Atlas of Asian Rhinoplasty (Volume 2) – Tác giả chưa rõ – Hướng Dẫn Giải Phẫu & Phẫu Thuật Mũi (file pdf)

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Asymmetric Lateral Crura
Buckling of Lateral Crura
Mild buckling of lateral crura can be corrected using concavity control suture (Fig. 9.44), and more severe cases will require
lateral crural onlay graft (Fig. 9.143). If the asymmetry is both in the convexity and concavity of lateral crura, different suture
techniques can be applied to address the separate problem in each lateral crura (Fig. 9.162).
Fig. 9.162 Correction of asymmetric lateral crura and deviated medial crura. (a) In this patient, the ala walls and nostrils are asymmetric. (b, c)
Medial crura are deviated. The right lateral crus has a buckling in the midportion, while the left lateral crus has a convex shape. (d) Double- mattress
sutures are used to straighten the medial crura. (e) Concavity control suture for the right lateral crus. (f) Convexity control sutures for the left lateral
crus. (g) Lateral crural onlay graft (septal cartilage) was placed on the left lateral crus to provide more support. (h) The lateral and medial crura are
much more symmetric. (i) At 1 week after operation, the nose appears much more symmetric
b
c
d
e
f
g
h
i
a
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Asymmetric Length of Lateral Crura
For length asymmetry, the shorter lateral crus is detached from the hinge complex and displaced caudally (Fig. 9.163) or the
longer lateral crus can be shortened. Lateral crural shortening is performed in the lateralmost portion of lateral crura and
requires overlapping suture (Fig. 9.158).
Fig. 9.163 Correction of asymmetry in the length of lateral crura. (a, b): This patient has asymmetric tip and nostrils. (c, d) The right medial
crus is shorter than left medial crus. The right lateral crus is also shorter than the left lateral crus. (e, f) The right lateral crus is detached from
the hinge area and pulled caudally. (g) Interdomal and transdomal sutures were placed to keep the crura in the symmetric position. (h)
Columellar strut graft was placed to correct the height discrepancy in medial crura
a
b
c
d
e
f
g
h
Correction of Asymmetric Lower Lateral Cartilages

440
Malpositioned Lateral Crura
Asymmetry in alar rim position can result from a malpositioned lateral crus (Fig. 9.15). This asymmetry can be corrected by
releasing the scroll area and repositioning the malpositioned lower lateral cartilage caudally. The repositioned cartilage is
then fixated using the interdomal suture.
Tip Plasty in Asians with Thick Skin and Soft Tissue
For nasal tip plasty, most of the focus and effort are placed on building up the nasal framework. However, the author cannot
emphasize enough the significance of the thickness and quality of the skin and soft-tissue envelope (SSTE), as it affects the
final surgical result and can limit the improvement expected from the skeletal framework.
Unlike Caucasian patients, thick nasal skin is extremely common in Asians. Thick dorsal skin decreases the risk of an
implant showing through, with significantly less implant- related problems. However, thick skin makes it difficult to develop
a defined nasal tip. Because of this, thick nasal skin is both an advantage and a shortcoming in Asian rhinoplasty.
Overview
Thick SSTE can cover up minor irregularity, asymmetry, and contour of cartilage graft, as well as mild degrees of technical
imperfection, with wider margin of error. However, thick tip skin conceals tip definition created by cartilage workup and
graft, because it obscures and masks the underlying nasal framework, leading to an amorphous rotund nasal tip that lacks
refinement. Because of this, thick skin represents a significant obstacle in obtaining a defined nasal tip and can become a
major cause of postoperative disappointment.
In most Asian patients, the nasal skin is inherently thick (i.e., significantly greater dermal component). However, the thick
skin can also be due to hyperactivity of sebaceous glands. The thick nasal tip skin is frequently accompanied by small and
underprojected lower lateral cartilage (Fig. 9.164). Such nasal tip does not undergo significant external change even with
extensive suture technique and cartilage graft, and is highly resistant to surgical refinement.
a
b
c
Fig. 9.164 Thick tip skin and small lower lateral cartilages in a male Asian patient
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After reduction of bulbous tip by suture techniques and cartilage graft, the tip skin redrapes over the cartilaginous frame-
work and continues to shrink and tighten slowly over time. This shrink-wrap effect is quite different between thick skin and
thin skin, where thicker skin does not conform as well over the skeletal framework as thinner skin does.
In addition, thicker skin is associated with greater amount of postoperative edema that persists for a longer period. In
certain cases, the final appearance of the postoperative nose may not be seen for 16 months, when the edema has completely
subsided.
Another potential problem with thick skin is that it is more prone to post-rhinoplasty fibrosis syndrome, especially in
patients with thick sebaceous skin. The syndrome represents persistent swelling of the soft tissue with prolonged lymph-
edema triggering fibrotic reaction in the soft tissue, which adds to the skin thickness. Post-rhinoplasty fibrosis practically
obliterates all the efforts in the surgical creation of a refined nasal tip and invites severe complaint from the patient who now
has a bulbous tip. Post-rhinoplasty fibrosis syndrome is discussed in Chap. 17.
Finally, thick-skinned noses are more prone to undergo contracture, compared to thin-skinned noses.
Pathology of Thick-Skinned Nose
Nasal SSTE is composed of skin, superficial fatty layer, fibromuscular layer, deep fatty layer, and perichondrium/periosteum.
Thick nasal skin often has larger pores, with thicker dermis and fatty layer. However, the more important difference is in the
fibromuscular, which is also much thicker. The resection of this fibromuscular layer is an important operative step in the
management of thick bulbous tip.
Pre- and Postoperative Skin Treatment
Hyperactive sebaceous gland with large pores should be treated prior to a tip plasty (Fig. 9.165). Otherwise, the tip plasty
may lead to undesirable outcomes with severe edema and fibrosis.
Fig. 9.165 A patient with hyperactive sebaceous gland and large pores
Tip Plasty in Asians with Thick Skin and Soft Tissue

