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Tip Rhinoplasty Treatment & Management

  • Author: Frederick J Menick, MD; Chief Editor: John R Taylor, MD, FRCSC, FACS  more...
 
Updated: Dec 11, 2013
 

Surgical Therapy

Primary Rhinoplasty

The entire character of the nose—its refinement, inclination, length, and width—is determined by the contour of the nasal tip. The shape and position of the alar cartilages and the overlying quality and thickness of the skin determine its appearance. The surgical result depends on the size, strength, curvature, and position of the tip cartilages, and the support of the suspensory ligaments, postoperatively. The bridge and hump are also important.

Ideally, during primary rhinoplasty, the tip cartilages are modified by partial excision, transection, repositioning, suture modification, or augmentation to form an attractively shaped midlayer support framework, which is visible through the skin. Conversely, when a rhinoplasty requires more improvement and a revision is contemplated, restoration of ideal alar cartilage form and function is the essential step in repair.

The principles and operative surgical sequence of all rhinoplasties are as follows:

  • Preoperative anatomic diagnosis
  • Adequate anatomic exposure of deformity
  • Preservation or restoration of normal anatomy and support
  • Correction of specific deformities
  • Maintenance and restoration of nasal airway

The elements of tip surgery may include the following:

  • Cephalic trim
  • Suture reshaping of the tip cartilages
  • Cartilage grafting of the columella, tip, and lateral crura (lateral crural strut, alar spreader graft, or alar strut), if needed
  • Suture repositioning of the tip complex with dome spanning sutures, interdomal sutures, projection control sutures, tip rotation sutures, lateral crural spanning sutures
  • Vertical transection and overlap of the lateral crus or medial crus
  • Trim of the caudal medial crura
  • Resection of the caudal septum

Cartilage grafts are used in rhinoplasty to augment the nose, increase cartilage rigidity, or modify cartilage shape. These grafts vary in dimension, rigidity, and length according to the needs of the repair. Septal or ear cartilage is used, depending on availability, strength, and inherent curvature. This cartilage adds volume, shapes external skin, and provides rigidity to support the nose or modify the shape of the normal cartilages.

The current popularity of tip grafting can be attributed to Sheen.[6, 7] Initially, when overresection of the alar cartilage was identified during a secondary rhinoplasty, single, rigid, septal cartilage shield-shaped grafts were placed within a limited subcutaneous pocket in the tip lobule, to increase projection and define the columellar/lobular angle. Subsequently, this technique was applied to primary rhinoplasties with inadequate tip projection. Problems with graft visibility, unnatural postoperative flatness, and graft position led to Sheen’s current modification, which uses multiple solid, bruised, and crush cartilage grafts. These are placed over an ethmoid bone brace to increase fixation and limit displacement. Uncorrected problems, such as inadequate rim support or alar retraction, were addressed by placing separate cartilage grafts in subcutaneous pockets or with composite skin grafts to supply both lining and support along the rim margin.

Peck corrected inadequate tip projection with an umbrella graft.[8, 9] This consisted of a vertical cartilaginous strut placed between the medial crura to increase tip support. A horizontal onlay graft, 9 X 4 mm in size, was positioned over the alar domes to further define the tip shape.

The developers of the open rhinoplasty technique approached the problem of graft displacement by taking advantage of increased exposure, provided by the open method, to suture solid tip grafts in position.[10, 11] Solid shield-shaped tip grafts, separate lateral crural onlay grafts, or anchor-shaped tip grafts were fixed in place with sutures to prevent shifting. Once in place, in situ cartilage sculpture was possible.

