Tip 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 in rhinoplasty 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.

Reconstruction of the injured nose was discussed in the earliest medical literature as part of the Susruta Samhita, the Hindu book of revelation, about 800 BC. However, it was not until 1891 that John Roe, an American surgeon, described an operation to improve the cosmetic appearance of the nose. He exposed the underlying osteocartilaginous structures through direct external incisions to reduce the size of a large nose. In 1896, Jacques Joseph, a German surgeon, manipulated the framework of the nose through intranasal incisions to avoid visible scarring of its skin surface. This closed technique remained the standard well into the late 20^th century.

Good results in rhinoplasty depend on a structurally sound nasal skeleton covered by a conforming skin and soft tissue envelope. The endonasal (closed) approach exposes the osteocartilaginous midlayer of the nose through intercartilaginous, infracartilaginous, and transcartilaginous incisions. The overlying skin envelope is elevated to identify the abnormality and allow its aesthetic modification. Many experienced surgeons find the closed technique adequate to obtain their desired results. However, when incisions are limited only to those within the nostrils, exposure is restricted and visibility and space to work limited. Because of these restrictions, many surgeons find the results of closed rhinoplasty to be less favorable than expected. ^[1]

Anderson, Johnson, ^[2] Toriumi, ^[2] Gunter, ^[3] Rohrich, ^[3] and Juri ^[4] repopularized the open approach during the late 20^th century. Bilateral rimming incisions were combined with an external transcolumellar incision. This allowed elevation of the nasal skin and wide visualization. The open technique allows the underlying supportive framework to be modified without the intraoperative distortion caused by closed delivery techniques. Diagnosis of the underlying deformity is easier, and bony and cartilaginous excision is more accurate. The underlying osteocartilaginous anatomy is more easily reshaped, and the suture modification and fixation of cartilage grafts facilitated.

Importantly, open rhinoplasty is considered more adaptable because it permits the use of surgical maneuvers that are precluded by the limited exposure provided by a closed approach. The open method creates a more rigid support and greater architectural stability and, some believe, a more predictable outcome.

When major changes are needed in cosmetic appearance or nasal function, open rhinoplasty has become the common approach. However, all methods have pros and cons. The wider exposure and more extensive dissection that occur with the open technique diminish normal nasal support. It must be restored before the surgery is completed, as each part of the nose is modified. To prevent postoperative collapse and loss of long-term shape, strong structural support is even more important in an open rhinoplasty to project and shape the nose. This has led to the development of refined suture and cartilage grafting techniques during open rhinoplasty to stabilize the modified intranasal anatomy. See the image below.

A small dorsal hump and a slightly underprojected and round ball-like tip are visible preoperatively.

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The essential elements of the open technique are as follows: ^{[5, 6]}

1. Exposure by open rhinoplasty

2. Anatomic diagnosis

3. Anatomic reconstruction by reduction, reshaping, or augmentation of the osteocartilaginous structure

4. Controlled contouring by in situ cartilage and graft sculpture, tip suturing techniques, and onlay grafting, if necessary

5. Secure suture fixation of modified cartilage structures and cartilage grafts

The nose is made up of covering skin; a midlayer framework of hard and soft tissue that supports, shapes, and braces the nasal soft tissues; and thin, vascular conforming lining. Although all anatomic layers contribute to overall nasal form, the osteocartilaginous midlayer contributes most to nasal shape. Aesthetically, the character of the nose — its refinement, inclination, length, and position — are determined by the contour of the nasal tip. ^[7]

The alar cartilages provide support and configuration to the tip lobule. Their shape, size, and position define tip aesthetics. Ideally, during primary rhinoplasty, the tip cartilages are modified by partial excision, transection, repositioning, suture modification, or augmentation to create the desired result. For more information, see the Medscape Reference article Alar Cartilage Resection Rhinoplasty.

Rhinoplasty is performed to improve appearance or poor nasal function. The airway may be obstructed because of septal deviation or internal or external valve soft tissue collapse.

In a typical rhinoplasty, the nasal bones, upper lateral cartilages, and lower lateral cartilages are altered.

Commonly required modifications of the tip complex include the following:

• Change in tip projection

• Decrease in the distance between the tip-defining points

• Decrease in tip fullness

• Creation of a supratip break

• Adjustment in the relationship between the columella and alar rim

• Alteration of tip rotation

• Lengthening or shortening the nose by repositioning the entire tip complex cephalically or caudally

Successful rhinoplasty requires knowledge of normal anatomy and its variations. It also necessitates an understanding of the relevance of anatomy to surface contour and the impact of its alteration on appearance and function.

