamic edema and an amorphous tip appearance, regardless of all the structural alterations. Understanding this concept may lead a surgeon to plan for debulking techniques that effectively, and safely, allow for more definition of the tip complex. Additional tip definition may require more aggressive grafting when indicated. The nasal tip blood supply should be understood in detail to protect from complications arising from devascularization of the skin via violation superficial to the subdermal plexis. There should remain a thick uniform cobblestone appearance to the soft tissue left behind after debulking the tip skin. Maintaining trepidation during the debulking process is imperative to protect from excessive thinning, scarring, and skin loss. Moreover, active smokers yield a significantly higher risk for postoperative fibrosis of skin flap, scarring, and columellar skin incision complications. The authors recommend extreme caution during the decision-making process of whether to operate on patients with active tobacco use. Debulking techniques are indicated for noses with ethnic features, including, but not limited to, those of patients of Middle Eastern, African American, Indian, or Hispanic (Mestizo) descent ( Fig. 2 ).
Conservation of the subdermal plexus and a thick uniform cobblestoned appearance of the subcutaneous tissue left behind are imperative for safety. By adhering to this principle, soft tissue necrosis or skin loss should be avoided. Additional grafts, such as various tip onlay and infratrip shied grafts, may be placed to help further reduce the interference of a thick skin envelope by providing visible grafts. By creating a heavier footprint on the overlying skin sleeve, subtle aesthetic highlights are not blunted. Selective soft tissue thinning at the apices of these onlay grafts assists with proper soft tissue draping and can be performed with curved scissors to excise the loose areolar fatty tissue. Lastly, crushed cartilage and cephalic rim remnants can be used to camouflage any graft or native cartilage edges as well as prevent unwanted soft tissue contracture in thin-skinned noses ( Fig. 3 ).
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