442
Rosacea and acne are the two most common disorders of sebum that can negatively influence a surgical outcome. Its early
symptoms can easily be overlooked. It is a common skin condition that causes redness and visible blood vessels in the face
and can induce skin thickness, edema, and acne. The condition may also produce small, red, pus-filled bumps, which are
more typical in later stages. Rosacea is a chronic disease that is difficult to cure, but the cutaneous inflammation can be con-
trolled. A surgeon must be able to identify a patient with rosacea and understand that the condition interferes with obtaining
good outcomes following nasal tip plasty.
Like rosacea, acne is a disease of inflammation and sebum and should be treated with Retina A (tretinoin) or Accutane
(isotretinoin) prior to an operation. Accutane delays epithelialization and wound healing, and can induce scar hypertrophy.
Because of this, the recommendation is not to operate on a patient within 6 months of Accutane treatment, but this is controver-
sial. In the past, the author has operated in patients with a total of 4-week window of Accutane cessation before and after an
operation, without any deleterious outcome. Dermabrasion or laserbrasion is a decent option for a patient with hyperactive
sebaceous gland. Accutane can induce wound-healing problem after skin abrasion procedures. As such, any abrasion procedure
should be performed prior to the initiation of Accutane or should be performed at least a year out from cessation of Accutane.
Kosins and Obagi have reported on preconditioning of thick oily skin with a combination of salicylic acid, mechanical
scrub, alpha hydroxy acids, and retinoids. They suggest that the preconditioning regimen works to shrink the oil glands,
decrease skin inflammation and swelling, and improve healing. This preconditioning is begun at least 6 weeks prior to an
operation, to optimize the soft-tissue envelope for cosmetic rhinoplasty. The regimen is stopped 5 days before and restarted
10 days after the operation. This “general repair” of the skin is continued for a total of 5 months. For thick oily skin with
texture problem, the same authors recommend a combination of trichloroacetic acid peel and CO2 Fraxel at 3–6 weeks post-
operation, to shrink pores and for textural smoothing and resurfacing. The peel effectively decreases pore size, while the laser
decreases the thickness of dermis and smooths the overlying contour.
Surgical Principle
The salient operative tips for thick nasal skin are to minimize edema, debulk soft tissue, create a firm rigid cartilage graft,
and prevent dead space and hematoma.
Minimizing the Edema
The effort to minimize edema is not simply an issue of decreasing recovery time. Rather, the foremost reason for reducing
edema is to reduce subsequent fibrosis. For this, it is important to minimize tissue trauma by dissection in the proper plane,
proper hemostasis, and gentle handling of tissue.
Preoperative steroid injection and intraoperative application of cold wet gauze are also necessary. For significant amount
of postoperative edema, dexamethasone (IV or IM) is administered at first follow-up visit. The patient should be instructed
on taping, which is to be continued at home for 2 months (Fig. 3.8). To decrease edema, triamcinolone can be injected around
nasal tip. It can be injected into supratip bulging at 1–2 weeks after an operation.
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Debulking
Debulking of the soft tissue can be of great benefit for a nasal tip with relatively thin skin and abundant subcutaneous soft
tissue. However, this approach is not effective for thick skin.
Debulking procedure is performed in the following manner. Through open rhinoplasty incision on the columella, the nasal
tip skin flap is elevated. Many operators elevate the soft tissue and lower lateral cartilage in a single maneuver and remove
the fibromuscular layer from the cartilages. However, the author prefers to elevate the soft tissue on the side of the skin flap
and remove the fibromuscular layer from the skin flap. The former method is a safer and easier approach than the latter.
However, the latter method allows the lower lateral cartilage to be manipulated independently, and the debulking can be
performed after the underlying skeletal frame has provided a base nasal tip volume and shape. This latter sequence mini-
mizes edema in the nasal tip skin. A debulking-first sequence is associated with a longer period of edema formation during
the operation, which is worse with thick skin. To minimize this nasal tip edema, it is best to leave the debulking as the last
step, just prior to wound closure.
Debulking is performed for all areas of the nasal lobule, but meticulous dissection is especially important in the supratip
midline area, to allow for folding of the skin envelop at the midline (Fig. 9.166). During the debulking process, the subdermal
plexus should be preserved without disruption.
a
b
c
Fig. 9.166 Debulking
procedure from the
midline (a) and both
sides (b) of the tip
lobule (c) removed
soft tissue
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444
Firm Rigid Structural Graft
To create a more defined tip in a thick-skinned nose, the tip should be projected with firm structural cartilage graft in combi-
nation with various suture techniques (Fig. 9.167). There are two reasons for this.
First, rigid cartilage graft is important in the formation of a defined tip. Simple cartilage suture techniques and debulking
cannot yield a defined tip because of the masking effect from thick skin. The cartilaginous framework needs to be maximally
firm and stable under a thick skin. The tip- defining effect is more conspicuous with increased rigidity.
Second, a thick skin places a lot of burden onto the cartilage framework, and this can easily lead to tip drooping. This is
especially a problem in Asian patients with weak and small lower lateral cartilage. A firm rigid graft overcomes the resistance
of thick skin.
However, it is not an easy task to come up with a strong structural graft in an Asian patient with bulbous tip with thick
skin because the septal cartilage usually is not large enough to yield a septal cartilage of decent size. In certain cases, costal
cartilage grafts may be necessary.
Another potential problem is whether the structural graft can withstand the contractile force of scar tissue during the
postoperative wound-healing phase.
Because of these challenges and obstacles, a rigid and secure structural graft is a prerequisite for transforming a thick-
skinned low-bulbous tip into a stable and refined nasal tip. Of course, rigid graft alone is not sufficient in obtaining the
desired nasal tip, but it is a necessary foundation for such a tip.
A firm structural graft is not as useful for a patient with thick skin whose nasal tip is already high prior to the operation.
In such a patient, stretching of the tip skin requires additional nasal tip projection, which will result in an unnaturally high
position of nasal tip. Without changing the nasal tip height, it is difficult to obtain a defined nasal tip in that situation, and
patients with relatively high nasal tip should be counseled on this potential issue.
For patients with thick skin, debulking and excessive skin tension from tip projection may impair blood circulation and
result in skin necrosis. The columella circulation should be evaluated during all operations. While skin necrosis is extremely
rare, the potentially disastrous complication should be considered for patients with compromised circulation, such as heavy
smoker, diabetes, peripheral vascular diseases, and history of multiple prior rhinoplasty operations. If the operator observes
signs of impaired circulation (e.g., congestion, loss of capillary refill, blanching), the debulking should be stopped. The
structural graft should be adjusted to decrease skin tension and employ methods to increase blood circulation. These include
the use of topical vasodilators, such as PGE1 ointment, during the operation, and, in the postoperative period, the use of oral
PGE1 agent and hyperbaric oxygen treatment.
a
b
Fig. 9.167 Strong structural graft is needed to resist thick nasal tip skin. In this case, the support was provided by a fixed type of columellar strut
graft
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445
Prevention of Dead Space and Hematoma
Another important aspect of tip plasty is not to leave behind any dead space between cartilages or between cartilages and
skin. A dead space will invite the formation of hematoma, which will lead to fibrosis and scar tissue formation. This is a
common cause of bulbous tip without definition.
Supratip suture eliminates the dead space between the skin and underlying cartilage while approximating the skin to the
cartilage (Figs. 9.46 and 9.47). Upon placing a temporary skin suture on the columella, the skin and the underlying dorsal
septum are marked with a pen at the supratip bulging area. The temporary suture is removed from columella, and 5-0 Vicryl
suture is passed through the subcutaneous tissue at the supratip area and approximated loosely to the underlying septal angle.
To prevent skin dimpling or necrosis, the suture should be tied without too much tension. In addition to elimination of dead
space, this suture can also be useful for lateral bulging of supratip area (Fig. 9.48).
Nasal tip plasty for thick-skinned nose requires meticulous hemostasis because hematoma can lead to fibrosis and forma-
tion of bulbous tip. Usually, a drain is not needed after a rhinoplasty but can be used if the concern for bleeding is high
(Fig. 9.168).
a
b
Fig. 9.168 Drains. (a) Drain using an angiocatheter. (b) Negative-pressure drain using a vacuum tube
Tip Plasty in Asians with Thick Skin and Soft Tissue

