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Figure 2-26. Intraoperative view of suturing of alar batten graft in place.
between the alar cartilage and the vestibular skin
in a pocket, extending out lateral to the piriform
aperture and extending up at least two thirds of the
length of the alar cartilage.32 Preferably, the graft
uses strong septal cartilage, but conchal grafts can
also be used. Although it is difficult to dissect the
pocket from the caudal margin using the delivery
posite graft from the anterior surface of the cymba
concha is required, to provide skin for vestibular lining, which can be sutured directly between the edges
of incision that was initially made at the caudal margin of the lower lateral cartilage. Upon suturing the
graft in place, one sees the immediate correction of
the alar retraction
flap approach, it is possible to perform this procedure with an endonasal approach. It is much
easier to perform the procedure using an external
columellar approach and to dissect vestibular skin
away from the alar cartilage from the cephalic margin. The graft is sutured directly to the lateral crus
with 5-0 Monocryl (Ethicon, Inc., Somerville, NJ)
sutures, then the vestibular skin is repositioned with
5-0 Dexon sutures.
Alar Retraction
Slightly retracted nasal alae are best corrected by
placing cartilage directly along the alar margin. One
can support the alar margin by making a small 1 or
2 mm pocket along the rim of the nostril and placing
a small, linear piece of cartilage in the pocket, forming a rim graft, which adds strength to the slightly
weakened or retracted alar rim
the alar margin is more significantly retracted than
can be repaired by this simpler technique, a com-
32
(Figure 2-27). If
Almost all rhinoplasties can be improved with atten-
tion to detail and small refinements as final steps in
the operation. The refinements are performed just
prior to placement of the nasal dressing. Plumping
grafts, morselized onlay grafts, crushed cartilage
grafts, alar rim grafts, and nostril-narrowing tech-
niques can “polish” the final aesthetic result. It is
common to use crushed cartilage grafts placed over
the rhinion in the supratip area to soften the con-
tours of the lowered bony and cartilaginous pyra-
mid. Some soft-tissue and crushed cartilage grafts
can be used in the lobule to soften the nasal tip,
particularly in patients with thin skin. They enhance
the use of radix grafts to soften and camouflage the
transition between the radix and the nasal pyramid.
Using temporalis fascia as an overlay graft, particu-
33
(Figure 2-28).
Finishing Touches Using
Refinement Techniques
Primary Rhinoplasty / 29
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A
C
Figure 2-27.
Intraoperative views of placement of an alar rim graft.
larly in thin-skinned patients when modifying the
nasal profile, is an excellent technique for “softening” the profile and camouflaging edges of cartilage
or bone. Finally, the last maneuver after closing the
marginal incision is to evaluate the strength and
contour of each alar rim and margin. If any weakness or asymmetry is noted, a small incision is made
and a 1 or 2 mm wide by 1 cm long rim graft is
placed in a separate pocket prior to performance of
alar base narrowing and placing the postoperative
nasal dressing.
B
D
Postoperative Nasal
Dressings and Care
The author uses tan 0.5-inch micropore tape overlying the skin and nasal lobule. The tape around the
lobule is pinched slightly to maintain hemostasis in
and around the lobule and supratip area. A metal
splint, such as a Brown-backed metal splint, is used
to provide stabilization of the nasal pyramid and
medially positioned nasal bones (Figure 2-29).
Additionally, a small ball of Surgicel (Ethicon, Inc.,
Figure 2-28. Oblique view of alar
retraction corrected by a cymba
concha composite graft.
A
B
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AB
C
Somerville, NJ) is placed under each dome to reapproximate the elevated vestibular skin and to prevent
any small hematomas in this region. No packing
is required, but a short Telfa pledget covered with
antibiotic ointment is placed in each nostril to help
collect the expected nasal drainage. Cold compresses
are applied continuously for 24 to 36 hours. At the
end of 1 week, the nasal dressing is removed and no
further dressing is required. The senior author finds
the use of intralesional steroids in the supratip area
helpful in selected cases of thick skin or previously
operated cases with a fair amount of fibrous scar
tissue in the supratip area.34 The author begins intralesional steroids, 0.1 cc of 10 mg/cc triamcinalone
(Kenalog), at 2 weeks postoperatively and repeats
the steroid administration once or (at most) twice
in the first 3-month postoperative period.
