Supratip Deformity Rhinoplasty

In 1977, Converse noted that 3 of the more common reasons for revision rhinoplasty were "poor aesthetic judgment on the part of the surgeon, the surgeon's inexperience, [and] the inevitable need for a secondary operation in the difficult rhinoplasty." He further suggested that the essential errors in primary rhinoplasty were excessive dorsal reduction, excessive resection of the caudal septum with overshortening, and technical maneuvers resulting in supratip protrusion. ^[1]  

Supratip deformity (or polly beak deformity, as it once was known) represents one of the most frequent complications of rhinoplasty necessitating secondary revision. ^[2] Early surgeons attributed this to a local excess of skeletal tissue in the supratip region and promoted overreduction of the distal septum in patients identified as prone to later deformity. However, Sheen challenged this opinion, stating that the predominant etiology was excessive dorsal septal resection with inadequate tip support. In remarking that 82% of his revisions were addressed adequately through dorsal augmentation and support of the tip without removal of scar tissue, ^[3] he warned that repeated attempts at subdermal dissection and resection of supratip scarring could cause multiple irregularities such as adhesions, telangiectasias, irregular thinning or thickening, and grooves and furrows. ^[4]

While often the result of technical misadventure and poor surgical planning, the supratip deformity also can exist in the primary rhinoplasty. As the manifestation of factors such as an overprojected supratip, an underprojected tip, cephalically oriented lower lateral cartilages, or a combination thereof, it may exist de novo. ^[5] The presence of this can be noted in children whose underdeveloped nasal skeleton prevents optimal draping of the overlying skin envelope, resulting in a natural, though generally transient, supratip deformity. ^[6]

The supratip area is defined as consisting of the distal portions of the upper lateral cartilage, the dorsal septum, anterior septal angle, and the parallel cephalic border of the lateral crura of the lower lateral cartilage. See the image below.

Surgery within this area has a profound impact on the tip and can result in polly beak deformity, alar retraction, saddle nose deformity, or tense supratip if overresected or underresected and disturbed without being reconstructed adequately. ^[7]

Supratip deformity is defined as fullness or convexity located immediately cephalad to the nasal tip and may occur as both a primary and secondary deformity. As previously mentioned, supratip prominence may occur de novo or as the result of technical misadventures and inadequate surgical planning. In this case, supratip prominence is persistent and is in contrast to the normal transient swelling commonly noted within the immediate postoperative period.

Instead of prominence, an aesthetically pleasing nose demonstrates a supratip breakpoint at the point cephalad to the nasal tip where the contour lines of the nasal dorsum rise toward the tip-defining points. Clinically, this break defines a nose in which tip projection slightly exceeds the profile line of the dorsum. Anatomically, the supratip break is a consequence of the projection differential between the domes of the lower lateral cartilages and the dorsal septal plane. For this to occur, the dome-defining points must be at least 6-7 mm above the plane of the anterior dorsal septum in thin-skinned individuals and 10 mm in those with thicker skin. ^[8] In patients with a supratip deformity, this breakpoint is lost, the supratip assumes a misshapen convex profile, and the aesthetic ideal is not attained.

Frequency

Although numerous authors have described appropriate overall rates of revision rhinoplasty ranging from 5-12%, ^{[9, 10, 11]} the true revision rate is arguably much higher (Baker, personal communication).

While several algorithms have been proposed for diagnosing and describing rhinoplasty deformities, the most straightforward is that of Stucker. In his 1984 review of 406 secondary rhinoplasties, he stated that the most common deformity was "...an uncorrected defect or pre-existing problem compounded by surgical insult." ^[12] Stucker divided deformities anatomically into those involving the upper, middle, and lower third of the nose. Deformities of the tip, or lower third, most commonly were associated with bossae (knuckling of the lower lateral cartilages) and a hanging columella. In the middle third, polly beak deformity and pinching of the supratip were most common. Finally, in the upper third, excessive dorsal reduction and dorsal irregularities were the most common reasons for secondary surgery.

In one review of 882 cosmetic rhinoplasties (with a 7.1% revision rate), the authors identified their primary deformity to be the polly beak or supratip deformity, followed by general irregularities of the bony dorsum. ^[13] In another review of 170 revisions, supratip deformity was identified as not only the most common deformity of the middle one third but as contributing to 33% of overall complications, making it their most frequent complication. ^[14] In their analysis of postoperative rhinoplasty complications, Kamer and McQuown identified the lower two thirds of the nose as the most common site of their postoperative deformities and supratip deformity as their most commonly observed complication, comprising 56% of their major deformities. ^[15]

Supratip deformity can result from a variety of misadventures. Rees et al attributed it to insufficient lowering of the dorsal septum but added that it also may be the result of other factors, including insufficient trimming of the dorsal borders of the upper lateral cartilages, excessive resection of the alar cartilage domes, insufficient trimming of the septal mucosa, inherent thickness of the skin and subcutaneous tissue, or the presence of a short columella. ^[16]

Regardless of the primary etiology, supratip prominence is accentuated by formation of scar tissue interposed within dead space between the dorsal skin flap and the septal border. The thicker the skin of the tip and supratip region, the more apparent the deformity. ^[17]

Inadequate tip support both may bring about and accentuate the supratip deformity. In reference to structural considerations, Anderson described the tip as a tripod constructed of two long legs of the lateral crura adjoined to the short leg of the conjoined mesial crura. When this support is lost, the lobule will "...tilt downward as much as the length of the mesial crura, the shortest leg of the tripod, will permit."