446
Postoperative Care
Mild compressive dressing is required for a week (e.g., bolster suture, aqua splint). However, the pressure should not be so
high that it impairs circulation. For the first day after an operation, the dressing should be adjusted after evaluating the nasal
tip and columella for color and capillary refill.
After removing the splint, compressive taping around the tip and steroid injection should be considered to further mini-
mize the edema.
Taping on the supratip and sides of the tip is continued for 2 months, at least during the night while the patient is at home
(Fig. 3.8).
With significant edema, triamcinolone acetonide is injected in the supratip bulging at 1–2 weeks out from the surgery. The
long-acting synthetic glucocorticoid decreases edema and prevents fibrosis. Injection of triamcinolone is described in Chaps.
3 and 16.
For thick skin with large sebaceous pores, a surgical incision can often lead to a conspicuous scar, especially after alar
base reduction surgery. If possible, the patient should be referred to a dermatologist prior to an operation.
Tip Plasty in Thin Skin
Thin-skinned nose is relatively uncommon among Asians. Thin nasal skin often heals with minimal incisional scar, with less
postoperative edema and shorter recovery period. Compared to thicker nasal skin, thin skin is less prone to mask underlying
changes after tip suture techniques or cartilage graft. This can be an advantage when the underlying framework is immacu-
lately constructed and a disadvantage when there are imperfections, with lower margin of error. Small irregularities are not
easy to hide, and even minor pinched deformities become conspicuous (Fig. 9.169).
Thin skin is also more prone to redness, telangiectasia, spider vein formation, and pigmentation. The shrink-wrap effect
after tip plasty is more noticeable for thinner skin. Therefore, correction of bulbous tip may be easier with thinner skin, but
with greater chance of deformation from contractile force during wound remodeling. While thin skin undergoes less contrac-
ture than thick skin, a contracture that does develop with thin skin may be more problematic because the skin will adhere
tightly to the underlying cartilage, resulting in contracted pinched appearance.
Fig. 9.169 In patients with thin nasal skin, it is much easier to observe
protrusion and contour irregularity of a cartilage graft
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Dissection of Thin SSTE
During elevation of skin and soft-tissue envelop, it is important to elevate the skin flap to the maximum thickness. The proper
dissection plane is just above the perichondrium of upper and lower lateral cartilages and under the periosteum of nasal bone.
Minimizing disruption of SMAS and fatty layer is important not only for preserving the vascular supply to the nasal tip and
columella but also for preserving the cushion between the thin skin and the underlying cartilage. Without the intervening soft
tissue in the subcutaneous plane, all of the minute irregularities of the cartilage will become readily visible through the thin
skin.
Reinforcement of Thin SSTE
A thin SSTE can be augmented using temporal fascia, superficial mastoid fascia, or dermal allograft. This can correct the
problem of visible underlying cartilage, improves skin texture, and results in a postoperative nose that appears supple and
natural. Of the various options, the deep temporal fascia provides the thinnest graft and does not result in soft-tissue bulki-
ness while providing adequate augmentation to a thin SSTE.
Tip Plasty Principle in Thin-Skinned Noses
Thin nasal skin easily betrays minor imperfections in suture techniques or cartilage graft. Because of this smaller margin of
error, the surgeon has to perform a more meticulous tip plasty.
The margin of a cartilage onlay graft is tapered thin to a beveled edge and should be sutured to the underlying structure.
More important than that, however, is to use a cartilage crusher on the beveled edge. The crusher makes a cartilage more
pliable, but it is important to make sure that the cartilage does not become too friable. To avoid this problem, crusher with
serrated bed is better than crusher with smooth bed (Fig. 9.60). In addition, crushed cartilage can be wrapped with a temporal
fascia, mastoid fascia, or dermal allograft (Fig. 9.170).
For projection in nasal tip with thin skin, a good option is to use an invisible structural graft like columella strut graft to
project the tip, and to minimize the height augmentation from a visible graft like cartilage onlay graft.
Alar rim graft can show through thin skin. Because of this, the periphery of graft should be morselized, and the graft
pocket should be made as close to the vestibular skin as possible.
To avoid the pinched constricted tip associated with thin skin, the cephalic portion of the lateral crura should be preserved
as much as possible, with appropriate use of suture technique. The suture should be tied with adequate but not strangulating
tension. Massaging of the nasal tip can loosen tight adherence of the thin skin onto the underlying framework.
Fig. 9.170 A conchal cartilage covered with dermal allograft
(Megaderm®, L&C Bio Co, Seoul, Korea)
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Further Reading
1. Guyuron B. Footplates of the medial crura. Plast Recontr Surg. 1998;101(5):1359–63.
2. Gyuron B, Behmand RA. Nasal tip sutures. Part II: the interplas. Plast Reconstr Surg. 2003;112(4):1125–9.
3. Gruber RP, Nahai F, Bogdan MA, Friedman GD. Changing the convexity and concavity of nasal cartilages and cartilage grafts with horizontal
mattress sutures: part I. Experimental results. Plast Reconstr Surg. 2005;115(2):589–94.
4. Gruber RP, Peled A, Talley J. Mattress sutures to remove unwanted convexity and concavity of the nasal tip: 12-year follow-up. Aesthet Surg
J. 2015;35(1):20–7.
5. Kridel RW, Konior RJ, Shumrick KA, Wright WK. Advances in nasal tip surgery: the lateral crural steal. Arch Otolaryngol Head Neck Surg.
1989;115(10):1206–12.
6. Kim MH, Choi JH, Kim MS, et al. An introduction to the septal extension graft. Arch Plast Surg. 2014;41(1):29–34.
7. Byrd HS, Andochick S, Copit S, et  al. Septal extension grafts: a method of controlling tip projection shape. Plast Reconstr Surg.
1997;100:999–1010.
8. Oh SH, Kang NH, Woo JS, et al. Stabilization of unilateral septal extension graft using pivot locking suture. J Korean Soc Aesthetic Plast Surg.
2008;14:156–60.
9. Ha RY, Byrd HS. Septal extension grafts revisited: 6-year experience in controlling nasal tip projection and shape. Plast Reconstr Surg.
2003;112:1929–35.
10. Lin J, Chen X, Wang X, et al. A modified septal extension graft for the Asian nasal tip. JAMA Facial Plast Surg. 2013;15(5):362–8.
11. Gunter JP, Friedman RM. Lateral crural strut graft: technique and clinical applications in rhinoplasty. Plast Reconstr Surg. 1997;99(4):943–52.
12. Guyuron B, DeLuca L, Lash R. Supratip deformity: a closer look. Plast Reconstr Surg. 2000;105(3):1140–51.
13. Anderson JR, Ries WR. Surgery of the nasal base: setting tip projection and location. In: Anderson JR, Ries WR, editors. Rhinoplasty: empha-
sizing the external approach. New York: Thieme; 1986. p. 63–78.
14. Sciuto S, Bianco N. Surgical correction of “rhinoplastic look”. Acta Otorhinolaryngol Ital. 2013;33(3):177–82.
15. Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg. 2006;8(3):156–85.
16. Gunter JP, Rohrich RJ. Correction of the pinched nasal tip with alar spreader grafts. Plast Reconstr Surg. 1992;90(5):821–9.
17. Clark JM, Cook TA. The ‘butterfly’ graft in functional secondary rhinoplasty. Laryngoscope. 2002;112(11):1917–25.
18. Kosins AM, Obagi ZE. Managing the difficult soft tissue envelope in facial and rhinoplasty surgery. Aesth Surg J. 2016;37(2):143–57.
19. Nagarkar P, Stark RY, Pezeshk RA, Amirlak B, Rohrich RJ.  Role of the cephalic trim in modern rhinoplasty. Plast Reconstr Surg.
2016;137(1):89–96.
20. Larrabee WF Jr. The tripod concept. Arch Otolaryngol Head Neck Surg. 1989;115(10):1168–9.
21. Gunter JP, Yu YL. The tripod concept for correcting nasal-tip cartilages. Aesthet Surg J. 2004;24(3):257–60.
22. Anderson JR. A reasoned approach to nasal base surgery. Arch Otolaryngol. 1984;110:349–58.
23. Choi JW, Suh YC, Song SY, Jeong WS. 3D photogrammetric analysis of the nasal tip projection and derotation based on the nasal tip quadripod
concept. Aesthet Plast Surg. 2017;41(3):608–17.
24. Westreich RW, Courtland HW, Nasser P, Jepsen K, Lawson W. Defining nasal cartilage elasticity: biomechanical testing of the tripod theory
based on a cantilevered model. Arch Facial Plast Surg. 2007;9(4):264–70.
25. Suh MK. Asian rhinoplasty. Seoul: Koonja; 2012. p. 169.
26. Kim JH, Song JW, Park SW, Oh WS, et al. Tip extension suture: a new tool tailored for Asian rhinoplasty. Plast Reconstr Surg. 2014;134(5):907–16.
27. Jang YJ, Hong HR. Augmentation shield grafts. JAMA Facial Plast Surg. 2015;17(4):301–2.
28. Dhong ES, Kim YJ, Suh MK. L-shaped columellar strut in East Asian nasal tip plasty. Arch Plast Surg. 2013;40(5):616–20.
29. Oh SH, Kang NH, Woo JS, Jeong JY. Stabilization of unilateral extension graft using pivot locking suture. J Korean Soc Aesth Plast Surg.
2008;14(2):156–60.
30. Paik MH. Correction of short nose. J Korean Soc Aesth Plast Surg. 2005;11(1):22–6.
31. Whitaker EG, Johnson CM Jr. The evolution of open structure rhinoplasty. Arch Facial Plast Surg. 2003;5(4):291–300.
32. Hong ST, Kim DW, Yoon ES, Kim HY, Dhong ES. Superficial mastoid fascia as an accessible donor for various augmentations in Asian rhi-
noplasty. J Plast Reconstr Aesthet Surg. 2012;65(8):1035–40.
33. Paik MH, Chu LS. Correction of the short nose using derotation graft. Arch Aesthetic Plast Surg. 2012;18(1):35–44.
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© Springer Nature Singapore Pte Ltd. 2018
M. K. SUH, Atlas of Asian Rhinoplasty,
Optimal Tip Projection in Asian Noses
10
The importance of effective tip projection cannot be emphasized enough for the Asian nose with low and short nasal tip. Tip
plasty in Asian patients is not limited to projection but also requires consideration of rotation, volume change, tip/ala har-
mony, and tip/nostril harmony.
Tip projection is the most frequently performed form of tip plasty for the Asian patients. In the past, tip augmentation was
performed by simply inserting a long L-shaped silicone implant from the dorsum to the nasal tip (Fig. 10.1). This method
continues to be employed in few Asian countries, but has been abandoned at most places because the distal end of implant
places too much pressure in the tip soft tissue, leading to a number of complications (skin thinning, redness, skin rupture, and
implant exposure) (Fig. 10.2). Some surgeons have covered the distal end of a long L-shaped implant with auricular cartilage
graft, with the hope of preventing the complications. However, the cartilage graft on the implant cannot prevent these com-
plications in the nasal tip, as the pressure from the long implant thins the auricular cartilage. With the cartilage gone, the
implant pressure can again lead to skin thinning and implant rupture. Regardless of the material type (silicone or e-PTFE), a
dorsal implant should be used for augmentation of the radix to supratip and should not be allowed to extend into the nasal
tip. This principle is widely accepted by and established among Asian rhinoplasty surgeons.
Safe and effective techniques for tip projection include suture techniques and cartilage grafts. In Asian patients, the lower
lateral cartilages are characteristically small and weak, which makes for a more difficult tip projection. The nasal tip is not a
static structure. Unlike the upper and middle third of nose, the lower third of nose is a dynamic, mobile structure. Ideally, tip
plasty should result in adequate tip projection while preserving the mobility of the nasal tip. However, this is not always pos-
sible in practice. Increasing amount of tip projection is associated with rigid tip, whereas maintaining a mobile tip will result
in inadequate projection or tip drooping in the long term. Among Asian patients, the standard for tip plasty outcomes has
skyrocketed in the recent past, which has increased the burden of technical excellence on rhinoplasty surgeons.
For Asian patients, tip projection is approached with concepts and techniques different from those developed for Caucasian
patients. Rhinoplasty surgeons should thoroughly understand the advantages and disadvantages of various surgical tech-
niques, be able to distinguish anatomic features specific to individual patients, and apply the appropriate operation technique
for a given patient and nose. The surgeon must also understand the expected outcome as well as how reliable that outcome
is over the long term.

