eMedicine Specialties > Plastic Surgery > Nose

Rhinoplasty, Tip Surgery

Author: Arian Mowlavi, MD, Consulting Staff, Department of Plastic Surgery, Cosmetic Surgery Clinics of Laguna Beach, CA
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
Contributor Information and Disclosures

Updated: Apr 26, 2006

Introduction

History of the Procedure

Sushruta 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.

Presentation

Patients 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.

Indications

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.
 
Finally, the alar lobules should be assessed independently, not only in the anteroposterior plane but also the lateral profile plane. In the anteroposterior plane, the alar base should span within 1-2 mm of the intercanthal distance. On lateral profile view, the alar rim should arch approximately 2-3 mm above the columella.

Relevant Anatomy

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.

Contraindications

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.

• Search for CME/CE on This Topic »

• Rhinoplasty, Tripod Theory (Plastic Surgery)
• Rhinoplasty, Postrhinoplasty Nasal Obstruction (Otolaryngology and Facial Plastic Surgery)
• Rhinoplasty, Asian (Plastic Surgery)
• Rhinoplasty, Supratip Deformity (Plastic Surgery)

• Cosmetic Procedures Down 12% in 2008

• Prevention of Nasal Injuries Secondary to NCPAP Application in ELBW Infants
• The Olfactory System and Its Disorders
• Facial Resurfacing With Coblation Technology