He suggested that support also would be compromised by several other factors including (1) disruption of the intracrural ligaments with cephalic trimming of the lower lateral cartilages, (2) excessive trimming of the cephalic margin of the lower lateral cartilages, leaving inadequate support for the tip, (3) lowering the profile projection of the cartilaginous portion of the septal dorsum (usually the most important factor and may be causal even if no tip cartilage modification or septal shortening is present), and (4) shortening of the cartilaginous septum, especially in the region of the anterior septal angle. ^[18]

When technical adjustments compromise the essential tip support framework, tip projection and rotation may be compromised, unveiling the anterior septal angle and supratip dorsum. Whether in concert with overresection or underresection of the dorsal septum or as an isolated event, the result is the supratip deformity.

In 1975, Sheen presented clinical results of 100 consecutive secondary rhinoplasties for supratip deformities of which 80% were corrected by dorsal augmentation with or without tip grafting. In evaluating the deformity, he applied direct pressure to the supratip, pressing it down to the underlying anterior septum. He proposed that by doing this, he could assess underlying local support of the supratip (or lack thereof) and identify the need for dorsal augmentation or local resection.

However, in his experience, he noted that in most supratip deformities, underlying support was lacking and commented that "...augmentation, not reduction, was the answer..." to supratip fullness. He added, "Besides the diagnosis and treatment of supratip deformity, the other aspect of this milestone is prevention. Understanding that the size of the skeletal framework must be proportionate to the size (and character) of the overlying soft tissue, the surgeon can prevent supratip deformity by retaining adequate dorsal support."

In support, Sheen demonstrated correction of this deformity in a young woman at Millard's 1975 Rhinoplasty Symposium in Miami. Intraoperatively, he noted the dorsal septum adjacent to the supratip to be undercut by 4-5 mm, requiring dorsal augmentation. Intentional overresection of the supratip dorsal septum previously was championed by Deneke and Meyer in 1967, who commented that, "...if at the end of the operation one leaves a straight dorsum just above the tip, then a hump is unavoidable formed by fibrous tissue due to the lateral compression of the dressing". ^[19]

A careful review of Sheen's treatment of the supratip deformity reveals that in most cases, he favored not only dorsal augmentation but emphasized the need for concurrent support of the nasal tip. He commented that the patient with a long skin sleeve was predisposed to the supratip deformity in which the nasal base appeared to fall off the anterior septal angle, producing elevated supratip positioning relative to a drooping nasal tip (Sheen, 1998).

Anderson proposed 3 basic preventative measures for avoiding supratip deformity. First, he emphasized minimizing production of scar tissue by (1) using a transcartilaginous approach, (2) abbreviating or eliminating the transfixion incision, (3) keeping the plane of dissection as close to the skeleton as possible, (4) performing all steps of the operation within an intramucosal plane, (5) carrying the plane of incision around the septal angle, and (6) designing dressings to eliminate dead space between the supratip soft tissue and underlying septal dorsum. ^[18]

Secondly, he identified the inevitable development of scar tissue and proposed focusing on reducing its contribution to postoperative tension of the middle and lower nasal third by (1) lengthening the mesial crural leg of the tripod to prevent it from tilting downward by inserting a cartilaginous strut between the mesial crura and thus preventing downward tilting, which could be caused by subsequent scar formation, and (2) by suggesting division of the lateral crura vertically just past mid alae when tension from recoil of these structures was anticipated, stating that along with cephalic trimming, this allows for less resistance to tip rotation.

Finally, he recommended maximal apposition and draping of the soft tissue overlaying the nasal skeleton. To achieve this, he suggested (1) undermining the soft tissue to the pyriform margins in all directions, taking care to avoid overresection, (2) lowering the cartilaginous septal dorsum until the superior septal angle is level with the nostril apices, (3) trimming soft tissue, as necessary, from the undersurface of the skin, and (4) as a last resort, carefully crosshatching the dermal undersurface. Although these latter two steps formerly were recommended, they now are considered of historical interest, having since fallen into disfavor, and generally are not recommended by most practicing plastic surgeons.

More recently, Guyuron, in his 1999 review, addressed the supratip deformity and recommended avoiding overzealous resection. ^[5] In addition, he proposed eliminating supratip dead space by directly suturing and coapting the skin envelope to the underlying cartilaginous framework, stating that direct contact between the cartilage and the subcutaneous element of the skin seemed to be the key factor in supratip deformity. Transcutaneous suture apposition of the supratip, while attractive as a preventative measure, has not gained widespread acceptance and largely has been supplanted by the use of compressive dressings and nasal splinting in the early postoperative period.

Supratip deformity, previously defined as the polly beak or parrot beak deformity, is defined as a fullness or convexity located immediately cephalad to the nasal tip and may occur as both a primary and secondary deformity. In addition, the patient commonly is noted to have a low dorsum, blunted tip lobule, and a wide nasolabial angle (Sheen, 1998). When it occurs as a secondary event, it is generally the result of technical misgivings and inadequate surgical planning and is persistent, in contrast to the normal transient swelling commonly noted within the immediate postoperative period.