450
a
b
Fig. 10.2 Exposure of a silicone implant through ruptured skin
a
cartilage onlay graft
b
Fig. 10.1 Regardless of an onlay graft, the use of L-shaped silicone implant is associated with the potential risk of nasal tip thinning and
rupture
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451
Ideal Tip Position in Asians
Ideal tip position is determined by tip height and tip rotation. Nasal tip projection is defined as the horizontal distance from
the alar-facial crease to the nasal tip on lateral view (Fig. 10.3). The ideal tip projection will vary according to each author,
but the following two methods are commonly used.
In the first method, the nasal tip projection is defined by the relationship to the anterior projection of the upper lip. Per the
illustration in Fig. 10.3, tip projection is considered to be ideal if the distance A (between anterior portion of upper lip and
the nasal tip) is 50–60% of the distance A + B (from nasal base (Goodie’s index)). If the index is greater than 60%, the tip is
considered to be in overprojection, and underprojection for index less than 50%.
In the second method, the tip projection is evaluated in relation to the overall length of the nose. If the tip height is less
than 0.67 times the length of the nose from the nasion to the tip-defining point, the tip is considered to be underprojected.
The height of infratip lobule should be one-third of the distance from alar base to the tip (Fig. 10.4). This is important for
the tip-nostril harmony. Excessive lengthening of the infratip lobule (e.g., multiple-layer cartilage onlay grafts on the dome)
can result in aesthetically unpleasing tip projection. This is also problematic for excessive elevation of nostril apex via long
columella strut graft or septal extension graft (Fig. 10.5).
The rotation of the nasal tip is just as important as tip projection.
For long drooping tip, tip projection procedures with cephalic rotation component are very effective techniques. Unlike
the low nasal tips in Caucasian patients, cephalically rotated nasal tip is a relatively frequent observation among Asian
patients, and short low tip with visible nostril is not rare. Because of this, tip projection in Asian patients often requires pre-
vention of cephalic rotation or rotation of the nasal tip in caudal direction, which is unique to Asian rhinoplasty.
Tip rotation can be evaluated using the reference provided by the angle between the columella and upper lip (columellar-
labial angle). This angle can be influenced by protrusion of the upper lip or prominence of caudal septum. Because of this,
most authors prefer the nasolabial angle, which provides a more objective evaluation of the tip rotation. Nasolabial angle is
formed between the vertical facial line and the line formed between the anterior and posterior ends of the nostril (Fig. 10.6).
In Caucasians, the nasolabial angle is 95°–100° in females and 90°–95° in males. In East Asians, the mean angle is around
90°–93°. Nasolabial angles wider than these values represent over-rotation of nasal tip (cephalic), by which the nostrils are
more visible from the frontal view.
Tip projection and rotation should not be evaluated only by the anthropometric standards described above. These are
purely average references, and an aesthetically pleasing nasal tip will require appropriate adjustments according to the over-
all shape and appearance of the face for individual patients. For example, an elderly patient with long midface will probably
benefit from slightly cephalically rotated tip. A long nose with normal nasolabial angle can be associated with aging appear-
ance. In addition, the nasal tip should be evaluated in the context of cultural and traditional standards across various Asian
countries and populations. There also exists a significant variation in the preference for the height of nasal tip across age
groups.
Ideal Tip Position in Asians

