Nasal Tip Recontouring in Primary Rhinoplasty:  The Endonasal Complete Release Approach

Figure 1. Incision lines for the endonasal complete release approach.This requires the combination of an intercartilaginous and a marginal incision. The latter is advanced medially into a partial paracolumellar incision. Subsequently the vestibular skin is dissected off the undersurface of the lower lateral cartilage and elevated as a bipedicled flap.

Figure 2. Complete release of the lower lateral cartilages. The endonasal complete release approach is completed by supraperichondrial dissection of both surfaces of the lower lateral cartilage (LLC). Identification and transection of the piriform ligament allows for luxation of the LLC into the nasal vestibule. A, Schematic illustration of the complete release of the LLC. B, corresponding intraoperative photograph.

Figure 3. Principle of nasal tip recontouring. Nasal tip recontouring requires reconfiguration of the 3-dimensional shape of the lower lateral cartilage without transection. In this instance, the configuration of the medial crus (green), dome (purple), and lateral crus (blue) results in an overprojecting nasal tip (left). To deproject the nasal tip, the original dome angle (*) and lateral crus (arrow) are advanced laterally and a new domal angle (†) is created. A, schematic illustration of the principle of nasal tip recontouring. Original configuration of the LLC on the left, new configuration after medial crural steal on the right. B, corresponding intraoperative photo after bilateral completion of nasal tip recontouring.

Figure 4. Placement of new domal angle. The cephalic resection is completed in a very conservative fashion. The new dome is created by anterior scoring and subsequent placement of intradomal sutures. Long alar strut grafts are fixated with mattress sutures.

Figure 5. Reconfigured lower lateral cartilages. A, Schematic illustration. The new domal angles (†) are created by conservative anterior scoring (small red arrowheads) and are fixated with intradomal horizontal mattress sutures. The original domal angle is straightened with alar strut grafts (blue). B, Corresponding intraoperative photograph. Subsequent placement of an intradomal suture (not shown) will set the width of the domes.

Figure 6. Case 1. Insufficient alar strut grafts. Alar strut grafts that do not extend far enough medially may allow for persistence of the original domal angle. This results in the appearance of an overly rounded tip and an S-shaped curvature of the alar rim. Placement of an interdomal suture may accentuate this deformity. A, Schematic illustration of the incomplete straightening effect of alar strut grafts that do not sufficiently stent the original domal angle. B, Corresponding postoperative basal view.

Figure 7. Applications of nasal tip recontouring through the endonasal complete release approach. The concept of nasal tip recontouring may be applied to various deformities. The boxy nasal tip (A) and the bifid tip (B). Once the lower lateral cartilage has been reshaped and secured with intradomal sutures and alar strut grafts, the alar lobule is gently stented and compressed with soft silicone foil (purple) (C).

Figure 8. Case 2 is representative of correcting asymmetries through the endonasal complete release approach. After release of the upper lateral cartilage, resection of the nasal dorsum, and closure of the open roof with standard osteotomies, asymmetric spreader grafts were suture fixated to correct the asymmetry of the middle third. The asymmetry of the nasal tip was addressed by repositioning of the domal angles, placement of alar strut grafts, and placement of fine, shaved cartilage grafts for camouflage. Preoperative and postoperative front (A and B) and three-quarter (C and D) views. Lateral views (E and F) highlight the reconfiguration of the nasal tip with correction of the ptotic appearance of the infratip lobule. Basal views (G and H) show bilaterally patent nasal valves as a result of the placement of the alar strut grafts.

Figure 9. Case 3 is representative of correcting a boxy nasal tip through the endonasal complete release approach. The original domal angles were straightened, and new domes were created through scoring and intradomal sutures as shown in Figure 7. Preoperative and postoperative frontal (A and B) and three-quarter (C and D) views.