Summary
Use of individualized rhinoplasty techniques and
the increasing armamentarium of rhinoplastic
maneuvers has significantly improved the initial
and long-term results of rhinoplasty over the past 25
years. By routinely incorporating a blend of endonasal and external columellar approaches to accomplish the desired aesthetic goals, the surgeon has the
Figure 2-29. Typical nasal dressing and splint.
ability to place grafts that not only achieve a better
initial result but also prevent adverse changes to the
overall functional and aesthetic result for patient
in the long term. Because of the increased need for
spreader grafts in the midnasal vault and placement
of alar strut grafts to support the lateral crura, the
use of alar-spanning grafts, the use of interdomal
grafts, and the use of soft-tissue onlay grafts as
well as refinement grafts in the nasal lobule, the
author now uses the external columellar approach
in approximately 75% of all primary rhinoplasties.
By paying attention to detail and using camouflage
cartilage grafting, the author’s revision rates for rhi-
noplasty have been reduced from approximately
7%–8% to 4% of all rhinoplasties.
35
References
1. Tardy ME. Rhinoplasty: The Art and Science.
Philadelphia, W.B. Saunders, 1997.
2. Perkins S W, Hamilton MM, MacDonald K. A
successful 15-year experience in double-dome tip
surgery via endonasal approach—Nuances and
pitfalls. Arch Facial Plast Surg 2001; 3(3):157–164.
3. Johnson CM, Toriumi DM. Open Structure
Rhinoplasty. Philadelphia, W.B. Saunders, 1991.
4. Perkins SW. The evolution of the combined use
of endonasal and external columellar approaches
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to rhinoplasty. Facial Plast Surg Clin North Am
2004;12(1):1–13.
5. Toriumi DM. Structural approach to primary
rhinoplasty. Aesthetic Surg J 2002;22:72–84.
6. Toriumi DM. Management of the middle nasal vault
in rhinoplasty. Operative Tech Plast Reconstr Surg
1995;2:16–30.
7. Guyuron B, DeLuca L, Lash R. Supratip deformity:
a closer look. Plast Reconstr Surg. 2000;105:1140–
1151.
8. Toriumi DM. Structure concept in nasal tip surgery.
Oper Tech Otolaryngol Head Neck Surg 2001;7(4):
175–186.
9. Tardy ME. Surgical anatomy of the nose. In: Bailey
BJ, editor. Head & Neck Surgery—Otolaryngology.
Philadelphia, Lippincott Williams & Wilkins, 2001,
pp. 2211–2228.
10. Gunter JP, Friedman RM. Lateral crural strut graft:
technique and clinical applications in rhinoplasty.
Plast Reconstr Surg 1997;99:943–955.
11. Perkins SW. Photodocumentation. In: Bailey BJ,
editor. Head and Neck Surgery—Otolaryngology.
Philadelphia, J.B. Lippincott, 1993, pp. 2084–2091.
12. Bronz G. Predictability of the computer imaging
system in primary rhinoplasty. Aesth Plast Surg 1994;
18(2):175–181.
13. Shah AR, Constantinides M. Nuances in tip
modification: specific applications of cartilage splitting
in rhinoplasty. Facial Plast Surg 2006;22(1):36–41.
14. May H. The Réthi incision in rhinoplasty. Plast
Reconstr Surg (1946) 1951 ;8(2):123–131.
15. Dyer WD II. Nasal tip support and its surgical
modification. Facial Plast Surg Clin North Am
2004;12(1): 1–13.
16. McCollough EG, English JL. A new twist in nasal
tip surgery: an alternative to the Goldman tip for
the wide or bulbous tip. Arch Otolaryngol 1985;111:
524.
