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Chapter A Predictable and Algorithmic Approach to Tip Renement and Projection 465
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e patient is shown months postoperatively; she is pleased with the aesthetic
result as well as the improvement of the nasal airway obstruction. e tip has
appropriate projection, and the boxy tip has been corrected with creation of aesthetically pleasing tip-dening points and contour, using invisible/nonpalpable
tip-suturing and graing techniques.
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is -year-old woman had sustained nasal trauma years earlier. Her reasons
for desiring surgery were nasal airway obstruction, greater on the le side than
on the right, a signicant dorsal hump with asymmetrical nostrils, and a wide,
poorly dened nasal tip.
Nasal analysis revealed the following:
■
A signicant osteocartilaginous dorsal hump (mm at its greatest point)
■
A C-shaped nasal septal deformity
■
A high dorsal septal deviation
■
A bid nasal tip
■
Asymmetrical nostrils with le narrowing and a short nostril-to-large tip
(lobule) disharmony
■
A hyperactive depressor septi nasi muscle
■
Compensatory right inferior turbinate hypertrophy
Chapter A Predictable and Algorithmic Approach to Tip Renement and Projection 467
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Tip sutures:
Intradomal
Transdomal
Surgical Plan
1. Use an open approach with transcolumellar incision and infracartilaginous
extensions.
2. Perform septal reconstruction and harvest cartilage gra material.
3. Perform dorsal hump reduction (mm) in component fashion.
4. Reduce the caudal septum (mm).
5. Perform a right inferior turbinate resection.
6. Perform bilateral percutaneous perforated lateral osteotomies (low-to-low).
7. Perform a cephalic trim, leaving a mm alar rim strip.
8. Place a oating columellar strut gra with medial crural suturing.
9. Rene the tip with interdomal and transdomal sutures.
10. Perform depressor septi nasi muscle dissection and transposition.
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Twelve months postoperatively, the patient has a smooth, straight nasal dorsum
with symmetrically shaped nostrils, consistent tip projection, and improved tip
denition. e patient’s nasal breathing has been signicantly improved.
Chapter A Predictable and Algorithmic Approach to Tip Renement and Projection 469
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KEY POINTS
■
e appearance of ideal tip projection is dependent on the relationship of the
nose-lip-chin complex, because an underprojected chin will make the nasal tip
seem overprojected, and vice versa.
■
In a patient with thick, sebaceous skin, alterations to the cartilaginous framework may need to be more aggressive to produce adequate tip denition and
projection.
■
Adequate tip projection is dened as % to % of the tip lying anterior to
the most projecting point of the upper lip.
■
Great care should be taken to preserve or restore the anatomic integrity of the
tip-supporting structures.
■
Columellar struts are the mainstay in providing a stable and strong nasal base
that will allow more liberal use of other tip-suturing techniques.
■
Suturing techniques should be employed incrementally, starting with the medial crural−columellar strut suture to secure and stabilize the columellar strut
gra.
■
Intraoperative evaluation of the depressor septi nasi muscle is unreliable, because animated views are required.
■
e skin envelope should be redraped aer each suture is placed to determine
whether modications in position or degree of tightness are needed.
■
If the desired tip projection and renement are not achieved using available invisible/nonpalpable tip-suturing and cartilage graing techniques, then visible/
palpable cartilage gras may be used. ese include an assortment of infratip,
onlay, and combined tip gras.
■
Nostril-lobule imbalances must be assessed preoperatively and reassessed intraoperatively, because a preexisting disproportion may be exaggerated by augmenting the tip and failing to address the nostril.
■
As much as to mm of tip projection will be lost before the nal postoperative tip projection has been achieved using the open approach.
REFERENCES
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support in open versus closed rhinoplasty. Plast Reconstr Surg :-, .
2. Ghavami A, Janis JE, Acikel C, Rohrich RJ. Tip shaping in primary rhinoplasty: an algorithmic ap-
proach. Plast Reconstr Surg :-, .
3. Tebbetts JB. Shaping and positioning the nasal tip without structural disruption: a new systematic
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4. Tebbetts JB. Secondary tip modication: shaping and positioning the nasal tip using nondestruc-
tive techniques. In Tebbetts JB, ed. Primary Rhinoplasty: A New Approach to the Logic and the
Techniques. St Louis: Mosby−Year Book, .
5. Janecke JB, Wright WK. Studies on the support of the nasal tip. Arch Otolaryngol :-, .
6. Beekhuis GJ, Colton JJ. Nasal tip support. Arch Otolaryngol Head Neck Surg :-, .
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7. McCollough EG, Mangat D. Systematic approach to correction of the nasal tip in rhinoplasty. Arch
Otolaryngol :-, .