The anatomic layers of the nose are as follows:

• A covering envelope of superficial epidermis, dermis, and a subcutaneous layer of fat; nasalis muscle; and associated fascia: This external envelope is separated from the underlying support layer by a loose areolar layer. The areolar layer provides an easy, relatively avascular dissection plane through which the nasal cover can be safely elevated to expose the underlying osteocartilaginous support.

• A midlayer of cartilage and bone, covered by perichondrium and periosteum, which support and shape the external skin: Fibrous ligaments extend between the adjacent upper lateral, alar, and septal cartilages, fixing tip position.

• An inner lining of vestibular stratified squamous and septal and nasal mucosa, which line the inner nose: In a routine rhinoplasty, lining should be preserved. Significant alteration of the lining layer is rarely indicated.

Nasal anatomy is depicted in the image below.

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.

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The nasal skin envelope

The skin of the tip and ala is thicker and more sebaceous than the more mobile and thinner skin of the dorsum and sidewall. Thinner skin is more likely to contract and redrape over the underlying framework. Thick sebaceous skin of the tip contracts less and requires a stronger and more angular framework, if the underlying support is to be visible through the overlying skin envelope. Very thick skin may preclude a rhinoplasty.

The nasal skin flap should be elevated in the deep areolar plane, just above cartilage and bone, to preserve the major arterial, venous, and lymphatic vessels, which lie in the musculoaponeurotic layer. Excessive soft tissue scarring or tissue necrosis must be avoided.

Midlayer support

The nose can be divided into an upper bony vault, a middle upper lateral cartilage vault, and a lower alar cartilage vault.

The lower lateral vault (the tip and ala) contains the external valve, which consists of the nostril rim and inner nostril, made up of the caudal edge of the alar cartilage, the soft tissue ala, the membranous septum, and the nostril sill.

The cartilage framework of the nasal tip is provided by the alar cartilages. Each ala is divided into a medial, middle, and lateral crus. Small accessory cartilages extend from the most lateral aspect of the alar cartilage and are bound together by continuous perichondrium, which provides stability to the entire cartilage complex. The shape and position of the distal nose is determined by the thickness of the skin and soft tissues, the underlying tip cartilages, and the suspensory fibrous attachments to the adjacent septum and upper lateral cartilages. Each contributes to the support and position of the entire lower cartilage vault. These ligamentous connections lie between the cephalic margin of the lower lateral cartilages, passing over the septal angle, and connect with the upper lateral cartilages.

Other ligaments connect the accessory cartilages to the piriform aperture. The medial crura are supported by fibrous attachments, which connect them to the caudal septum, and by the soft tissue that lies between the inferior aspect of the feet of the media crura and the premaxilla. These suspensory ligaments are disrupted by the surgical incisions and excisions used to expose and modify the tip cartilages. Overall tip support is diminished by simple elevation of the skin off the underlying cartilage framework; intercartilaginous, transfixion incisions and rimming incisions; cephalic trim of the alar cartilage; excision of the septal angle and caudal septum; and disruption of the various suspensory ligaments.

The interrelationship of anatomy, nasal form and aesthetics

The nasal tip is a 3-dimensional structure of curves and angles. The underlying alar cartilages support and configure the tip lobule. The shape, size, and position of the paired alar cartilages are reflected through the skin as surface anatomy. Each alar cartilage consists of the medial crus, middle crus, and lateral crus; each component influences the form and function of the specific part of the nose in which it lies.

The medial crus lies within the columella and ends at the medial genu, where it joins the middle crus (the columella/lobular junction or columellar breakpoint). The middle crus controls the columellar/lobular ratio and the cephalad or caudal position of the columella.

The middle crus bridges the medial and lateral crus. Its length, configuration, and angularity determine the shape, height, and protrusion of the infratip lobule. Its cephalad angulation is the angle of rotation that starts at the columellar/lobular junction. Its lateral angulation from the midline (the angle of diversion) determines the intracrural distance. The middle crus extends to its junction with the lateral crus (the lateral genu or domes).

The domes of the alar cartilage determine tip projection, width, and definition. The lateral crura extend into and fill the tip lobule, abutting and partially entering the superior ala. Thus, a tripod is formed by the paired medial crura (fixed within the columella by fibrous tissue), which support an inferior central leg, and the paired lateral crura, which extend laterally within the tip lobule to form the 2 superior spanning legs.

Reduction/resection of any limb weakens that leg of the tripod and reduces support of that limb. Augmentation by grafts or struts increases limb strength and length. A shorter lower leg brings the tip inferior and back. A shorter upper leg brings the tip superior and back in the direction of that upper leg. If all 3 legs are shortened, the tip falls back. Lengthening the lower leg moves the tip forward and superior.

