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Rhinoplasty, Tip Surgery: Multimedia
Updated: Oct 12, 2009
Multimedia
 | Media file 1: A small dorsal hump and a slightly underprojected and round ball-like tip are visible preoperatively. |
 | Media file 2: After minimal dorsal rasping, modest cephalic trim of the lateral crura to decrease superior tip fullness, placement of a columellar strut to strengthen the medial crura, advancement of the tip complex with a projection control suture, dome spanning sutures to define the tip, and a well integrated onlay tip graft, overall nasal aesthetics are improved. The postoperative result establishes the characteristics of the ideal nose. The dorsum is straight. The tip projects above the dorsal line with a supratip break. The dorsal width fits the face. The dorsum extends inferiorly as gently curvilinear lines that merge into a tip of appropriate width, definition, and projection. |
 | Media file 3: The nose is supported and shaped by the nasal bones and upper lateral cartilages in its superior 2 thirds. The inferior third of the nose (the tip and ala) is supported by the septal angle, alar cartilages, fibrofatty tissue of the alae, and suspensory fascial ligaments, which extend from the upper lateral cartilages and septal angle to the lateral and medial crura. |
 | Media file 4: (A) When the dorsum is lowered and the juncture of the upper lateral and septal cartilage is excised, the dorsal aspect of the upper lateral cartilages fall inward, narrowing the mid vault and internal valve. (B) Lateral spreader grafts are useful to reposition the cut edges of the upper lateral cartilages outward and restore aesthetic dorsal lines. Extended lateral spreader grafts can be fixed to the dorsal septum and designed to extend caudally, beyond the septal angle. They envelop a columellar strut, which is designed to lengthen the nose and push the tip inferiorly. (C, D) Dome-spanning sutures or horizontal mattress sutures placed through the junction of the middle and lateral crura, which, on tightening, narrow the domes. (E) A projection control suture can be placed between the septal angle/ caudal border of the septum to the columellar strut and medial crura. The tip complex can be advanced anteriorly or posteriorly, with these sutures, to increase or decrease tip projection and tip stability. This suture can also be employed to rotate the tip cephalad. |
 | Media file 5: (A) A wide round tip reflects the 3D contour of the underlying alar cartilage. (B) Bulbous tip cartilage exposed by open rhinoplasty. (C) The lateral crura are marked for excision, maintaining a strong rim strip to maintain support. The cephalic rim excision decreases superior tip fullness. (D) A columellar strut is fixed between the medial crura to stabilize the tip complex and add projection. The alar cartilages are advanced and fixed on the strut. (E) Horizontal mattress sutures (dome-spanning sutures) span the junction of the middle and lateral crura, increasing tip projection and definition. (F) An onlay tip graft can be positioned over the paired alar cartilages to augment projection or alter infratip fullness or tip contour. |
 | Media file 6: Loss of caudal septal support causes the nasal tip and cartilaginous dorsum to fall posteriorly, creating loss of tip projection and a saddle nose deformity. The upper lip is displaced posteriorly, due to the loss of the caudal septum. |
 | Media file 7: After restoration of dorsal support with a rib osteocartilaginous graft, the tip is projected with a columellar strut that extends from the nasal spine to the tip. The normal intact alar cartilages are advanced and fixed with suture to the anterior edge of the strut. The domes are narrowed and further defined by dome-spanning sutures and a covering tip graft. |
 | Media file 8: Postoperatively, the aesthetic contours of the nose and lip are restored, along with airway function. |
 | Media file 9: The nasal form and function are severely impaired after prior rhinoplasties. The patient's internal and external valves are collapsed. The dorsum is overresected. The radix is inferiorly displaced and the bridgeline scooped. The tip is overly narrowed and inadequately supported. Aesthetically, the loss of normal tip contour and projection are the most significant abnormality. Because her skin is thin, the irregularity and distortion of the underlying support is especially visible. The nose is overly narrow and pinched. The nostrils are poorly supported. Nasal breathing is poor because of the collapse of the internal and external valves. |