452
Fig. 10.3 Methods of
evaluating tip projection
1/3
2/3
Fig. 10.4 The height of
infratip lobule should be
one-third of the distance from
alar base to the tip
10 Optimal Tip Projection in Asian Noses

453
Fig. 10.6 Nasolabial angle
a
b
Fig. 10.5 Examples of inharmonious tip projection.
(a) Infratip lobule is excessively long. (b) The nostril is
excessively long
Ideal Tip Position in Asians

454
Factors Determining the Tip Height in Asians
The height of nasal tip is determined by the anatomical characteristics of the lower lateral cartilages, such as size, height, and
strength of the cartilage. However, there are additional factors that also contribute to the height of nasal tip.
As mentioned in Chap. 1, the fibrous connecting tissues support the lower lateral cartilages, and these tissues influence
the height of nasal tip height, as do tip skin/soft tissue, septal cartilage, and ANS. The extent to which each of these contrib-
utes to nasal tip height differs between Asians and Caucasians.
Major Determinants
Inborn Anatomy of the Lower Lateral Cartilage
In both Asian and Caucasian patients, the shape, length, and strength of lower lateral cartilages have the biggest influence on
the height of nasal tip. In Asian patients, a low nasal tip with short columella often has significantly weak medial crura or is
congenitally absent in certain cases (Fig. 10.7). With weak or absent medial crura, gentle pressure on the nasal tip will dem-
onstrate a significant lack of resistance to depression.
a
b
Fig. 10.7 Congenitally small, weak, and twisted medial crura
(a) and congenital absence of the medial crura (b)
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455
Tip Skin/Soft-Tissue Thickness
In Caucasian patients, the tip skin and soft-tissue thickness has a very small influence over tip height. However, the situation
is extremely different for Asian patients. Thick tip skin and soft tissue is a cause for bulbous tip. At the same time, the
increased bulk can add to the overall height of nasal tip with a small lower lateral cartilage (Fig. 10.8). However, such nose
is very resistant to improvement after alterations with tip cartilage graft. The thick skin masks structural changes due to
cartilage grafts, and the weight and elasticity of soft tissue may place undue stress on the graft and become a cause for tip
drooping. Furthermore, scar contracture is often severe in thick skin, which can also be a cause for tip drooping.
a
b
Fig. 10.8 Thick skin and soft tissue of the nasal tip
Major Determinants

456
Caudal Septal Cartilage
The dorsal dimension of septal cartilage is an important factor for the overall length of the nose and nasal tip height, but the
caudal septal cartilage cannot be ignored when it comes to nasal tip height. Most retracted caudal septum is accompanied by
tip drooping, and it is easy for the nasal tip to become droopy after cartilage onlay/shield graft, if the retracted caudal septum
is not addressed.
Scroll Area
Among various fibrous connecting tissues, the scroll area is the most important for the lower lateral cartilages. For simple
onlay graft or shield graft, it is important to preserve the scroll area. However, releasing the scroll area may be advantageous
for very low nasal tip or short-nose correction, where the lower lateral cartilages need to be directly suspended or caudally
repositioned.
Minor Determinants
Interdomal Ligament (Suspensor Ligament)
Interdomal ligament is considered to be a major determinant to the tip height in Caucasians where this ligament suspends on
the well-developed anterior septal angle. This is, however, less important in Asians, because they have less developed liga-
ment and anterior septal angle.
Footplate-Septal Connection
Compared to Caucasians, the footplate-sepal connection in Asians plays less of a major role in supporting the tip. However,
the connection cannot be ignored completely and is more important than the hinge complex. It is important to preserve this
connection during the process of harvesting septal cartilage harvest.
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457
Surgical Techniques for Nasal Tip Projection in Asian Patients
The key tip-projection techniques can be categorized into four categories (Fig. 10.9):
1. Cartilage augmentation on the dome: cartilage onlay/shield graft on the tip
2. Conversion of the lateral crura into the middle crura: medialization of lateral crura (lateral crural steal)
3. Straightening the curved medial crura: double-mattress suture, floating-type columellar strut graft, footplate suture
4. Direct anterior suspension of whole lower lateral cartilages: medial crural-septal suture, fixed-type columellar strut graft,
septal extension graft
The goal of tip projection is long-lasting projection of a nasal tip that remains movable and soft. However, these two ele-
ments—projection and mobility—are contradictory. Rigid fixation of the tip will maintain long-lasting tip projection. This
will, however, result in a rigid nasal tip that is uncomfortable to the patient and that can lead to pressure-related complica-
tions such as skin thinning, cartilage visibility, and skin redness. In contrast, soft and mobile tip may be comfortable to a
patient and less likely to be associated with skin problem. This, however, can develop into nasal tip drooping. Ideally, a tip
projection technique should be able to address both of these qualities, but this is not always possible. Depending on the clini-
cal context, one of these two goals should be sacrificed for the other, and this choice should be determined through a thor-
ough discussion between the surgeon and patient.
Surgical Techniques for Nasal Tip Projection in Asian Patients

458
a
c
d
b
Fig. 10.9 Surgical techniques for the tip projection. (a) Cartilage onlay/shield graft. (b) Lengthening of medial crura by medialization of lateral
crura. (c) Straightening of curved medial crura. (d) Direct anterior suspension of whole lower lateral cartilages
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Tip Onlay/Shield Graft
Cartilage onlay/shield graft is the most commonly performed tip-projection technique in Asian rhinoplasty. For Asian
patients, the auricular cartilage is the preferred source of graft. The auricular cartilage has more of a curvature than septal
cartilage, which translates better into a smooth anatomic shape over the dome. In addition, the auricular cartilage almost
always yields adequate amount of cartilage, whereas the septal cartilage can often be lacking in Asian patients.
Operative Technique
The thicker portion of auricular cartilage, the cavum concha, is more preferable, but the graft can also be prepared from
cymba concha or the septum. Operative details for cartilage harvest are discussed in Chap. 4.
A 6–8 mm long cartilage is laid on the dome of lower lateral cartilages. Depending on the need for tip projection and
shape, the graft can consist of a single or multiple layers. In patients with thin tip skin, the graft cartilage may be visible
through the skin. If this is the case, the following three procedures should be employed:
1. Graft margin should be tapered thin to have a beveled edge.
2. The graft margin or the whole body of the graft can be slightly crushed using a cartilage crusher.
3. The graft should be fixed to the underlying dome in a meticulous manner. Four to six stitches are necessary to fix the graft
margin to the lower lateral cartilages (Fig. 10.10).
Temporal fascia or dermal allograft can be used to cover the graft in thin skin patients (Fig. 10.11). If the three procedures
above are not sufficient in hiding the graft margin, the margin can further be masked by the placement of crushed cartilage
or fascia or allograft dermis at the periphery of graft.
Shield graft can advance the infratip lobule caudally as well as projecting the tip. The operative technique is the same as
onlay graft technique, except that the cartilage is prepared in the shape of a shield and that it is located from the caudal part
of dome to the middle crura (Fig. 10.12).
Fig. 10.10 A three-layer conchal cartilage graft is
fixed over the lower lateral cartilages
Tip Onlay/Shield Graft