8. Rich JS, Friedman WH, Pearlman SJ. e eects of lower lateral cartilage excision on nasal tip pro-
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nior Residents’ Conference, San Diego, May .
11. Gunter JP. e merits of the open approach in rhinoplasty. Plast Reconstr Surg :-, .
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14. Rohrich RJ, Muzaar AR. A plastic surgeon’s perspective. In Romo IT III, Millman A, eds. Aesthetic
Facial Plastic Surgery: A Multidisciplinary Approach. New York: ieme, .
15. Tebbetts JB. Rethinking the logic and techniques of rhinoplasty: a perspective of the evolution of
surgery of the nasal tip. Otolaryngol Clin North Am :-, .
16. Gunter JP, Hackney FL. Basic nasal tip surgery: anatomy and technique. In Gunter JP, Rohrich RJ,
Adams WP Jr, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. St Louis: Quality Medical
Publishing, .
17. Rohrich RJ, Adams WP Jr, Deuber MA. Graduated approach to tip renement and projection. In
Gunter JP, Rohrich RJ, Adams WP Jr, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. St
Louis: Quality Medical Publishing, .
18. McCollough EG, English JL. A new twist in nasal tip surgery: an alternative to the Goldman tip for
the wide or bulbous lobule. Arch Otolaryngol :-, .
19. Tardy ME Jr, Cheng E. Transdomal suture renement of the nasal tip. Facial Plast Surg :-,
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20. Daniel RK. Rhinoplasty: creating an aesthetic tip. Plast Reconstr Surg :-, .
21. Daniel RK. Rhinoplasty: a simplied, three-stitch, open tip suture technique. Part I: Primary rhi-
noplasty. Plast Reconstr Surg :-, .
22. Baker SR. Suture contouring of the nasal tip. Arch Facial Plast Surg :-, .
23. Rohrich RJ, Adams WP Jr. e boxy nasal tip: classication and management based on alar carti-
lage suturing techniques. Plast Reconstr Surg :-; discussion -, .
24. Gruber RP, Chang E, Buchanan E. Suture techniques in rhinoplasty. Clin Plast Surg :-,
.
25. Behmand RA, Ghavami A, Guyuron B. Nasal tip sutures. Part I: e evolution. Plast Reconstr Surg
:-; discussion -, .
26. Guyuron B, Behmand RA. Nasal tip sutures. Part II: e interplays. Plast Reconstr Surg :-
; discussion -, .
27. De Carolis V. e infradome gra: a new technique to improve dome reshaping in rhinoplasty.
Plast Reconstr Surg :-, .
28. Guyuron B, Poggi JT, Michelow BJ. e subdomal gra. Plast Reconstr Surg :-; discus
sion -, .
29. Guyuron B. Dynamics of rhinoplasty. Plast Reconstr Surg :-; discussion , .
30. Gonzalez-Ulloa M, Stevens E. e role of chin correction in proleplasty. Plast Reconstr Surg
:-, .
31. Byrd HS, Hobar PC. Rhinoplasty: a practical guide for surgical planning. Plast Reconstr Surg :-
; discussion -, .
32. Rohrich RJ, Janis JE, Kenkel JM. Male rhinoplasty. Plast Reconstr Surg :-, .
33. Rohrich RJ, Muzaar AR. Rhinoplasty in the African-American patient. Plast Reconstr Surg
:-, .
34. Rohrich RJ, Ghavami A. Rhinoplasty for Middle Eastern noses. Plast Reconstr Surg :-,
.
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Chapter A Predictable and Algorithmic Approach to Tip Renement and Projection 471
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35. Daniel RK. Hispanic rhinoplasty in the United States with emphasis on the Mexican American
nose. Plast Reconstr Surg :-; discussion -, .
36. Johnson CM Jr, Godin MS. e tension nose: open structure rhinoplasty approach. Plast Reconstr
Surg :-, .
37. Rohrich RJ, Deuber MA, Adams WP Jr. Pragmatic planning and postoperative management. In
Gunter JP, Rohrich RJ, Adams WP Jr, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. St
Louis: Quality Medical Publishing, .
38. Gunter JP, Hackney FL. Clinical assessment and facial analysis. In Gunter JP, Rohrich RJ, Adams
WP Jr, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. St Louis: Quality Medical Publishing, .
39. Guyuron B, Ghavami A, Wishnek SM. Components of the short nostril. Plast Reconstr Surg :-
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40. Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg :-, .
