The “pinched nasal tip” is a deformity caused primarily by collapse of the lateral crura of the lower lateral cartilages. Such collapse may be congenital due to inherent hypoplasia, weakening, or malposition of the cartilaginous support but is often secondary to acquired, commonly iatrogenic, causes. The resultant pinching effect gives an unaesthetic appearance characterized by an alar groove, which extends to the alar rim, causing shadowing between the tip and alar lobules. Such shadows give rise to a ball-shaped tip, and the basal view exhibits a typical pinched appearance. At its worst, it can lead to severe knuckling and bossae formation in the nasal dome region with resultant nasal obstruction by impedance of the airflow on inspiration. Correction of the functional and aesthetic components to this problem is achieved with restoration of the alar cartilaginous strength and structure and requires appropriate, ideally autogenous, grafting material. This chapter describes the relevant anatomical basis for the deformity, causes and prevention of iatrogenic problems, and techniques for correction.
Anatomy of the Nasal Vestibule
The ideal aesthetic of the basal view of the nasal tip is that of an equilateral triangle. The lateral crura should have an outward convexity of the posterior alar rims and gentle rounding in the dome region; specifically there should be no pinching of the lateral alar walls. Various factors, including thickness of the overlying skin, musculature (dilators), and strength and position of the lower lateral cartilages, can directly influence the tip shape and dynamics.
The caudal margin of the lateral crus should ideally lie in a horizontal plane such that it lies just inferior to the cephalic margin. If the cartilage is angulated such that there is a significant superior to inferior relationship between the cephalic and caudal margins, this may predispose to loss of support in the lateral alar region and consequent pinched tip deformity ( Figures 19-1 and 19-2 ).
Inherent or postoperative weakness in the lateral crus can cause the anterior and midportion of the tip to collapse. Posterolaterally, there is thick alar soft tissue and skin, so fewer problems are encountered.
Causes of Deformity
Weakness of the lateral cartilaginous support leads to the nostril rim contracting inwards under the weight of the thick alar skin and soft tissue envelope. Inspiration may exacerbate this collapse. The basal view exhibits a typical appearance resembling a teat on a baby’s bottle ( Figure 19-3 ).
Congenital
Congenitally weak lower lateral cartilages predispose to this deformity. The lateral nasal rim is typically convex and its most severe form can buckle in so dramatically so as to restrict the nasal airway even in the resting state.
Acquired/Iatrogenic
By far the most common cause for this deformity is iatrogenic weakening of the lower lateral cartilages due to overresection of the cephalic edge of the lower lateral cartilages with subsequent weakening of the intact rim strip. The useful edict of leaving behind more cartilage than that resected should always be remembered although the authors recommend an absolute minimum of 6-mm cartilaginous support but leaving more may be favorable.
Knuckling of the lower lateral cartilages in the domal area forms “bossae” ( Figure 19-4 ).
The inexperienced rhinoplasty surgeon may not be aware of the triad of thin skin, strong alar cartilages, and bifidity of the tip, which together predispose to their formation when there is an excess cephalic strip reduction and inadequate narrowing of the domes. Postoperative scar contracture in this area causes the deformity. Controversy surrounds the predisposition of vertical dome division techniques to formation of the pinched tip and bossae, and distinguished authors have both suggested and refuted this possibility.
Overzealous cephalic strip resection can further lead to alar retraction due to the visoring effect caused by contraction as healing occurs. If vestibular mucosa is not preserved, this complication, too, can contribute to contracture and promote further retraction.
Aggressive domal suturing with its resultant alteration in tip orientation and dynamics can cause notching in the dome region predisposing to a pinched tip effect. Ensuring the suture is not tied overtightly such that significant pinching of the domes occurs should reduce the risk of this.
Other more unusual causes of this deformity include collapse of the alar cartilaginous region following inflammatory conditions (see Fig. 19-5 ) such as Wegener’s granulomatosis, but this may also occur following cocaine abuse.
Assessment
A complete and discerning history regarding the perceived cosmetic problem and function, any prior procedures, and accurate chronologic detailing of postoperative changes is important when considering revision surgery. As ever, copies of a detailed prior operative report are helpful but rarely available for the revision rhinoplasty surgeon. Overall, it is vital to ensure that the patient’s concerns and expectations are elucidated early in the consultation. Dissatisfaction expressed by the patient should be specific rather than general and should be perceived as realistic and true by the evaluating specialist.
The surgery is best not performed if the patient’s expectations are thought to be unrealistic. When in doubt, sensitive counseling of the patient and referral for psychiatric review is always prudent, and surgery is deferred pending this.
Diagnosis of the underlying anatomic deformity is essential prior to embarking upon a surgical plan. Inspection and palpation of the integrity of lower lateral support are equally important. It may not be possible to assess whether there is an intact strip of the lower lateral cartilage, and prior operative notes may be helpful in this regard.
Specific assessment for analysis of the pinched nasal tip includes analysis of functional obstruction. It is important to check whether there is alar collapse on inspiration, but in its absence, valve collapse cannot be excluded. Assessment with the Cottle maneuver is often advocated but can be nonspecific and lateralizing the alar cartilage with a probe or cotton tip applicator may be a better evaluator.
Operative Techniques
Endonasal Approach
Correction of the pinched tip deformity can be achieved in a variety of ways. For a minor deformity, an endonasal approach may prove adequate for placement of supporting grafts in primary surgery or to correct prior overzealous tip suturing. Marginal incisions may allow delivery of the lower lateral cartilages that can be repositioned and modified as required. Small specific pockets can also allow batten grafts to be inserted to correct concavities caused by weakness of the cartilage. An isolated aesthetic deformity caused by inherent concavity of the lateral crus may be corrected by complete mobilization of the lower lateral cartilage from the vestibular skin. An incision is then made just lateral to the domal area and the lateral crus flipped over such that the concavity now becomes a convexity. The rotated, reconstructed crus is then sutured to the medial segment. Figure 19-6 outlines such a reconstruction, albeit performed via an external approach.