17. Byrd HS, Meade RA, Gonyon DL Jr. Using the
autospreader flap in primary rhinoplasty. Plast
Reconstr Surg 2007;119(6):1897–1902.
18. Becker DG, Pastorek NJ. The radix graft in cosmetic
rhinoplasty. Arch Facial Plast Surg 2001;3(2):115–
119.
19. Godin MS, Waldman SR, Johnson CM. Nasal
augmentation using Gore-Tex: A 10-year experience.
Arch Facial Plast Surg 1999; 1:118–121.
20. Rohrich RJ, Hollier LH. Use of spreader grafts in
the external approach to rhinoplasty. Clin Plast Surg
1996;23:255–262.
21. Guyuron B, Jackowe D. Modified tip grafts and tip
punch devices. Plast Reconstr Surg 2007;120(7):2004–
2010.
22. Peck GC. The onlay graft for nasal tip projection.
Plast Reconstr Surg 1983;71:27–37.
23. Perkins S W. The evolution of the combined use of
endonasal and external columellar approaches to
rhinoplasty. Facial Plast Surg Clin North Am 2004;
12:35–50.
24. Kridel RW, Konior RJ. Controlled nasal tip rotation
via the lateral crural overlay technique. Arch
Otolaryngol Head Neck Surg 1991 ;117(4):411–415.
25. Lipsett EM. A new approach to surgery of the lower
cartilaginous vault. Arch Otolaryngol 1959;70:42.
26. Baker SR. Suture contouring of the nasal tip. Arch
Facial Plast Surg 2000;2:34–42.
27. Tardy ME, Cheng EY. Misadventures in nasal tip
surgery: analysis and repair. Otolaryngol Clin North
Am 1987;20:797.
28. Toriumi DM, Josen J, Weinberger M, Tardy ME
Jr. Use of alar batten grafts for correction of nasal
valve collapse. Arch Otolaryngol Head Neck Surg
1997;123(8):802–808.
29. Simons RL, Fine IJ. Evaluation of the Goldman
tip in rhinoplasty. In: Plastic and Reconstructive
Surgery of the Face and Neck: Proceedings of the
Second International Symposium. New York, Grune
&Stratton, 1977; 1:3946.
30. Kridel RWH, Konior RJ, Shumrick K, Wright WK:
Advances in nasal tip surgery: The lateral crural steal.
Arch Otolaryngol Head Neck Surg 1989;115:1206.
31. Gunter JP, Rohrich RJ. Lengthening the aesthetically
short nose. Plast Reconstr Surg 1989;83(5): 793–800.
32. Toriumi DM. New concepts in nasal tip contouring.
Arch Facial Plast Surg 2006;8(3):156–185.
33. Tardy ME, Toriumi DT. Alar retraction: composite
graft correction. Facial Plast Surg 1989;6(2):101–107.
34. Hanasono MM, Kridel RW, Pastorek NJ, Glasgold
MJ, Koch RJ. Correction of the soft tissue pollybeak
using triamcinolone injection. Arch Facial Plast Surg
2002;4(1):26–30.
35. Kamer FM, McQuown SA. Revision rhinoplasty:
analysis and treatment. Arch Otolaryngol Head Neck
Surg 1988;114:257–266.
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Tip Rhinoplasty
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Rami K. Batniji, MD, FACS and Stephen W. Perkins, MD
3
Introduction
The key to successful nasal tip surgery is precise
preoperative analysis, a thoughtful operative plan,
and meticulous execution of that plan. To that end,
an understanding of the anatomy of the nose, the
pathology present, the desires of the patient, and the
maneuvers necessary to achieve the desired result
are essential. Furthermore, appreciation of the longterm effects of healing has resulted in increased use
of external rhinoplasty and of grafting techniques to
avoid long-term complications.
