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18 / Primary Rhinoplasty
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A
B
Figure 2-13. 5-0 poliglecaprone sutures placed for individual dome narrowing.
AB
Figure 2-14. Dome division for narrowing of the nasal tip.
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ABC
DE
Figure 2-15. Frontal (A) and basal (B) views preoperatively showing patient with a broad nasal tip. Double
dome narrowing and stabilization suture (C). Frontal (D) and basal (E) views postoperatively showing results of
single and double dome sculpting sutures. Drawing sheet showing single and double dome sutures (F).
(Figure 2-15). Occasionally, additional pinching
or scoring of the dome to weaken the cartilage to
achieve definition is required.
Bulbous Tip
The bulbous tip is an extension of a wide or broad
tip, in that the cartilages are more bulky and require
more individual dome narrowing, such as complete
dome division or, at least, scoring. Lateral alar support is often required because bulbous tips often
have some cephalic malposition of the alar cartilages7 (Figure 2-16). (Alar strutting is discussed
in detail below.) Placement of an alar-spanning
F
suture may be required to complete the appropriate
aesthetic narrowing of these convex cartilages (Fig-
ure 2-17).
Correction and Narrowing
of a Boxy Tip
Boxy Nasal Tip
The single- and double-dome suturing techniques
are used to narrow the boxy tip. The boxy tip is
somewhat trapezoidal but not a completely divergent intermediate crura. Weakening the strong alar
cartilages is required, and occasionally camouflage
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A
A3 A4 A5
Figure 2-16. A, A1, and A2 Preoperative frontal, basal and oblique views showing patient with bulbous tip. A3,
A4, and A5 postoperative frontal, basal, and oblique views showing patient with double and single dome suture
technique to narrow and define the bulbous tip and the use of bilateral alar strut grafts to support the weak
lateral crura.
A1 A2
in the infratip lobular area is necessary to fill in the
residual bifidity (Figure 2-18).
E ace Bi dity
Bi d Tip
Correcting or effacing the infratip or columellar
bifidity often requires the same maneuvers as correcting the boxy tip. In addition, augmentation of
the infratip lobule or the length of the columella
with cartilage batten grafts, morselized cartilage,
or alar cartilage grafts might be necessary. Direct
suture approximation of the medial crura or overlay
with a full-length shield graft can be done via the
external columellar approach.
Approximate Divergent
Intermediate Crura
Trapezoid Tip with Divergent
Intermediate Crura
A trapezoid tip is a more definitive degree of a boxy
tip with marked divergence of the intermediate
crura and strong alar cartilages.27 It can sometimes
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A
B
Figure 2-17. A. Alar spanning suture placed to further narrow the convex alar cartilages. B. Double dome suture
narrowing the tip complex.
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Alar strut grafts
5-0 Prolene
Double dome suture
5-0 Monocryl
Double dome suture
A
Figure 2-18. (A and B) Pre- and postoperative basal view of narrowing a boxy nasal tip with single and double
dome sutures, and infratip lobular camouflage graft, and bilateral alar strut grafts illustrated by figure 2-18C.
involve some cephalic malposition or orientation
of the alar cartilages. Surgical correction of the
broad or trapezoid tip should never be performed
using the cartilage-splitting or transcartilaginous
cephalic margin reduction technique, which will
most likely result in the late development of bossae
of the dome.27 The alar cartilages must be delivered,
or an external columellar incision approach can be
used. Surgical correction of the broad trapezoid
tip requires removal of the soft tissue between the
domes and intermediate crura. One must always
B
conservative in the cephalic resection of alar cartilages so that further weakening of the lateral alar
walls or external valve does not occur, resulting
in a postoperative appearance of recurvature of
the alar cartilages.28 One must either reorient the
cephalic position of the alar cartilages more caudally or add a caudal alar strut graft on the vestibular
surface of the alar cartilage margin (Figure 2-20).
In addition, it is frequently necessary to divide the
domes to narrow the tip and to straighten the lateral
ala themselves.