Specific methods

See the list below:

  • Tip projection
    • Tip projection can be increased by strengthening the medial crura with a columellar strut or by suturing the medial surfaces of the middle crura together, which effectively adds length to the middle crura. A tip graft provides additional projection and definition.
    • Tip projection can be decreased by reducing tip support. See the image below.
      (A) When the dorsum is lowered and the juncture of (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.
    • Any combination of skin elevation, transfixion and intercartilaginous incisions, cephalic trim, dome excision (usually followed by covering tip grafts to recreate tip shape after dome excision), and transection or excision of the medial crura or the accessory cartilages or lateral crus decreases tip support and projection. If the lateral or medial crural cartilages are transected, they fall posteriorly. To maintain support and position, the cut ends are overlapped and fixed with suture to reestablish stability. The medial crura, if transected, are resupported and sutured over a columellar strut, which acts as a jig, to prevent displacement and uncontrolled overlapping.
    • Loss of tip projection may cause flaring of the alar bases or bowing of the columella. These secondary deformities are treated by alar base excision or membranous or caudal septal cartilage excision.
  • Tip rotation
    • Tip rotation depends upon the adherence of the skin to the upper lateral and alar cartilages, nasal bones, the fibrous attachments of the lower lateral cartilages to the upper lateral cartilages and the caudal septum, the tip complex to the piriform aperture, and to the size of the cartilage framework.
    • These elements can be altered by the following actions:
      • Elevation of the skin
      • Intercartilaginous incision
      • Cephalic trim
      • Lateral transection of the lateral crus
      • Trim of the upper lateral cartilage
      • Trim of the anterior caudal septum
      • Lowering of the septal angle
      • Suture positioning of the tip complex to the septal angle (tip rotation suture)
      • A columellar strut (which lengthens and increases strength of the medial crura)
  • Nasal lengthening (positioning the tip inferiorly): Extended lateral spreader grafts and/or a columellar strut lengthen the nose by pushing the tip complex caudally, extending the effective length of the caudal septum.
  • Nasal shortening (positioning the tip complex superiorly): Cephalic trim, trim of the inferior aspect of the upper lateral cartilage, or excision of the caudal septum (with nasal spine) can produce nasal shortening.
  • Distance between tip-defining points: This can be narrowed by cephalic trim and by suturing the middle crura together (interdomal suture).
  • Tip fullness: This is decreased by cephalic trim, weakening the lateral crura by transection, and horizontal mattress sutures that flatten the convexity of the lateral crus.
  • Supratip break
    • A supratip break is created by altering the relationship between projection of the tip-defining points and the dorsum. This is obtained by lowering the dorsal septum, and augmenting tip projection with a columellar strut, dome suturing, or tip grafting.
    • Limited excision of excess soft tissue on the undersurface of the supratip skin should be performed with extreme care to avoid skin devascularization and soft tissue necrosis.
  • Alar-columellar relationship
    • The alar-columellar relationship is changed by altering the shape and position of the medial crura. The columella can be displaced caudally by placement of a columellar strut or superiorly by excision of the caudal septum or membranous septum.
    • An unattractively shaped nostril margin, which hangs below an ideally positioned columella, can be trimmed by direct excision along its rim.

Secondary Tip Rhinoplasty

When a primary rhinoplasty requires further improvement, a normal and aesthetic tip framework must be restored. See the images below.

(A) A wide round tip reflects the 3D contour of th (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.
Loss of caudal septal support causes the nasal tip 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.
After restoration of dorsal support with a rib ost 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.
Postoperatively, the aesthetic contours of the nos Postoperatively, the aesthetic contours of the nose and lip are restored, along with airway function.
The nasal form and function are severely impaired 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.
The right lateral and medial crus and the left lat The right lateral and medial crus and the left lateral crus are missing. The open approach permits the underlying anatomical injury to be visualized.
The septal cartilage at the septal angle was lower 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.
Postoperatively, a defined and projected tip and a 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.

In some secondary rhinoplasty cases, the alar cartilages may be distorted or malpositioned but remain intact. In that case, they can be manipulated with routine methods.[12] Unfortunately, in many cases, the alar cartilages have been completely excised or so severely injured that their remnants are not available for repositioning and repair. Although a combination of nonanatomic columellar struts, tip grafts, and lateral crural onlay grafts have been successfully employed, a truly anatomic replacement of the missing alar cartilages may be more successful in restoring tip aesthetics and function.