Facial Analysis
In order to embark upon nasal surgery, the surgeon
must be familiar with the anatomy of the nose,
abnormalities of the underlying bony-cartilaginous
framework that result in nasal deformity, and the
surgical maneuvers necessary to treat deformities
and to achieve a satisfying aesthetic and functional
result. After mastering an understanding of the
anatomy of the nasal tip, the surgeon can predict
the underlying structures of the tip via visualization and palpation. Structural support of the nasal
tip is determined by three major and six minor
tip-support mechanisms. The major tip-support
mechanisms include: (1) the size, shape, and resilience of the lower lateral cartilages, (2) the medial
crural footplate attachment to the caudal border of
the quadrangular cartilage, and (3) the attachment
of the caudal border of the upper lateral cartilages
to the cephalic border of the lower lateral cartilages.
The minor tip-support mechanisms include: (1) the
interdomal ligament, (2) the cartilaginous septal
dorsum, (3) the sesamoid complex extending the
support of the lateral crura of the lower lateral car-
tilages to the pyriform aperture,1 (4) the attachment
of the lower lateral cartilages to the overlying skin
and musculature, (5) the nasal spine, and (6) the
membranous septum.
Anderson’s tripod theory is a helpful method
of conceptualizing the nasal tip and the effects any
change to one of the three limbs of the tripod will
have upon the nasal tip. Two limbs of the tripod are
each of the lateral crural legs of the lower lateral cartilages, and the third limb of the tripod is the joined
medial crural feet.
While both the internal and external valves are
important in maintaining proper airflow through
the nasal passageways, the external valve is of particular interest in tip rhinoplasty. The external valve
is formed by the nasal alar sidewall laterally and the
columella/medial crural footplate medially. Weakness of the lateral crus of the lower lateral cartilage
results in dynamic collapse of the nasal alar sidewall
and, thus, external valve collapse.
Preoperative Considerations
Preoperative consultation is essential in determining the techniques that will be required to achieve
the aesthetic and functional results.2 Consultation
with the patient allows the surgeon to understand
the patient’s aesthetic and functional goals and
whether the goals are realistic. The onus is upon the
surgeon to balance the patient’s desires with what
is realistically possible given the anatomic limitations of the individual nose. History-taking during
the consultation affords the opportunity for the surgeon to document a history of trauma to the nose or
of previous rhinoplasty.
Accurate diagnosis is also essential and requires
a thorough preoperative assessment, including a
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complete facial analysis in addition to analysis of
the nose (see Chapter 2). Specific examination of
the nasal tip begins with evaluation of the overlying skin. Nasal skin that is thick and contains many
sebaceous glands does not reveal subtle changes to
the underlying framework. Failure of thick skin to
contract favorably over time may lead to excess softtissue scar, an amorphous nasal appearance, and
the soft-tissue pollybeak deformity. Thin skin may
more readily show minor deformities and irregularities; therefore, camouflaging techniques are more
necessary in the thin-skinned patient.
Through palpation of the nasal tip, the surgeon will gain valuable insight into the nature of
the intrinsic support of the nasal tip, especially the
septum and septal angle. Palpation also provides
the surgeon with an opportunity to determine the
nature, volume, strength, and resiliency of the lower
lateral cartilages. It behooves the surgeon to evaluate the orientation of the lower lateral cartilages; if
the lower lateral cartilages are cephalically malpositioned, then alar strut grafts may be necessary to
prevent curvature of the alar sidewalls.
On frontal view, the brow-tip aesthetic line follows a gentle curve from the medial brow to the
nasal tip with slight narrowing at the middle nasal
vault and slight widening at the alar margins. The
nasal tip-defining points represent light reflection
on the skin overlying the domes of the lower lateral
cartilages. Asymmetries and/or width of these tipdefining points should be noted. Also, facial asymmetries on frontal view should be documented and
pointed out to the patient. On profile, nasal projection is evaluated using any of a number of techniques; however, the Simons relation of the nasal
projection to the upper lip length, ideally in a 1:1
ratio, is a helpful and reliable method of evaluating projection. On profile, the nasal-chin relationship should be noted, as a patient with inadequate
chin projection may perceive the nose to be overprojected when in reality the projection of the nose
is adequate. The nasofrontal angle is typically 115–
130 degrees. The nasolabial angle is typically 90–95
degrees in men and 95–115 degrees in women,
depending upon the height of the patient. On profile, 2–4 mm of columellar show should be visible.
