New Concepts in Nasal Tip Contouring

On frontal view, the nose should have 2 divergent concave lines that extend from the medial brow to the nasal tip (hourglass appearance) with the brow-tip aesthetic line narrowing into the middle nasal vault and then widening slightly along the alar margins.

Excessive narrowing or pinching of the nasal tip can result in an unfavorable shadow or demarcation between the tip lobule and alar lobule. A, Note the abnormal shadows that flank the tip lobule. B, This pinching is noted as notching of the alar margin on base view.

The nasal base can be divided into the tip lobule and base or pedestal. The base consists of the medial crura as they meet the posterior septal angle. The dome angle is the angle created between the medial/intermediate crura and the lateral crura. Note the normal divergence between the intermediate crura that is responsible for the columellar-lobular angle or double break.

Favorable nasal tip contour has a horizontal orientation with a shadow in the supratip area that continues into the supra-alar regions. A, There is a smooth transition from the tip lobule to the alar lobule without a line of demarcation. The tip-defining points are seen as a horizontally oriented highlight with shadows above and below. B, Two horizontally oriented, opposing curved lines outline the tip highlight. The lateral extent of the highlight should continue into an elevated ridge that passes in continuity with the curvilinear contour of the alar lobule.

On the oblique view, a favorable tip contour should demonstrate a subtle supratip break shadow that continues into the supra-alar groove. These shadows represent narrowing as the tip transitions into the supratip and middle nasal vault. The soft tissue triangles or facets should be subtle, casting only an attenuated shadow.

The base view shows a triangular shape with no notching between the tip lobule and the alar lobule. Note the horizontal component of the nasal tip with a defined width set by the position of the domes.

On the lateral view, the tip projects above the dorsum with a supratip break. Most surgically untreated noses have a slightly more cephalic supratip break, preserving a rounder nasal tip. The double break is soft with a subtle shadow at the soft tissue triangle. A more refined tip is created by lowering the position of the supratip break.

The normal divergence of the intermediate crura creates the columellar-lobular angle or double break. For clarity of illustration, the columellar lobular angle and divergence between the intermediate crura have been exaggerated. The distance between the domes and divergence of the intermediate crura can be decreased to create favorable tip contour. One should avoid suturing the intermediate crura together to avoid blunting the columellar-lobular angle.

To maximize support of the alar margin, the caudal margin of the lateral crura should lie near the same level as the cephalic margin of the lateral crura. A, This patient had cephalic positioning of the lateral crura. The lateral crura were dissected from the vestibular skin, and a lateral crural strut graft was sutured to the undersurface of the lateral crura. The lateral crura were then repositioned into caudally positioned pockets. Note how the caudal margin of the lateral crura lie near the same level as the cephalic margin of the lateral crura. B, Postoperative frontal view of this patient shows a natural-appearing nasal tip with normal contours. The width of the nose fits with the round shape of her face. C, This close-up postoperative frontal view of the same patient shows how the alar margins are well supported with a good transition from tip to alar lobule. There is shadowing in the supratip that transitions into the supra-alar groove. The horizontal orientation of the tip is represented by the 2 light reflexes over the dome structures and is highlighted by the 2 light sources directed at 45° off of midline.

To provide good support to the alar margin, it is preferable to have the caudal margin of the lateral crura lie close to the same level as the cephalic margin of the lateral crura. The inset shows a cross section of this favorable orientation illustrating how the caudal margin of the lateral crura lies near the same level as the cephalic margin.

In this patient, the dome suturing method created an abnormal relationship between the caudal and cephalic margins of the lateral crura. A, Intraoperative view of the cartilages reveals that the caudal margin of the lateral crus is well below the cephalic margin of the lateral crus. B, From the frontal view, one can see the dome sutures that are pinching the domes. This view demonstrates the extent of descent of the caudal margin of the lateral crura below the cephalic margin. C, The frontal view of this patient demonstrates the isolation of the tip lobule and pinched appearance to the nasal tip. There is an obvious demarcation of the nasal tip and visible shadows between the tip and alar lobule. The descent of the caudal margin of the lateral crura resulted in loss of support of the alar margin. Additionally, the pinched cartilage structure is too small for this patient's skin envelope, leaving the amorphous tip contour.

When the caudal margin of the lateral crura is displaced below the cephalic margin, the alar lobule may lose support, giving the tip a pinched appearance. The inset shows a cross section through the lateral crus, illustrating the unfavorable angulation of the cartilage with the caudal margin well below the cephalic margin. This is particularly problematic when the caudal margin was close to the level of the cephalic margin preoperatively. This change creates a smaller tip structure to support the same sized skin envelope.

The length and strength of the medial crura provides insight into the stability of the nasal base and the likelihood of losing projection postoperatively. A, Patient with long, strong medial crura that extend to the nasal spine. B, Patient with short medial crura and footplates that do not reach the nasal spine and sit along the caudal margin of the septum. The patient with the long medial crura will be less likely to lose projection postoperatively.