During an open rhinoplasty, a fabricated and rigid framework is designed to replace exactly the missing medial, middle, or lateral crus of one or both alar cartilages. The entire tip tripod is recreated. These anatomic cartilage reconstructive grafts create tip definition and projection, fill the lobule, restore the expected lateral convexity, position the columella and establish columellar length, secure the position of the ala rim, brace the external valve against collapse, support the vestibular lining, and restore a nostril shape. They can restore the anatomic form and function of the nasal tip. Anatomically designed alar cartilage replacements allow an aesthetically structured skeleton to contour the overlying skin envelope. When seen through the covering skin, they recreate the form and function of a normal nose.[13, 14, 15]

The anatomic reconstruction of the alar cartilages in secondary rhinoplasty is designed to provide a precise anatomic replica of the missing normal anatomy, using septal, ear, or rib grafts. During open rhinoplasty, a fabricated rigid framework is designed to replace the missing medial crus, the middle crus, or the lateral crus of one or both alar cartilages. They restore the alar tripod and are securely positioned and fixed with sutures.

Conceptually, the technique acknowledges that the alar cartilages control more than tip projection or definition. They are integral to the form and function of the entire lower nose, including the tip lobule, columella, alar rim, and external valve function.

To begin the anatomic alar cartilage graft procedure, a preoperative evaluation of the columella, tip, lobule, ala, and nostril margin is completed. During open rhinoplasty, a precise anatomic diagnosis of the tip deformity is made. The medial crural remnants are identified if present. When the residual cartilage remnants are not available for repositioning and repair, an anatomic reconstruction of the alar cartilages is performed. A columellar strut provides rigidity, restoring the central alar tripod and permitting a secure jiglike fixation between the medial residual crura and the newly reconstructed middle and lateral crural cartilage graft replacements.

At the completion of the tip reconstruction, an anatomically correct replica of one or both alar cartilages restores all or part of the medial, middle, and lateral crura. Similar to normal alar cartilages, they restore the form and function of the columella, tip lobule, nostril, and alar margin.

The essential elements of the anatomic tip technique are as follows:

  1. Exposure by open rhinoplasty
  2. Anatomic diagnosis
  3. Anatomic reconstruction
  4. Secure graft suture fixation
  5. Controlled contouring by in situ graft sculpture, tip suturing techniques, and shield-shaped onlay grafting, if necessary
  6. Forcible remodeling of the skin envelope by the underlying restored skeletal structure
  7. The release, repositioning, and reshaping of both cover and lining by wide undermining and release of subcutaneous scars

The technique is useful when the alar cartilages are significantly destroyed or absent in secondary rhinoplasty and the residual alar remnants are insufficient for repositioning and repair. It replaces the alar cartilages anatomically and functionally. Anatomic alar cartilage replacements, fixed with sutures during open rhinoplasty, allow an aesthetically structured skeleton to positively influence the contour of the overlying skin envelope.

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Follow-up

A hard dorsal splint and tape fix the position of the nasal bones and nasal cartilages for 1 week postoperatively. The patient is seen intermittently over the next 6-12 months to follow the expected resolution of edema and the normal remodeling of the skin envelope to the newly shaped underlying hard tissue framework.

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Complications

Aside from failure to achieve the desired aesthetic result, serious complications are rare. Infection is very unusual.

The blood supply of the nasal skin is profuse. Skin necrosis is unlikely but can be devastating. Necrosis is most often secondary to elevation and dissection of the skin flap in too superficial a plane, which injures its vascular supply within the musculoaponeurotic layer, or by direct injury to the dermis. If the surgeon elevates the nasal skin correctly in the areolar plane between the osteocartilaginous skeleton and the skin/fat/musculoaponeurotic layer, skin necrosis should not occur.

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Outcome and Prognosis

Longlasting improvement in the appearance of the nose is to be expected. Most patients are happy with the results of tip surgery; 80-90% of patients are pleased with the overall changes in nasal appearance. The final result can be compromised by thick and stiff skin or a large skin envelope, which may not conform to the altered cartilage and soft tissue framework. The final result depends on balancing patient goals with the ability of the skin to shrink and conform to an attractive cartilage framework. The surgical plan must consider the quality and size of the skin envelope.