A double break is noted between the columella and
nasal tip; this double break is created by the intermediate crura of the lower lateral cartilages. Finally,
on base view, the nose has the form of an equilateral triangle, with the lobule representing one-third
of the triangle. Weakness of the alar sidewall with
inward curvature should be noted, as this condition
may require supporting the sidewall with alar strut
grafts.
Digital photography (in the standard views for
rhinoplasty with proper lighting and background)
is essential to a rhinoplasty practice and provides
consistency in photographs. Computer imaging
facilitates communication between patient and surgeon by providing a medium through which the
surgeon can demonstrate to the patient realistic
surgical outcomes and the limitations that existing anatomy imposes. For example, a patient with
inadequate chin projection may benefit from a chin
implant. Computer imaging also allows the surgeon
to learn about the patient’s desires, such as profile
relationships, which may or may not mirror the surgeon’s preferences. It is important for the surgeon to
be honest and accurate about the corrections made
on computer imaging. Finally, each patient is asked
to sign a waiver stating he/she understands that
computer imaging demonstrates a predictive illustration and is not a guarantee of the exact aesthetic
surgical result.
Technique
Tip rhinoplasty is performed under monitored
anesthesia care or general endotracheal anesthesia.
The patient is placed on cephalexin 500 milligrams
every 12 hours, starting the day before surgery. In
the operating room, once an appropriate level of
anesthesia is achieved, the nose is infiltrated with
2% lidocaine with epinephrine (1:50,000) and cottonoid pledgets soaked with 4% topical cocaine
solution are placed in the nasal passageways. After
an appropriate amount of time for the epinephrine
and topical cocaine to take effect, surgery is begun.
Tables 3-1 and 3-2 list the treatment options available to the patients and key instrumentation and
materials required during the procedures.
Endonasal Rhinoplasty
Endonasal rhinoplasty is performed via the delivery
approach. Access for delivery of the lower lateral
cartilages involves bilateral marginal and intercartilaginous incisions. The intercartilaginous incision
at the limen vestibula is connected with a high septal
transfixion incision. If necessary, de-projection of
the nasal tip is achieved by extending the high septal
transfixion incision inferiorly to release the medial
crural feet from the septum; if this maneuver is per-
Tip Rhinoplasty / 35
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TABLE 31 Treatment Options
Endonasal Rhinoplasty
Advantages
1. Excellent method of performing tip
rhinoplasty on select individuals.
2. No external incisions.
Disadvantages
1. If a tip gra is needed, there is an increased
risk of poor placement or eventual
displacement of the tip gra when it is placed
via an endonasal rhinoplasty.
2. Di cult to accurately place spreader and/or
alar strut gra s.
External Rhinoplasty
Advantages
1. Increased exposure, thus a ording the
surgeon the opportunity to fully appreciate
the underlying nasal anatomy.
2. Ability to control the midnasal vault with
accurate placement of spreader gra s.
3. Tip gra s, when used, can be placed
accurately to minimize poor placement
and sutured into position to minimize
displacement.
Disadvantages
1. Potential for columellar scar.
2. Increased operative time.
formed, the medial crural feet are reconstituted to
the septum with a 3-0 chromic gut suture on a Keith
needle at the end of the surgery.
The septum is approached via the septal transfixion incision and septoplasty is performed as indicated. Septal cartilage is harvested for rhinoplasty
while preserving 10 mm of dorsal and caudal septal
cartilage, thus preserving support to the nasal tip
and dorsum of the nose.
Once the bipedicled chondrocutaneous flaps are
delivered, cephalic margin trim is performed as indicated to narrow and define the nasal tip; the cephalic
margin trim is conservative, so that 8–10 mm of lateral crus laterally and 5–7 mm of lateral crus medially
are preserved. One should avoid cephalic trim of the
lateral one-third of the lateral crus to avoid lateral wall
collapse. Long-term follow-up has shown that weakened crura and nasal tip support are subject to contracture forces that cause distortions to the nasal tip.