This patient has an overly long caudal septum, hanging columella, and a prominent tip lobule. She underwent dissection between her medial crura with elevation of bilateral mucoperichondrial flaps. The medial crura were sutured to the overly long midline caudal septum to elevate her tip lobule and correct the hanging columella. She also underwent placement of lateral crural strut grafts and dome sutures to correct the bulbous tip. Panels A, C, E, and G show preoperative views; panels B, D, F, and H, 2-year postoperative views.

If the patient has a hanging columella and prominent caudal septum that would otherwise require trimming, the surgeon can set the medial crura back on the midline caudal septum. A, Dissection between the medial crura with elevation of bilateral mucoperichondrial flaps and exposure of the septum. B, The caudal septum is too long, so the medial crura are sutured to the caudal septum with 4-0 plain catgut suture on a straight septal needle. Note that the caudal septum is sutured between the medial crura to stabilize the base of the nose. The fixation sutures are placed along the cephalic margin of the medial crura to avoid retraction of the columella. Special care is taken to create symmetry of the tip structures.

The caudal extension graft typically overlaps the existing caudal septum and is sutured with at least three 5-0 clear nylon sutures. This graft is rectangular in shape to provide support with little change in rotation or nasal length. The caudal margin of this graft must be in the midline; otherwise, the tip may deviate or the airway may be obstructed. A 4-0 plain catgut suture and 5-0 clear nylon suture are used to fix the medial crura to the caudal extension graft.

Caudal extension graft. A, The caudal extension graft is overlapping the existing caudal septum. Care is taken to make sure the caudal margin of the extension graft is in the midline and that the cephalic margin is not blocking the airway. The caudal septum was slightly deviated to the patient's right in this case, so the caudal extension graft was overlapped on the left. The extension graft has a slight curvature to bring the caudal margin back to the midline. B, The medial crura are sutured to the caudal margin of the extension graft with multiple 5-0 clear nylon sutures. Note the midline tip structure.

Caudal extension graft used for correction of the ptotic nasal tip with acute nasolabial angle. A contoured septal cartilage graft that is longer along the inferior margin is used to augment the nasolabial angle and rotate the nasal tip. This graft can be fixed to the periosteum around the nasal spine to further stabilize the graft.

This patient has a modest retraction of her nasolabial angle with weakness in her nasal base, She underwent placement of a caudal extension graft to augment her nasolabial angle. The graft was longer along its inferior margin. Dome sutures were used after placing lateral crural strut grafts to flatten the lateral crura. A bruised cartilage graft was placed horizontally over the domes to provide additional tip definition. Panels A, C, E, and G show preoperative views; panels B, D, F and H, 1-year postoperative views.

Caudal extension graft used for correction of the foreshortened nose. This graft is longer along its superior border to counterrotate the tip and lengthen the nose. The graft can be further stabilized using bilateral extended spreader grafts.

The extended columellar strut is usually carved from autologous costal cartilage and fixed to the nasal spine periosteum or to a notch in a premaxillary graft. To aid in fixation, a notch can be created at the base of the strut to integrate with the nasal spine and premaxilla. Splinting grafts can be sandwiched on both sides of the graft to stabilize the graft superiorly. In the left inset, note how the lower lateral cartilages are suture fixated to the extended columellar strut.

Cephalically positioned lateral crura. A, Cephalically positioned lateral crura create excess vertical supratip tip fullness. Prior to manipulation, the caudal margin of the lateral crura lies below the cephalic margin. B, The lateral crura are dissected from the underlying vestibular skin. C, Lateral crural strut grafts are sutured to the undersurface of the lateral crura with 5-0 clear nylon sutures. D, A more caudally positioned pocket is created to accommodate the lateral crus. E, After lateral crural strut grafts are sutured to the undersurface of the lateral crura, the lateral crura are repositioned into the new, caudally positioned pockets to correct the cephalic positioning. After graft placement and repositioning, the lateral crura are now oriented close to 45° off of midline instead of the preoperative cephalic orientation.

Lateral crural strut grafts are shown in light blue. These cartilage grafts are sutured to the undersurface of the lateral crura to flatten the crura and eliminate the bulbous contour of the nasal tip. After the lateral crural strut grafts are placed, dome sutures can be positioned to narrow the domes and decrease the dome angle. Note how the 5-0 clear nylon sutures are oriented with the knots above the lateral crura. The dark blue structure between the medial crura represents a strut or caudal extension graft.

Placement of 2 separate 5-0 clear nylon dome sutures will narrow the dome angle. Then a 5-0 clear nylon interdomal suture sets the width between the domes. Note how there is some pinching at the junction between the tip lobule and alar lobule. This will require placement of alar rim grafts to reposition the alar margin and avoid a visible transition from tip lobule to alar lobule. Note how the alar rim grafts create a triangular shape to the nasal base.

