INTRODUCTION
Anatomic subtleties of the nasal tip have a dramatic impact on the overall appearance of the nose. Here, we provide a focused review of nasal tip analysis and surgical technique, with particular emphasis on tip sutures and cartilage grafts.
NASAL ANALYSIS
Preoperative nasofacial analysis is systematically performed from frontal, lateral, and basal views in the “10-7-5” fashion described by the senior author (R.J.R).1 The 4 points of the “four-quadrant” approach (supratip break, infratip lobule, left tip, and right tip domal transition zones) should create 2 equilateral triangles.2 Areas of cartilaginous excess, deficiency, malposition, and asymmetry should be noted because these will guide the selection of tip sutures and grafts.
OPERATIVE TECHNIQUE
Using an organized and systematic open rhinoplasty approach is the safest and most precise technique for tip shaping.3
Cephalic Trim
Cephalic trim reduces the length of the cartilaginous frameworks and facilitates passive cephalic rotation of the lower lateral cartilage. It is performed by separating the lower lateral cartilages from the upper lateral cartilages and trimming them, leaving at least a 6-mm-wide rim strip (See Video 1 [online], which displays cephalic trim).4
Video 1. Cephalic trim. Video 1 from “Developing Consistency in Nasal Tip Shaping”.
Septal Extension Graft
Septal extension graft is used to control tip projection, rotation, and shape, whereas a columellar strut graft is only effective for unifying the nasal tip, maintaining its position while lacking control over nasal tip rotation (See Video 2 [online], which displays shaping of the septal extension graft) (See Video 3 [online], which displays septal extension graft fixation and stabilization: part 1) (See Video 4 [online], which displays septal extension graft fixation and stabilization: part 2).
Video 2. Shaping of the septal extension graft. Video 2 from “Developing Consistency in Nasal Tip Shaping”.
Video 3. Part 1 - Septal extension graft fixation and stabilization. Video 3 from “Developing Consistency in Nasal Tip Shaping”.
Video 4. Part 2 - Septal extension graft fixation and stabilization. Video 4 from “Developing Consistency in Nasal Tip Shaping”.
Medial Crura Footplate Approximation
Medial crura footplate approximation corrects footplate deformities and asymmetries (See Video 5 [online], which displays tip suturing: part 1).
Video 5. Tip suturing. Part 1. Video 5 from “Developing Consistency in Nasal Tip Shaping”.
Medial Crura Approximation
A “low” suture is placed to stabilize, correct footplate asymmetries, reduce flaring, control columellar width, and strengthen the medial crura. A “high” suture is placed at the infradomal portion of the medial crura to aid in establishing tip width and symmetry (See Video 5 [online], which displays tip suturing: part 1).
Transdomal Suture
Transdomal suture is used to correct asymmetries, correct lateral crural convexities/concavities, and narrow the tip. The end result should be straight, everted lateral crura with the caudal portion higher than the cephalic portion (See Video 6 [online], which displays tip suturing: part 2).
Video 6. Tip suturing. Part 2. Video 6 from “Developing Consistency in Nasal Tip Shaping”.
Interdomal Approximation
Interdomal approximation decreases the angle of divergence, narrows the tip-defining points, corrects vertical asymmetries, enhances the infratip lobule, helps camouflage cartilage grafts, and increases tip projection (See Video 6 [online], which displays tip suturing: part 2).
Tip Grafts
Soft tip grafts camouflage prominent and sharp angles of the underlying framework. Cap grafts, infratip lobular grafts, and morselized cartilage are commonly used grafts (See Video 7 [online], which displays butterfly graft).5
Video 7. Butterfly graft. Video 7 from “Developing Consistency in Nasal Tip Shaping”.
Dead Space Closure
Dead space closure minimizes scar formation and displacement of newly aligned tip structures. It begins with placement of medial crura footplate horizontal mattress sutures and then proceeds inferior to superior and caudal to cephalic (See Video 8 [online], which displays dead space closure).
Video 8. Dead space closure. Video 8 from “Developing Consistency in Nasal Tip Shaping”.
CONCLUSION
A systematic approach to the nasal tip requires a combination of techniques that will help correct tip deformities, improve tip shape, and minimize deformities due to loss of support.
Footnotes
Published online 10 April 2020.
Disclosure: Dr. Rohrich receives instrument royalties from Eriem Surgical, Inc, and book royalties from Thieme Medical Publishing. None of the other authors has any financial disclosures.
Related Digital Media are available in the full-text version of the article on www.PRSGlobalOpen.com.
REFERENCES
- 1.Villanueva NL, Afrooz PN, Carboy JA, et al. Nasal analysis: considerations for ethnic variation. Plast Reconstr Surg. 2019;143:1179e–1188e. [DOI] [PubMed] [Google Scholar]
- 2.Tanna N, Nguyen KT, Ghavami A, et al. Evidence-based medicine: current practices in rhinoplasty. Plast Reconstr Surg. 2018;141:137e–151e. [DOI] [PubMed] [Google Scholar]
- 3.Sieber DA, Rohrich RJ. Finesse in nasal tip refinement. Plast Reconstr Surg. 2017;140:277e–286e. [DOI] [PubMed] [Google Scholar]
- 4.Afrooz PN, Carboy JA, Mendez BM, et al. Cephalic rotation of the nasal tip. Plast Reconstr Surg. 2019;143:734e–743e. [DOI] [PubMed] [Google Scholar]
- 5.Rohrich RJ, Afrooz PN. The infratip lobule butterfly graft: balancing the transition from the tip lobule to the alar lobule. Plast Reconstr Surg. 2018;141:651–654. [DOI] [PubMed] [Google Scholar]