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Contributor Information and Disclosures
Author

Frederick J Menick, MD Clinical Associate Professor, Department of Surgery, Division of Plastic Surgery, University of Arizona College of Medicine; Facial and Nasal Reconstructive Surgeon, Tucson, Arizona

Frederick J Menick, MD is a member of the following medical societies: American Society of Maxillofacial Surgeons, Canadian Society of Plastic Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

George Peck, MD 

George Peck, MD is a member of the following medical societies: American Society for Aesthetic Plastic Surgery

Disclosure: Nothing to disclose.

Chief Editor

John R Taylor, MD, FRCSC, FACS Independent Practice, Ontario

John R Taylor, MD, FRCSC, FACS is a member of the following medical societies: American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons, Canadian Medical Association, Canadian Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Frederick J Menick, MD Clinical Associate Professor, Department of Surgery, Division of Plastic Surgery, University of Arizona College of Medicine; Facial and Nasal Reconstructive Surgeon, Tucson, Arizona

Frederick J Menick, MD is a member of the following medical societies: American Society of Maxillofacial Surgeons, Canadian Society of Plastic Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

References
  1. Johnson C, Toriumi D. Open Structure Rhinoplasty. Philadelphia: Saunders; 1990.

  2. Gunter JP, Rohrich RJ. External approach for secondary rhinoplasty. Plast Reconstr Surg. 1987 Aug. 80(2):161-74. [Medline].

  3. Juri J. Salvage Techniques for Secondary Rhinoplasty. Daniel R. Aesthetic Plastic Surgery: Rhinoplasty. Boston, Mass: Little Brown; 1993.

  4. Gunter J, Rohrich R, Adams W. Dallas Rhinoplasty. 2nd ed. St. Louis, Mo: Quality Medical Publisher; 2007.

  5. Tebbetts J. Primary Rhinoplasty: Refining the Logic and Techniques. 2nd ed. St. Louis, Mo: Mosby Elsevier; 2008.

  6. Sheen J, Sheen A. Aesthetic Rhinoplasty. 2nd ed. St. Louis, Mo: Mosby; 1987. Vol 1 and 2:

  7. Sheen JH. Tip graft: a 20-year retrospective. Plast Reconstr Surg. 1993 Jan. 91(1):48-63. [Medline].

  8. Peck GC Jr, Michelson L, Segal J, Peck GC Sr. An 18-year experience with the umbrella graft in rhinoplasty. Plast Reconstr Surg. 1998 Nov. 102(6):2158-65; discussion 2166-8. [Medline].

  9. Peck G. Techniques in Aesthetic Rhinoplasty. 2nd ed. New York: Gower Medical; 1989.

  10. Daniel RK. Rhinoplasty: a simplified, three-stitch, open tip suture technique. Part I: primary rhinoplasty. Plast Reconstr Surg. 1999 Apr. 103(5):1491-502. [Medline].

  11. Daniel RK. Rhinoplasty: a simplified, three-stitch, open tip suture technique. Part II: secondary rhinoplasty. Plast Reconstr Surg. 1999 Apr. 103(5):1503-12. [Medline].

  12. Constantian MB. Differing characteristics in 100 consecutive secondary rhinoplasty patients following closed versus open surgical approaches. Plast Reconstr Surg. 2002 May. 109(6):2097-111. [Medline].

  13. Burget G. Reconstruction of the Alar Cartilage Arches. Operative Technique and Plastic Surgery. 1998. 5:76.

  14. Menick FJ. Anatomic reconstruction of the nasal tip cartilages in secondary and reconstructive rhinoplasty. Plast Reconstr Surg. 1999 Dec. 104(7):2187-98; discussion 2199-2201. [Medline].

  15. Menick F. Nasal Reconstruction: Art and Practice. Philadelphia, Pa: Saunders Elsevier; 2008.

 
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A small dorsal hump and a slightly underprojected and round ball-like tip are visible preoperatively.
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.
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.
(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.
(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.
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.
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.
Postoperatively, the aesthetic contours of the nose and lip are restored, along with airway function.
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.
The right lateral and medial crus and the left lateral crus are missing. The open approach permits the underlying anatomical injury to be visualized.
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.
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.
 
 
 
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