460
Fig. 10.11 Dermal allograft-
conchal cartilage onlay graft
(MegaDerm®, L&C Bio, Seoul,
Korea)
Fig. 10.12 Shield graft using
conchal cartilage
10 Optimal Tip Projection in Asian Noses

461
Size of the Graft
For Caucasian noses with two apparent tip-defining points (TDPs), the graft width should be 6–8 mm to represent the two
tip-defining points. However, Asian noses have less defined tip-defining points, and most Asians are not interested in having
two defining points. Also, the thick skin makes it more difficult to obtain tip-defining points. In Asian rhinoplasty, the pri-
mary objective is to obtain a non-bulbous, slimmer, and projected nasal tip. For patient wanting slimmer tip, the graft size
should be less than 6 mm in width. Narrow onlay graft can give the illusion of a slimmer tip in patients with bulbous tip.
Location of the Graft
Depending on graft location on the dome, tip can appear to be rotated either cephalically or caudally than it really is. If the
graft is located more cephalically on the dome, the tip will appear to be rotated cephalically, and the nose will look shorter.
If the graft is located more caudally on the dome, the nose will look longer, and the profile line will become more straight
(Fig. 10.13).
a
b
Fig. 10.13 Location of the tip cartilage graft. (a) Cephalic
positioning of the graft on the dome will result in a nasal tip that
appears to be rotated cephalically. The nose will appear to be
shorter. (b) Caudally located graft on the dome will make the nose
appear longer. The dorsum will appear to be more straight from the
lateral view
Tip Onlay/Shield Graft

462
Cautions in Tip Projection for Asian Noses
This graft can project the nasal tip height depending on its thickness and the number of layers of cartilage. But, further more
important factor for its successful result is the stability of the underlying medial crura of the lower lateral cartilages. Generally,
this graft alone will be insufficient in the following situations:
1. Nose with weak medial crura
2. Nose with short columella
3. Nose with retracted or hanging columella
The tip compression test will reveal all three of these situations (Fig. 9.65).
It is not unusual that the medial crura are small and weak, and sometimes twisted, in Asian noses (Fig. 10.7a). In such
cases, tip onlay graft by itself is not effective in projecting the nasal tip and will require the following procedures.
Interdomal Suture
Lower lateral cartilages with weak medial crura usually have alar domes which are separate from each other (wide inter-
domal distance) or which easily separate under the weight of a cartilage onlay graft. If the domes easily separate, cartilage
onlay graft can settle lower into the space between the alar domes, resulting in the counterproductive loss of the tip height.
To prevent/solve this problem, the interdomal suture should be performed prior to the placement of cartilage onlay graft
(Fig. 10.14).
Fig. 10.14 Interdomal suture to prevent the cartilage
graft from dropping between the domes
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463
Reinforcement of the Medial Crura
For an onlay graft to be effective and long lasting, the medial crura should be strong and stable enough to support the graft.
Otherwise, the weight of graft may compress the weak medial crura, which results in the loss of tip projection gained through
the onlay graft (Fig. 10.15). Therefore, weak medial crura should be reinforced with columellar strut graft, in order to allow
the cartilage onlay graft to be effective in projecting the tip. Without stabilizing the base for a solid foundation, postoperative
loss of tip projection cannot be avoided.
If a multilayer cartilage onlay/shield graft is used for aggressive tip projection, the newly projected tip can end up with the
pinched appearance (Fig. 10.16, Fig. 9.141). This occurs because the transition is not smooth between the cartilage onlay/shield
graft and lateral crura. Alar rim graft prevents the depression of proximal alar rim towards the nostril, which helps to avoid the
pinched deformity. Another method to avoid pinched appearance is lateral crural onlay graft behind the cartilage onlay/shield graft.
Tip projection using cartilage onlay/shield graft can be accomplished through closed approach if the medial crura are rela-
tively strong, with thin skin and minor nasal tip deformities. Additional procedures are also possible through closed approach
(interdomal suture, transdomal suture, and columellar strut graft). However, tip projection will require open approach for
short nose, bulbous tip, thick skin, severely short and retruded columella, and small nostril.
a
b
Fig. 10.15 Weak
medial crura is often
a cause for tip-
projection failure
following tip
cartilage graft
Fig. 10.16 Pinched-tip deformity after multilayer cartilage onlay graft
Reinforcement of the Medial Crura

464
Aesthetic Consideration of the Infratip Lobule Ratio
The height of infratip lobule should be one-third of the distance from alar base to the tip from the worm’s-eye view (Fig. 10.4).
Excess height of the multilayered onlay grafts may lengthen the infratip lobule only disproportionally, which results in a very
unnatural appearance of the tip from basal view (Fig. 10.5a). The nasal tip projection should be harmonious with the nasal dorsum.
If the tip is excessively high or is not harmonious with infratip lobule, the nose will appear very unnatural in East Asian patients.
For low and round nostril, columellar strut graft and medialization of lateral crura can increase nostril height while alter-
ing the shape from round to a more vertical, triangular shape. The onlay graft can increase the infratip lobule. The operator
should aim for harmony of the shapes.
Medialization of Lateral Crura (Lateral Crural Steal)
This technique converts the lateral crura into the middle crura to increase the tip height (Fig. 10.17). This technique is effec-
tive for 2–4 mm of tip projection.
However, this technique is insufficient in providing adequate tip projection in Asian patients with low nasal tip, who will
most likely require the addition of cartilage onlay graft or shield graft.
If the medial crura are weak, the lateral crural steal will increase the burden onto the medial crura, which may undergo
twisting or compression and result in loss of tip projection. As such, columella strut graft may be required to bolster the
medial crura (Fig. 10.18).
In addition, medialization of lateral crura will induce cephalic rotation of dome and can result in shortening of the nose.
This cephalic rotation should be countered with spanning suture, derotation suture, or derotation graft.
Fig. 10.17 Effective medialization of lateral crura can yield 2–4 mm of tip projection
a
b
Fig. 10.18 Medialization of lateral crura can lead to twisting (a) or compression (b) of weak medial crura
10 Optimal Tip Projection in Asian Noses

465
Straightening the Curved Medial Crura
In Asian patients with low tip, it is quite common to encounter twisted medial crura. Straightening the curved, twisted medial
crura can increase the height of nasal tip by 3–5 mm while reinforcing the support it provides to the domes and onlay graft.
Twisted medial crura can be straightened using double-mattress sutures, and more definite correction can be applied by
the addition of columellar strut graft (Fig. 10.19).
a
b
Fig. 10.19 Straightening twisted medial crura. (a)
Twisted medial crura cause low tip. (B) Straightening
of twisted medial crura using strut graft can yield
more than 4 mm of tip projection
Straightening the Curved Medial Crura