C
Infratip camouflage graft
reconstitute the intradomal ligaments by way of
single- and double-dome suturing techniques.
Tip grafting of the infratip lobular area in a
sutured or non-sutured fashion is often required
(Figure 2-19). It is equally important to support
the medial crura with a strut and occasionally
the lateral ala with a strut. It is important to be
Provide Strength to Lobular Cartilages
Amorphous Tip
The amorphous tip is similar to an infantile tip
with poorly developed alar cartilages, but it involves
more substantial alar cartilages and usually a thick
A A1 A2 A3
Figure 2-19. Pre- and postoperative basal views of narrowing a trapezoid nasal tip.
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Figure 2-20. In addition to single dome narrowing sutures, each dome was divided to help
straighten and further narrow the domes and tip. An alar spanning suture was required. The
long lateral crura were also shortened by a lateral crural overlay.
overlying skin envelope. Dome division is required
in addition to the typical double-dome unit
technique. Dome division itself allows for more
narrowing of any given nasal lobule. Dome division
can produce upward rotation, can assist in correcting tip asymmetries, and can be used to increase or
29
decrease tip projection simultaneously.
The domes
can be divided laterally, recruiting the lateral crura
to increase the height of the tip. Dome division can
be performed at the dome to produce narrowing,
or medially to the dome so that the height of the
domes can be decreased using the Lipsett maneuver
or complete dome truncation.
Infantile Tip
The infantile tip requires adding strength to the new
lobular complex by using the single- and doubledome unit techniques, adding a strong, supportive
strut between the medial crura, and, often, tip grafting to provide defined structure. One of the problems with the infantile tip is the ratio of the height
of the lobule to the length of the nostrils. The normal ratio is 1:2. With an infantile tip, the height of
the infratip lobule is often small compared to the
length of the nostrils, and the ratio can be 1:3 or
1:410 (Figure 2-21).
Figure 2-21. Basal view of pre- and post-
operative single and double dome sutures
technique improving the projection and strength
of the infantile tip cartilages.
AB
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Increase Tip Projection
Under-Projected Nasal Tip
One can recruit the lateral crura using the lateral crural “steal” technique with intact domes.30
By suturing the individual dome, one recruits the
lateral crura to add to the height of the medial crus,
thereby elevating the nasal tip as much as 2.0 mm.
If more height is required or desired, one can divide
lateral to the dome and recruit more lateral crus.
Dome division is usually performed in relatively
thick-skinned individuals. Finally, the external columellar incisional approach is used to suture in a tall
shield graft to provide extra height and increased
projection (Figure 2-22A-B).
Decrease Tip Projection
Over-Projected Tip
Most over-projected tips are primary rhinoplasty
cases and might or might not require an external
columellar approach. A double-dome endonasal
delivery flap approach is ideal to treat each dome
individually, first suturing the lateral and medial
segments of the dome together with the 5-0 Dexon
suture. Then the entire dome is truncated or excised
with a #15 blade, lowering from 2 to 4 mm depending on the height of the preoperative lobule (Figure
2-23). One then reconstitutes the dome unit with
the transdomal suture. Depending on the thickness
of the skin, it might be helpful to onlay a soft-tissue
or morselized cartilage camouflage graft.
Correct Asymmetries or Crural
Length Disparity
Asymmetrical or twisted tip
An asymmetrical or twisted tip is ideally treated by
a Lipsett maneuver, unilateral truncation, or by way
of dome division, which can be done through the
endonasal approach.25 If the medial crura are too
twisted, however, it is helpful to use the external
ABC
Figure 2-22. (A & B) Lateral view (preoperative
and postoperative) of a patient with an underprojected nasal tip corrected by an extended shield
graft. (C) Intraoperative view of an extended shield/
tip graft to increase projection. (D) Extended tip
graft illustrated.