Importantly, the lower nose, composed of skin, compact fat, muscle, and alar cartilage can become obstructed if support is lost. The external valve may collapse because of weakening or overresection of the supporting structures, seventh nerve palsy, or stenosis of the vestibular lining due to scarring.

Aesthetics

The aesthetics of the nasal tip are created by the underlying skeleton. As characterized by Sheen, the essential landmarks of a refined tip are the lateral projections of the right and left domes, the points of tip differentiation from the dorsum (supratip break), and the columellar/lobular junction (columellar break).

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.

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Less emphasized is the contribution of the tip cartilages to the form and function of the entire lower third of the nose. More than just tip aesthetics, the alar cartilages define tip/lobular contour; columellar length, width, and position; nostril shape; alar rim position; alar support and airway potency; and apparent nasal length. A predictable reconstruction requires that all the anatomic and functional components of the alar cartilages (medial, middle, and lateral crus) are maintained or restored.

When planning a rhinoplasty, the surgeon must consider the overall nasal "gestalt," ie, the balance, symmetry, and proportion of the entire nose (dorsum, tip, sidewall, and ala). An aesthetic tip is of great importance.

On frontal view, the nasal dorsum is defined by 2 slightly diverging lines that extend from the medial brow ridges to the tip defining point. The alar bases should lie within a line dropped from the medial canthi, depending on the patient's ethnic background. Normally, the flare of the ala is 2 mm wider than the alar base. The surgeon must distinguish between excessive interalar width and alar flaring. ^[8] The alar bases should be symmetric and have a slightly outward flare in an inferior-lateral direction. The alar rim and columella should resemble the gentle curve of the seagull in flight, with the columella just inferior to the alar rim on frontal view.

The basal view of the columella and nasal base should outline an equilateral triangle. The nostril should have a teardrop shape, with its long axis lying in a slight medial direction from base to apex.

On lateral view, the ideal dorsal nasofrontal angle should lie between the upper eyelash and supratarsal fold in horizontal gaze. Tip projection is determined by analyzing the distance from the alar rim/cheek junction to the tip. Fifty to sixty percent of the tip should be anterior to a vertical line drawn adjacent to the most projecting part of the upper lip.

Ideal nasal length is determined by the ratio of nasal length to tip-defining points. It should be 0.67 X RT (radix-to-tip distance) and is equal to distance from the stomion (horizontal junction of the upper and lower lips) to mentum.

The tip has 4 defining landmarks: bilateral tip-defining points, supratip break, and columellar lobular angle, which should create 2 equilateral triangles. The supratip break should be more prominent in women than in men. It increases definition and distinguishes the dorsum from the tip. The columella should lie just inferior to the alar rim, creating a gullwing appearance of the columella and nostril rims in the frontal view. The columellar lobular angle is the junction between the columella and the infratip lobule (columellar break point) and should be between 30 and 45 degrees.

Tip rotation equals the angle of rotation. A straight line is drawn through the anterior and posterior nostril in relation to a perpendicular line drawn through the natural horizontal plane. Ideally, the angle of rotation should measure 95-100 degrees in women and 90-95 degrees in men.

A cosmetic rhinoplasty is an elective procedure performed to alter nasal appearance or improve function. The goal is to improve the appearance of an otherwise normal structure. The decision for surgery must be carefully made to ensure that the gains of surgery are worth the risk of complications or a poor result.

Occasionally, the results of the initial primary operative are less than desired, and a secondary rhinoplasty is needed to improve the initial result. The difficulty of nasal repair increases with the degree of inherent anatomic and aesthetic deficiency. It is significantly increased by the additional distortion of anatomy which may follow a previous surgery. The consequences of inappropriate excision, malposition, augmentation, scarring, destruction of donor cartilage, or tissue necrosis make a secondary rhinoplasty more difficult.

Rhinoplasty success requires careful preoperative examination and detailed planning. The consultation is an opportunity to compile a history and perform a physical examination. The nose itself must be carefully analyzed to define the specific aesthetic and anatomic deformities that require correction.

Communication must be established between patient and surgeon to define goals, outline a plan, and identify the limitations of surgery. The patient's concerns and their order of importance must be understood and any functional problems identified.

The patient must be emotionally, medically, and physiologically prepared for surgery with clear and realistic expectations. Although the risk of surgery should never be minimized in rhinoplasty, it is a relatively noninvasive procedure and is well tolerated by patients in general good health.

In practical terms, the psychologic makeup of the patient may be the more difficult factor to evaluate. A change in nasal appearance will not improve social relationships, emotional comfort, or necessarily attract a mate or a job. Single, immature, overly expectant, and narcissistic patients, often males, seem at greater risk for dissatisfaction. This can occasionally lead to severe psychiatric problems postoperatively.