Therefore, there has been a progressive movement
toward more conservative handling of the nasal tip.
3
External Rhinoplasty
The need to achieve more refined results and to prevent late complications has resulted in increasing use
TABLE 32 Key Instrumentation and Materials
#15 Bard Parker
Bipolar cautery
McCollough Elevator (Storz N2341)
Jovanovic Bone Plugger (Hu-Friedy PLGO/4)
Joseph Single Hook (Storz N4720)
Osteotomes
Osteome #2 (Storz N4302)
Osteome #3 (Storz N4303)
Osteome #4 (Storz N4304)
Curved 6 mm Cottle Osteotome (Storz N4345)
Neivert Osteotome (Storz N4362)
Cinelli Osteotome #10 (Storz N4380)
#12 (Storz N4382)
#14 (Storz N4384)
#16 (Storz N4386)
Rasps
Glabella Rasp (Storz P3000)
#1 Push-Pull Rasp (Snowden Pencer LO1996)
#2 Push-Pull Rasp (Snowden Pencer LO1997)
#3 Push-Pull Rasp (Snowden Pencer LO1998)
#4 Push-Pull Rasp (Snowden Pencer LO1999)
Cutting Block (Sowden Pencer 88-7724)
Boise Nasal Elevator (Storz N4655)
#3 Knife Handle (Storz N1710)
Nasal Mucosa Bayonet (Storz P0525)
Wright-Rubin Septum Morselizer (Storz N5345)
Forceps Guard (Storz N5345G)
Converse Nasal Retractor (Storz N4882)
Forceps
Ferris Smith Forceps (Storz N5485)
Takahashi Nasal Forceps (Storz N2995)
Speculums
Septum Speculum (Storz N2181)
Cottle Septum Speculum (Storz N2200)
Ferguson Frazier #9 (Storz N1379)
Cottle Crusher (Snowden Pencer 88-7227)
Shears
Caplan Shears (Storz N5295)
Gorney Shears (Storz N5296)
Castroviejo Flat Handle (Snowden Pencer 32-0440)
Forceps
Adson Forceps (Snowden Pencer 32-0500)
Gerald Forceps (Snowden Pencer 32-0510)
Storz Eye Scissors, curved (Storz E3426)
Crile Hemostatic Forceps (Storz N5520)
Par Needle Holder (Storz P0404)
Lead-filled Mallet (Storz N1782)
5 mm Curved Mets Scissors (Storz E5284)
Half-inch Micropore™ tape, tan (3M™)
Small Brown Nasal Splint without extension (Integra
P363)
Sutures
4-0 plain gut on short Keith needle
5-0 plain gut
5-0 clear Prolene
5-0 clear polydiaxanone
6-0 polydiaxanone
3-0 chromic gut
5-0 polyglygolic acid
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of the external columellar approach. Indications for
external rhinoplasty include: revision cases, marked
asymmetry of the tip, significantly poor tip support,
lower lateral cartilages that are weak, marked underprojection, the foreshortened nose that requires
lengthening and de-rotation with extended spreader
grafts, the need for spreader grafts to stabilize the
middle nasal vault, and cephalic malposition of the
lower lateral cartilages that requires alar strut grafts.
4
Tip-Sculpting Techniques
A graduated approach is used when sculpting the
nasal tip during rhinoplasty. First, cephalic margin
trim of the lateral crura of the lower lateral cartilages is performed as described previously. Second,
individual treatment of the dome to narrow and
gain definition is performed; this is achieved via
pinching the dome with Griffith’s Brown forceps,
beveling the cephalic edge of the dome unit, and
suturing the single dome with a 5-0 Dexon™ suture
in a mattress fashion. Prior to suturing the single
dome, the vestibular skin on the undersurface of the
alar dome is dissected free from the cartilage; this
maneuver avoids incorporation of the vestibular
skin and mucosa in the mattress suture, thus allowing for better scarification and maintenance of the
desired narrow single dome. Third, double-dome
unit suturing with 5-0 clear Prolene suture is performed in a mattress fashion so that the knot rests
between the domal units. The combination of individual dome narrowing and double-dome suturing
techniques allows for individual dome treatment,
which might be different for each dome or crus,
then reconstitutes them into a single tip-lobular
complex. Whereas these techniques will achieve definition and narrowing of a broad tip, a bulbous tip
that has bulky cartilage may require scoring as well.