466
Columellar Strut Graft
This graft is one of the best techniques for projection of nasal tips with the short columella, retracted subnasale, and acute
nasolabial angle. There are several mechanisms through which this graft increases the nasal tip height.
First, the long fixed type of columellar strut graft can lift up and suspend the whole of lower lateral cartilage anteriorly,
which can have very strong effect on nasal tip projection, albeit at the cost of nasal tip rigidity (Fig. 10.20).
Second, the shorter floating type of columellar strut can increase the nasal tip height by:
1. Straightening the twisted medial crura, which restores the hidden length of medial crura to the nasal tip height (Fig. 10.21).
2. Reinforcing the weak medial crura and providing a strong foundation for the tip projection. The shorter floating type of
strut graft can minimize the compression and twisting of the medial crura from the suture technique and cartilage onlay
graft. Thus, the tip projection effect of suture techniques and cartilage onlay graft can be preserved and maintained.
Columellar strut graft is also effective in preventing tip drooping in smiling tip.
A columellar strut graft should be sufficiently long enough for low nasal tip with short columella—long enough to almost
reach the anterior nasal spine. Columellar strut graft can lead to cephalic rotation of the tip with weak lateral crura, which is
undesirable and should be prevented. Methods of prevention include spanning suture, derotation suture, derotation graft, and
lateral crural onlay graft. The spanning suture and derotation suture are effective only if the lateral crura are stable. Otherwise,
the suture techniques can result in buckling of lateral crura. Lateral crural onlay graft or derotation graft is required to prevent
it (Fig. 10.22).
Fig. 10.20 Direct suspension of the
lower lateral cartilage anteriorly by
fixed-type columellar strut graft
Fig. 10.21 Straightening twisted medial crura with columellar strut graft
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467
Fig. 10.22 Low tip with
short columella. (a–c) This
male patient has a low tip and
short columella. (d, e) Low
tip with short columella
requires a long fixed-type
columellar strut graft. (f):
The cephalic rotation of the
tip from columellar strut graft
is prevented using derotation
graft
a
b
c
d
f
e
Straightening the Curved Medial Crura

468
a
b
Fig. 10.23 Modified columellar strut graft. (a) L-shaped columellar strut graft. (b) Rein-shaped columellar strut graft
For prevention of cephalic rotation of dome, columellar strut graft has been modified in a couple of ways: L-shaped colu-
mellar strut graft and rein-shaped columellar strut graft (Fig. 10.23). These two modified columellar strut grafts allow precise
placement of the cephalic end of the graft, which allows the operator to avoid cephalic rotation of dome. The operative details
for this are described in Chap. 9.
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469
Footplate Suture
Approximation of the footplates advances the subnasale caudally and slightly projects the tip.
Usefulness of Columellar Strut Graft
Columellar strut graft is a highly useful tip projection technique in Asian rhinoplasty. However, the operator must understand
the potential gains and losses possible through this technique.
If intercrural ligament is disrupted to place the strut graft, the fibrous supporting tissue of the tip is destroyed. In addition
to this, the process of harvesting the septal cartilage can involve disruption of membranous septum, loosening of the foot-
plate-septal connection, and scar contracture in the columella. All of these factors can lead to re-drooping of the tip over the
long term. As such, columellar strut graft should be used when it can cancel out and overcome all these negative factors in
projecting the nasal tip.
Routine use of columella strut graft is not recommended if the medial crura are without any weakness, twisting, or com-
pression. Columellar strut graft is most appropriate for weak medial crura with the potential for twisting and compression
and also for retracted short columella and asymmetric medial crura (Fig. 10.24).
a
c
b
Fig. 10.24 (a, b) Columellar strut graft supports weak medial crura and acts as a strong base for shield or onlay graft. (c) Strong medial crura can
sustain tip graft well and would not require columellar strut graft
Usefulness of Columellar Strut Graft

470
Direct Suspension of Whole Lower Lateral Cartilage
These techniques suspend the whole of lower lateral cartilage in a more anterior position. These include medial crural-septal
suture, septal extension graft, fixed-type columellar strut graft, L-shaped columellar strut graft, and tongue-in-groove technique.
Medial Crural-Septal Suture
This technique is effective for low tip with hanging columella but has limited effectiveness in Asian patients with weak
medial crura (Figs. 9.26 and 9.28).
Septal Extension Graft
For low tip with thick tip skin and short and retruded columella, septal extension graft is the most effective method of tip
projection, similar to fixed-type columellar strut graft. This technique is especially effective if the lower lateral cartilages are
very small. In such cases, other operative techniques do not allow for sufficient tip projection, and septal extension graft is
perhaps the most appropriate.
The septal cartilage is the most preferred graft source. The harvested cartilage should be of adequate size and strength. If
the cartilage graft is not strong enough, the projected tip may decrease in height over time from the tension of scar contrac-
ture. It is absolutely necessary to use a graft that is strong beyond doubt. Otherwise, a weak graft can lead to high revision
rate. If the septal cartilage cannot provide a strong donor, the costal cartilage can be considered as a good alternative.
Thick strong septal extension graft has the shortcoming of rigid nasal tip but also has a very good long-term result
(Fig. 10.25).
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471
a
b
c
e
d
f
h
g
Fig. 10.25 Tip projection using the septal extension graft. (a–c) Preoperative photographs. (d, e) Intraoperative view of septal extension graft
using septal cartilage. (f–h) Postoperative photographs after hump reduction, radix augmentation with silicone implant (2 mm in height), and septal
extension graft for tip projection
Direct Suspension of Whole Lower Lateral Cartilage

472
Fixed-Type Columellar Strut Graft
Fixed-type columellar strut graft is another technique that allows ample projection of the nasal tip. However, this technique
can lead to cephalic rotation of tip, which is undesirable and to be avoided. For small, weak lower lateral cartilages, long
columellar strut graft should be performed with the derotation graft to prevent cephalic rotation. This combination will result
in a more supple and movable tip, compared to the nasal tip resulting from septal extension graft (Fig. 10.26).
a
b
c
d
Fig. 10.26 Columellar strut graft and derotation graft for a movable tip. (a, b) Low nasal tip with small lower lateral cartilages. (c, d) Columellar
strut graft and small derotation graft are used to achieve higher and longer nasal tip that remains movable and soft. (e–g) Preoperative view of the
patient with low short tip and wide nasal bone. (h–j) Postoperative view at 1 year after osteotomy, radix augmentation with silicone implant (2 mm
in height), tip plasty with columellar strut graft with conchal cartilage, and derotation graft and tip onlay graft using conchal cartilage
10 Optimal Tip Projection in Asian Noses

473
g
h
f
i
j
e
Fig. 10.26 (continued)
Direct Suspension of Whole Lower Lateral Cartilage