 | Media file 10: The right lateral and medial crus and the left lateral crus are missing. The open approach permits the underlying anatomical injury to be visualized. |
 | Media file 11: The septal cartilage at the septal angle was lowered and lateral spreader grafts were placed to support the midvault. Two 6-mm x 3-cm x 2-mm anatomic septal cartilage grafts, with a 35-degree angle of rotation, were sutured together with 5-0 nonabsorbable sutures along the cephalic margins middle crural replacements. These unified strips of cartilage were then stabilized to the residual normal medial crura and bent backward to simulate normal medial, middle, and lateral crura and the contour of medial and lateral genu. They were fixed with sutures to the nasal lining to abut and parallel the caudal margin of the upper lateral cartilages. These sutures resuspended the vestibular lining skin. Dome-spanning sutures were used to further define nasal projection and tip definition after careful cartilage scoring to control graft cartilage bending. Projection control sutures were placed through a transfixion incision to securely position the tip complex reconstruction. An onlay tip graft was placed to improve further tip definition and projection. |
 | Media file 12: Postoperatively, a defined and projected tip and attractive dorsal lines have been restored by anatomically replacing the previously overresected alar cartilages and by dorsal grafting. The underlying anatomic cartilage grafts have remodeled the overlying skin. An attractive nose is recreated. Normal, comfortable breathing is restored by the placement of lateral spreader grafts to open the internal valves and reconstruction of the lateral crural to support the external valve and nostril rim. |
More on Rhinoplasty, Tip Surgery |
| Overview: Rhinoplasty, Tip Surgery |
| Treatment: Rhinoplasty, Tip Surgery |
| Follow-up: Rhinoplasty, Tip Surgery |
 Multimedia: Rhinoplasty, Tip Surgery |
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References
Johnson C, Toriumi D. Open Structure Rhinoplasty. Philadelphia: Saunders; 1990.
Gunter JP, Rohrich RJ. External approach for secondary rhinoplasty. Plast Reconstr Surg. Aug 1987;80(2):161-74. [Medline].
Juri J. Salvage Techniques for Secondary Rhinoplasty. In: Daniel R. Aesthetic Plastic Surgery: Rhinoplasty. Boston, Mass: Little Brown; 1993.
Gunter J, Rohrich R, Adams W. Dallas Rhinoplasty. 2nd ed. St. Louis, Mo: Quality Medical Publisher; 2007.
Tebbetts J. Primary Rhinoplasty: Refining the Logic and Techniques. 2nd ed. St. Louis, Mo: Mosby Elsevier; 2008.
Sheen J, Sheen A. Aesthetic Rhinoplasty. Vol 1 and 2. 2nd ed. St. Louis, Mo: Mosby; 1987.
Sheen JH. Tip graft: a 20-year retrospective. Plast Reconstr Surg. Jan 1993;91(1):48-63. [Medline].
Peck GC Jr, Michelson L, Segal J, Peck GC Sr. An 18-year experience with the umbrella graft in rhinoplasty. Plast Reconstr Surg. Nov 1998;102(6):2158-65; discussion 2166-8. [Medline].
Peck G. Techniques in Aesthetic Rhinoplasty. 2nd ed. New York: Gower Medical; 1989.
Daniel RK. Rhinoplasty: a simplified, three-stitch, open tip suture technique. Part I: primary rhinoplasty. Plast Reconstr Surg. Apr 1999;103(5):1491-502. [Medline].
Daniel RK. Rhinoplasty: a simplified, three-stitch, open tip suture technique. Part II: secondary rhinoplasty. Plast Reconstr Surg. Apr 1999;103(5):1503-12. [Medline].
Constantian MB. Differing characteristics in 100 consecutive secondary rhinoplasty patients following closed versus open surgical approaches. Plast Reconstr Surg. May 2002;109(6):2097-111. [Medline].
Burget G. Reconstruction of the Alar Cartilage Arches. Operative Technique and Plastic Surgery. 1998;5:76.
Menick FJ. Anatomic reconstruction of the nasal tip cartilages in secondary and reconstructive rhinoplasty. Plast Reconstr Surg. Dec 1999;104(7):2187-98; discussion 2199-2201. [Medline].
Menick F. Nasal Reconstruction: Art and Practice. Philadelphia, Pa: Saunders Elsevier; 2008.
Further Reading
Keywords
rhinoplasty, tip surgery, nose surgery, nose job, nose reconstruction, nasal reconstruction, nose tip surgery, nasal surgery pictures, nasal surgery, nasal tip reconstruction, reconstructive rhinoplasty, rhinoplasties, tip rhinoplasty