A boxy nasal tip may require camouflaging in the
infratip lobular area to fill in the residual bifidity. A
bifid tip may require a full-length shield graft.
Tip Grafts
While suturing techniques may provide increased
tip definition and projection, there are times
when these techniques fall short of the desired
outcome. Therefore, tip grafts are utilized to provide enhanced shape to the poorly defined tip and
increased projection. Furthermore, tip grafts may
provide improved definition of the infratip lobule.
Finally, tip grafts may also be used for camouflaging
persistent asymmetries. The graft should be shaped
and beveled along its edges to integrate seamlessly
with the surrounding cartilaginous architecture.
The tip graft is placed after the columellar strut is
positioned (Figure 3-1).
The types of tip grafts used include shield grafts,
cap grafts, blocking grafts, blanket grafts, infratip
lobular grafts, and Peck grafts. A cephalic transverse onlay (Peck) graft is placed on top of the nasal
dome, thus providing more height and definition
to the nasal tip.5 A cap graft is typically sutured to a
shield graft in the infratip lobular region to give more
infratip lobular length (Figure 3-2). A blocking graft
is also used in conjunction with a shield graft and
AB
Figure 3-1. (A) Extended tip graft sutured into position with several 6-0 Dermalon ™ sutures. Alternatively, 6-0
PDS suture may be used to anchor the tip graft to the underlying lower lateral cartilages. Note that the tip graft
is shaped and beveled along its edges to integrate seamlessly. (B) Preoperative photograph of a patient seeking,
among other changes, an improvement in tip projection. (C) A tip graft was used to obtain the desired aesthetic
result.
C
Tip Rhinoplasty / 37
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ABC
Figure 3-2. (A) A cap graft sutured to a shield graft in the infratip lobular region to give more infratip lobular
length. (B) Preoperative photograph demonstrating, among other findings, a deficiency in the infratip lobular
length. (C) Of interest, note the increased length of the infratip lobule achieved with the cap graft.
is sutured into position at the supratip region; the
blocking graft prevents rotation of the shield graft
and fills in supratip dead space (Figure 3-3).
Controlling Tip Projection
In order to control tip projection, the surgeon must
be aware of the factors that influence it, including:
the length and strength of the lower lateral cartilages, the anterior septal angle, the suspensory ligament from the anterior septal angle to the lobule,
the height of the anterior nasal spine, the attachments of the upper lateral cartilages to the lower
lateral cartilages, and fibrofatty attachments of the
medial crural footplate of the lower lateral cartilages
to the caudal septum. Maneuvers that manipulate
any one of these factors will influence tip projection. For example, a columellar strut may lengthen
and strengthen the medial crura of the lower lateral
cartilages, thus providing a modest increase in tip
projection, and individual dome mattress suture
and transdomal mattress sutures both provide
increased projection of approximately 1–2 mm.
The lateral crural steal technique with intact
domes is used to recruit the lateral crura to increase
the length of the medial crus at the expense of the
lateral crus, thus elevating the tip as much as 2
mm. This provides not only increased projection,
but also increased rotation. If more projection is
required, then dome division lateral to the dome
will further lengthen the lateral crura to increase the
tip projection; dome division is typically reserved
for relatively thick-skinned individuals. Otherwise,
an effective means of providing increased tip projection includes a shield graft.
If the tip is overly projected and requires deprojection, a complete transfixion incision provides
Figure 3-3. A blocking graft is used in
conjunction with a shield graft and sutured into
position at the supratip region; the blocking
graft prevents rotation of the shield graft and
fills in supratip dead space.
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