Patient with bulbous nasal tip treated with conservative cephalic trim, lateral crural strut grafts, dome sutures, and bilateral alar rim grafts. The caudal septum was long, but it was not trimmed. Instead, the medial crura were sutured to the caudal septum to stabilize the base of the nose. The medial crura were sutured to the caudal septum in a slightly deprojected position. Panels A, C, E, and G show preoperative views; panels B, D, F, and H, 1-year postoperative views.

Alar rim grafts are soft, thin cartilage grafts placed into a pocket along the caudal margin of the marginal incision. Note how the medial margins of the grafts are crushed to make them soft after they are sutured to the surrounding soft tissue. The sutures are placed around the graft to avoid fracture.

Alar rim grafts. A, After dome sutures are placed, shadows are created between the right tip lobule and alar lobule. The tip contour is unfavorable. B, Alar rim grafts are placed about 3 mm caudally to the alar margin. C, The grafts are relatively thin and measure around 12 to 15 mm in length. D, Converse scissors are used to make a narrow pocket along the caudal margin of the marginal incision. The pocket extends laterally and is made closer to the internal vestibular skin so that the graft is not visible postoperatively. E, The thin strip of cartilage is placed into the pocket. F, Suture fixation with 6-0 Monocryl (Ethicon Inc, Somerville, NJ) passed through soft tissue and around the graft. G, Brown-Adson forceps are used to crush the medial margin of the graft. H, Note how the medial margin of the graft is soft, so it will not be visible in the tip. I, After alar rim grafts are placed, there are deeper shadows in the supra-alar region, and the shadow between the tip lobule and alar lobule is eliminated. There is a prominence or ridge that extends from the tip to the alar lobule that aids in defining the supra-alar shadows. These changes represent the elevation of the alar lobule with placement of the alar rim grafts.

Alar base reduction after placement of alar rim grafts. Small triangular segments of skin are excised near the junction between the nostril and nostril sill. The excision will make the nostril smaller and decrease flare of the alar margin created by placement of the alar rim grafts. The excision is executed with a slight favorable bevel of the skin excision to promote eversion of the skin edges with closure. A 5-0 polydioxanone subcutaneous suture is placed followed by skin closure with 7-0 nylon vertical mattress sutures.

Soft cartilage (cephalic trim of lateral crus) can be sutured across the domes to provide additional projection and definition. A, Domes after placement of separate dome sutures and interdomal suture to set interdomal distance. Note that the normal divergence between the intermediate crura is preserved. B, Orientation of soft cartilage graft (cephalic trim of lateral crus) across domes (horizontally oriented). The graft sits along the caudal margin of the domes and extends lateral to the domes. C, 6-0 Monocryl sutures (Ethicon Inc, Somerville, NJ) are used to fix the graft. D, Note how the graft is relatively flat, thus avoiding postoperative visibility.

The sutured-in-place shield tip graft. A, The graft is camouflaged with a soft, bruised cartilage graft sutured behind the leading edge of the graft. B, Note how the soft graft extends laterally to the margins of the tip graft to help with the transitions to the existing lateral crura.

Shield tip grafts that project over 3 mm above the existing domes are stabilized with lateral crural grafts. A, These grafts are oriented obliquely off of the posterior surface of the tip graft and then sutured to the lateral crura. B, The lateral crural grafts typically overlap the lateral crura by at least 5 mm.

This Asian patient underwent prior placement of a silicone implant that extruded through her nasal tip and left a scar. Reconstruction required use of a costal cartilage extended columellar strut fixed to the nasal spine periosteum. A costal cartilage dorsal graft was used as well. A shield tip graft with lateral crural grafts was used to contour the nasal tip. The tip graft was covered with a layer of perichondrium from costal cartilage. Panels A, C, E, and G show preoperative views; panels B, D, F, and H, 2-year postoperative views. Note the change in the nasolabial angle with the extended columellar strut. The shield tip graft is supported from behind with the lateral crural grafts to prevent cephalic rotation and provide improved nasal tip definition with a horizontal tip orientation.

Patient who underwent 3 previous rhinoplasties. Overreduction of the cartilage structure and thick skin resulted in a constricted ball appearance to the nasal tip and polly beak deformity. Correction required a tip graft with lateral crural grafts. A cartilage dorsal graft was used to increase dorsal height. The nose was made larger on the lateral view to expand the thick skin and create a more defined frontal view. Note the horizontally oriented nasal tip highlight on the postoperative frontal view. Panels A, C, E, and G show preoperative views; panels B, D, F, and H, 2-year postoperative views.

Perichondrium is sutured over the tip graft and lateral crural grafts to help ensure a smooth contour and help camouflage the tip graft.