D
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AB
5-0 Prolene double dome suture
Dome division/truncation
Lipsett maneuver
C
Figure 2-23. Lateral view of an over-projected nasal tip corrected with dome truncation/division.
columellar incision to straighten the asymmetries
Change Rotation of Lobule
Bilateral alar struts
of the medial crura by suturing the crura together
with a strut to straighten them. In such cases, the
lengths of the alar cartilages are often quite different. The Lipsett procedure is performed pos-
Under-Rotated Tip
There are several ways to rotate a lobule cephali-
28
cally:
terior to the dome. A length of medial crus (1–3
mm) is excised in the intermediate crus or incised,
overlapped, and sutured with a 6-0 PDS suture to
reconstitute the integrity of the medial crus, which
will lower the unilateral dome, maintaining natural domal highlights, which is especially helpful in
thin-skinned individuals (Figure 2-24A-B).
1. Resecting an inverted triangle of caudal septum
with corresponding vestibular skin to allow
cephalic positioning of the nasal lobule; this is
assisted with the use of a columellar strut.
2. A lateral crural flap24 can be performed,
shortening the length of the long lateral crura;
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A1 A2
Lipsett maneuver
2 mm right and 3 mm left
excisions of the intermediate
crura to equalize the lengths
and allow straightening.
B1
B2 B3 B4
Figure 2-24. (A) Basal view of asymmetrical tip corrected with Lipsett maneuver. (B) Drawing and intraoperative
view demonstrating Lipsett maneuver equalizing disparity in lengths of medial crura and allow straightening of
columella.
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the lateral crura flap technique is an overlapping
of the lateral crural segments after dividing
laterally then suturing with 5-0 Monocryl.
3. Dome division itself will assist in rotation of the
lobule.
Over-rotated Tip
Methods of lengthening the short or over-rotated
nose31 include:
1. Excision of a posterior caudal septal angle (the
simplest maneuver).
2. Lengthening via tip grafting, which will add
some length, or lengthening via a double tip
graft, which will add more length.
3. Spreader grafts can be used as cantilever to push
the entire lobular complex more caudally by
suturing the spreader grafts to the septum and to
the septal strut.
Alar Recurvature and Alar Collapse
Analysis of the long-term results in tip rhinoplasty
makes apparent the paramount importance of lateral alar wall stability for long-term airway maintenance and improved aesthetic results.28 Treating a
retracted ala as a primary finding has always been
a component of the primary rhinoplasty plan. Preventing alar collapse or recurvature as a late consequence o rhinoplasty maneuvers has been a more
recent addition to advanced rhinoplasty techniques.
Alar batten grafts, alar strut grafts, composite grafts,
and rim grafts are critically important for maintain-
ing a symmetrical and aesthetically pleasing nasal
alar base.
32
Cephalic Malposition of
Alar Cartilages
Recognizing cephalic malposition of the alar cartilages as a preexisting condition that predisposes
the patient to inward or recurvature of the alar
cartilages and alar collapse has been important in
planning the use of alar batten and strut grafts.32
Treating a retracted or potentially collapsed lateral
ala and external nasal valve involves use of lateral
crural grafts, which can use septal cartilage or conchal cartilage as struts or as battens.
Alar Batten Grafts
Alar batten grafts are often required to provide
some additional support to a weakened lateral ala.
The septal cartilage graft or, commonly, a curved
portion of the cymba concha of the ear cartilage can
be sutured as an onlay to the weak lateral nasal alar
crus. The senior author uses a transvestibular skin
and 5-0 Dexon suture in a mattressing fashion in
two to three locations to stabilize the graft (Figures
2-25 and 2-26).
Alar Strut Grafts
An alar strut is often required as a more substantial graft to resist the inspiratory contracture or
collapse of the lateral ala and specifically to correct
the predisposing condition of cephalic malposition
of the alar cartilages. This is a longer graft, placed
AB
Figure 2-25. Basal view of unilateral collapsed ala, postoperative view of correction by an alar batten graft, and
surgical drawing.
Right alar
batten graft
C
L Rim graft
Blocking graft
Shield graft
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