27 The Nasal Tip
27.1 Boxy Tip
An aesthetic disproportion between a thin nasal pyramid, a narrow middle vault, and a wide, boxy nasal tip following primary rhinoplasty may have two different causes. Either the nasal tip was ignored in the previous operation—a common oversight in isolated hump removals—or the surgical measures failed to produce the intended result. 1 , 2 Helpful aids in making this determination are the initial photographs taken before the primary rhinoplasty and the surgical report. It is important to analyze the morphologic problem. Were the resections inadequate? Were sutures loosened by the tension from thick alar cartilages? Is there an open dome angle? Is the tip shape compromised by flaring lateral crura? 2 , 3
Based on the broad spectrum of potential causes, a large palette of corrective options are available that depend in part on the patient′s skin and connective-tissue type. In patients with thick or moderately thick skin, tip refinement can be achieved with tip and shield grafts. Corrections in patients with thin skin should be limited to suture techniques. 4 , 5
If no previous surgery has been done on the nasal tip, the surgeon has the advantage of being able to perform a “primary” rhinoplasty in that area, free from scar contractions and deformities. But if, say, multiple previous operations have been done that involved the tip area, the surgeon will face the challenging problem of altered tip anatomy due to scarring. This may be so pronounced in extreme cases that it is impossible to dissect in normal tissue planes. Revision surgery then requires a dissection technique that I call “carving.” Using a sharp No. 11 or No. 15 blade, the surgeon carves the shape of anatomic structures out of blocks of scar tissue. In most cases the carved structure should be camouflaged with a suitable material such as perichondrium.
Illustrative Case 38
Introduction
A 34-year-old woman had undergone rhinoplasty for hump removal 9 years ago. As a fashion model, she felt that her wide nasal tip was unphotogenic and that her nose had an unsightly appearance in photographs of her face ( Fig. 27.2a, b ).
Findings
Frontal view ( Fig. 27.3a ) shows a wide nasal tip, a wide nasal pyramid with an open-roof deformity, a mild inverted-V deformity, and a washed-out transition from supratip area to tip. Profile view ( Fig. 27.3b ) shows a small residual hump with a polly beak deformity and a poorly defined tip. Basal view ( Fig. 27.3c ) shows a wide, boxy tip.
Surgical Procedure
A delivery approach was used, and the residual hump was removed with a Rubin osteotome. Medial and lateral curved osteotomies were performed. Transdomal sutures were placed to shorten the inter- and intradomal distance ( Fig. 27.3g–n ).
Psychology, Motivation, Personal Background
The patient had a clear and reasonable motive for seeking aesthetic revision. The individual critical points were clearly addressed, and an overall surgical goal was defined jointly by the patient and surgeon. All these elements provided a solid foundation for undertaking a revision rhinoplasty.
Discussion
In this case the nasal tip had been untouched in the previous operation, so all revision options were available to the surgeon. The suture technique was an obvious choice for narrowing the tip and moving the tip-defining points closer together. The nasal bones were of moderate length, suggesting that reosteotomies could be successfully used to narrow the bony pyramid and the brow-tip aesthetic lines. If the nasal bones had been short, the use of spreader grafts would have been considered.
27.2 Nasal Tip Asymmetry
Asymmetries and irregularities of the nasal tip may arise in various ways during and after previous surgery. A frequent cause is inadequate mobilization and asymmetric resections through a “minimal approach” that does not afford adequate exposure. In many cases, minor variants in the shape of the medial and intermediate crura of the alar cartilages will not affect the nasal tip shape. But if a deviated S-shaped intermediate crus has been mobilized in a previous operation and freed from its attachment by intercrural fibers, a previously nonexistent problem may become apparent after the surgery (see the case report below).
Uni- or bilateral asymmetric divisions of the alar cartilages are another potential cause of tip asymmetry. Reconstructive corrections with cartilage grafts or approximating suture techniques are appropriate in these cases (domal equalization sutures, interdomal sutures). The vault of the dome can be reconstituted with, say, domal creation sutures or lateral crural mattress sutures if the alar cartilages are sufficiently pliable. Asymmetric dome heights can be equalized by uni- or bilateral sliding maneuvers, the Lipsett maneuver ( Fig. 27.4a, b ), or by vertical lobule division. A columellar strut provides the main structural support for the creation of symmetrical domes ( Fig. 27.4c ).
A common problem is an amorphous nasal tip after primary rhinoplasty in a patient with thick skin and fragile cartilage. Cap and shield grafts may be useful for improving tip definition in these cases. The complete excision of subcutaneous scars may be advisable, but the skin should not be thinned too much, as this may cause trophic disturbances and acrocyanotic redness. Small injections of triamcinolone may be appropriate in patients with repeated strong connective tissue reactions or thick subcutaneous scarring. If tip support has been permanently destroyed by overresections, the only remaining option is to reconstruct the missing cartilage with implants (see Case 53).
Case 39
Introduction
A 35-year-old man stated that he had undergone a septorhinoplasty 3 years ago and that a nasal tip deformity had developed afterward. He now sought deprojection of the nasal tip, the creation of a round, harmonious shape, and elimination of the tip deformity.
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