41. Rohrich RJ, Huynh B, Muzaar AR, Adams WP Jr, Robinson JB Jr. Importance of the depressor septi
nasi muscle in rhinoplasty: anatomic study and clinical application. Plast Reconstr Surg :; discussion -, .
42. Daniel RK. Rhinoplasty: large nostril/small tip disproportion. Plast Reconstr Surg :-;
discussion -, .
43. Rohrich RJ, Grin JR. Correction of intrinsic nasal tip asymmetries in primary rhinoplasty. Plast
Reconstr Surg :-; discussion -, .
44. Guyuron B, DeLuca L, Lash R. Supratip deformity: a closer look. Plast Reconstr Surg :-;
discussion -, .
45. Janis JE, Trussler A, Ghavami A, Marin V, Rohrich RJ, Gunter JP. Lower lateral crural turnover ap
in open rhinoplasty. Plast Reconstr Surg :-, .
46. Rohrich RJ, Kurkjian TJ, Hoxworth RE, et al. e eect of the columellar strut gra on nasal tip
position in primary rhinoplasty. Plast Reconstr Surg :-, . Erratum in Plast Reconstr
Surg :, .
47. Rohrich RJ, Hoxworth RE, Kurkjian TJ. e role of the columellar strut in rhinoplasty: indications
and rationale. Plast Reconstr Surg :e-e, .
48. Guyuron B, Varghai A. Lengthening the nose with a tongue-and-groove technique. Plast Reconstr
Surg :-; discussion -, .
49. Rohrich RJ, Deuber MA. Nasal tip renement in primary rhinoplasty: the cephalic trim cap gra.
Aesthet Surg J :-, .
50. Ghavami A, Janis JE, Guyuron B. Regarding the treatment of dynamic tip ptosis using botulinum
toxin A. Plast Reconstr Surg :-, .
51. Rohrich RJ, Raniere J Jr, Ha RY. e alar contour gra: correction and prevention of alar rim de-
formities in rhinoplasty. Plast Reconstr Surg :-; discussion -, .
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plasty. Plast Reconstr Surg :-; discussion -, .
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balance between the nose and chin. In Gunter JP, Rohrich RJ, Adams WP Jr, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. St Louis: Quality Medical Publishing, .
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22
Correction of the Boxy Nasal Tip
Using the Open Approach
Rod J. Rohrich William P. Adams Jr. Jamil Ahmad
e boxy nasal tip is dened as a broad, rectangular tip, as seen on the basal view. is is described
anatomically using the open approach as one of
three types.
-
Type I anatomy:
Divergence angle .308
Domal width #4 mm
.308
#4 mm
Type II anatomy:
Divergence angle normal
Domal width .4 mm
308
.4 mm
Type III anatomy:
Divergence angle .308
Domal width .4 mm
.308
.4 mm
Type Iis characterized by an increased intercrural angle of divergence (more than
degrees) and normal dome arc (mm or less) that are manifest as the tipdening points. Type II shows an increased angulation of the domes of the lower
lateral cartilage segment that creates a widened dome arc (more than mm)
,
and normal angle of divergence ( degrees or less). Type III represents a combination of an increased angle of divergence (more than degrees) and widened
crural dome arc (more than mm).
473
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Correction of the boxy tip includes repositioning the tip-dening points, angulating the domes, and shaping the lateral crura so the basal view appears triangular
with a slightly rounded apex and straight or slightly concave lateral walls. e
width of the tip is determined by the distance between the tip-dening points, the
angulation of the domes, and the thickness of the skin. e position and shape of
the lateral walls depend on the angulation of the domes and the shape (at, convex, concave) and orientation (horizontal versus cephalad) of the lateral crura.
e operative goal is to reposition the tip-dening points, angulate the domes,
and shape the lateral crura.
Although a variety of techniques are available, consistent surgical correction of
the boxy nasal tip has proved particularly diult.
-,-
In this chapter we will discuss the techniques for correction of the boxy tip and present our algorithmic
approach for the management of the boxy tip using the open approach.
EVOLUTION OF TECHNIQUES
With careful preoperative and intraoperative analysis, a variety of potentially
reversible reshaping suture techniques, and an individualized algorithmic approach, the boxy tip can be accurately and consistently corrected.
Rhinoplasty techniques for correcting the boxy tip have evolved from aggressive
intervention (transection and resection techniques) to a gradual transition, and
then to more moderate, measured, and potentially reversible reshaping techniques (cartilage conservation and suturing).
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