474
Tongue-in-Groove Technique
The tongue-in-groove (TIG) technique is the suture fixation of medial crura to the caudal septum (Fig. 10.27). This technique
is a valid solution for hanging columella, and can project and rotate the nasal tip.
The technique begins with dissection between the medial crura. The caudal septal cartilage is exposed fully. Septoplasty
is performed as indicated. The medial crura are then advanced cephaloposteriorly, placing the medial side of each crura to
both sides of caudal septal cartilage. Medial crura are fixed to the caudal septal cartilage with 5-0 PDS.
The membranous septum may need to be sometimes necessary to remove the excess tissue resulting from shortening of
the hanging columella. The location of medial crural fixation to the caudal septum determines the degree of columella retrac-
tion and tip projection. The tongue-in-groove (TIG) technique provides a method for correcting excess columellar show and
maintaining correction of caudal deviation. It is also indicated for controlling nasal tip rotation and projection while preserv-
ing the integrity of lobular cartilaginous complex. The technique may be combined with either the external or the endonasal
rhinoplasty, and is typically used in combination with other septorhinoplasty maneuvers. The TIG technique consists of a
method by which the medial crura are advanced cephaloposteriorly onto the caudal septum into a surgically created space
between them.
Alternatively, the use of TIG technique can reduce a hanging columella with little or no excision of the caudal septum.
This is particularly useful in a patient with both excess columellar show and acute nasolabial angle.
The TIG technique can effectively project a low tip with hanging columella, but is rarely used for low nasal tip in Asian
patients with weak and small medial crura.
Fig. 10.27 Tongue-in-
groove technique for tip
projection
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475
Operative Algorithm for the Tip Projection in Asian Rhinoplasty
During projection of nasal tip in Asian patients, the important anatomical characteristics to overcome are small and weak
lower lateral cartilages, short columella, tendency for cephalic rotation with manipulation of the tip, and thick nasal tip skin.
In each patient, these characteristics must be addressed using an individualized combination of operative techniques.
Tip projection of short nose and long nose is described in Chaps. 11 and 12. In this chapter, the operative algorithm is
developed for tip projection in normal length of the nose (Fig. 10.28). The main factors determining surgical decision-mak-
ing process are stability of medial crura, tip skin thickness, and nostril shape.
According to the algorithm, an operation that leads to cephalic rotation of the tip will require additional procedures such
as derotation suture, derotation graft, and lateral crural graft.
With strong medial crura and vertical oval shape nostril, a nasal tip can be projected with just an interdomal suture and
cartilage onlay/shield graft (Fig. 10.29). However, this can offer minimal-to-mild augmentation of the nasal tip. An onlay
graft with more than four layers can result in visible graft margin, pinched tip, inharmonious infratip lobule height, and
medial crural collapse. Creation of a vertical shaped nostril will require medialization of lateral crura with or without colu-
mellar strut graft (Fig. 10.30). A nasal tip with short columella and relatively thin skin can be projected using a floating-type
columellar strut graft, but fixed type of strut graft should be used if long-term stability is a concern (Figs. 10.31 and 10.32).
Septal extension graft is another rigid structural graft. Cartilage onlay graft and lateral crural steal is not effective in project-
ing the tip with thick skin, unless the soft tissue is debulked and either fixed-type strut graft or septal extension graft is used
(Fig. 10.33). With thick skin, avoidance of rigid graft for soft movable tip increases the likelihood of tip drooping, and this
must be explained thoroughly to the patient prior to the operation.
Tip Compression Test
Resist
Tip sking
Thin
Thick
Nostril Shape
Round, Horizontal
Triangular
Interdomal suture &
cartilage onlay/shield graft
Medialization of lateral crura
& tip cartilage graft
Collapse
Hanging columella
Short retruded columella
Tip skin
Thin
Floating type
columellar strut graft
& tip cartilage graft
Correction of hanging columella
& tip cartilage graft
Thick and tight
Fixed type
columellar strut graft
& tip cartilage graft
or
Septal extension graft
Fig. 10.28 Algorithm for nasal tip projection
Operative Algorithm for the Tip Projection in Asian Rhinoplasty

476
a
b
c
e
f
g
f
h
d
Fig. 10.29 Tip projection with conchal cartilage tip
graft. (a–d) Preoperative photographs. (e–h) Photograph
at 1 year after dorsal augmentation with silicone implant
(5 mm in height) and tip projection with shield graft,
through bilateral inframarginal incision
10 Optimal Tip Projection in Asian Noses

477
a
b
e
f
g
h
d
c
Fig. 10.30 Tip projection with medialization of lateral
crura and conchal cartilage tip graft. (a–d) Preoperative
photographs show flat radix and low tip. (e–h) At 2 years
after operation, the dorsum remains well augmented. The
nasal tip is slimmer and remains projected with a vertical
shaped nostril. (Operation: dorsal augmentation with
silicone implant, tip plasty with medialization of lateral
crura, and conchal cartilage shield graft, through bilateral
inframarginal incision)
Operative Algorithm for the Tip Projection in Asian Rhinoplasty

478
a
b
e
f
h
d
c
g
Fig. 10.31 Tip projection with fixed-type columellar
strut graft. (a–d) This patient has a flat nasal dorsum and
low tip. The skin and soft tissue of the tip are thick, with a
short columella. (e–h) The patient underwent dorsal
augmentation with silicone implant (3 mm height), tip
plasty with fixed-type strut graft (septal cartilage), and tip
cartilage onlay graft. At 4 years, the nasal tip height is
maintained well with the nostrils in a more vertical
triangular shape
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479
a
e
f
b
g
h
d
c
Fig. 10.32 Fixed-type L-shaped columellar strut graft for
the tip projection. (a–d) Preoperative photographs show
dorsal hum and tip drooping. (e–h) The postoperative
photographs are taken 3 years after hump reduction,
osteotomy, and tip plasty with L-shaped columellar strut
graft, bilateral alar rim graft, and alar base reduction
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480
a
b
c
d
e
f
Fig. 10.33 Septal extension graft for a
nasal tip with thick skin and soft tissue.
(a–c) Preoperative photographs show that
the drooping tip has thick skin and soft
tissue. (d–f) Postoperative photographs
after dorsal augmentation (silicone
implant), tip plasty with debulking, septal
extension graft (septal cartilage), and onlay
graft (septal cartilage)
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Premaxillary Graft as an Adjunct Procedure
Medial crura are adjacent to the base of premaxilla. A retracted base cannot adequately support the medial crura. Additionally,
retracted columella cannot support caudal traction of the nasal tip. This area can be reinforced using columellar strut graft or
septal extension graft, but premaxillary graft can also support the medial crura and project the entire base of the nose. The
premaxillary augmentation can be performed using septal cartilage, auricular cartilage, and at times costal cartilage. The
graft is inserted into a supraperiosteal pocket that is created from below the medial crura to just above the upper incisor roots
(Fig. 10.34). Like the columella strut, the graft moves the subnasale caudally and supports the nasal tip.
Fig. 10.34 Premaxillary graft
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482
Long-Term Stability of the Tip Projection
Long-term stability of a tip projection is dependent on the sum vector of anteriorly pushing and posteriorly pulling forces.
Factors that contribute to anteriorly pushing forces include the strength of medial crura, strength of structural grafts (e.g.,
columellar strut graft and septal extension graft), thickness of cartilage onlay/shield graft, and stability of tip suspension
suture. Long-term stability is high if the medial crura are straight and strong and the columellar strut graft or septal extension
graft is strong and rigid. However, this long-term stability comes at the cost of tip rigidity.
The posteriorly pulling vector includes scar contracture from the columella and subnasale, the weight of cartilage onlay/
shield graft, elasticity of tip skin and soft tissue, amount of twisting and depression in the medial crura, and strong DNS
muscle. Long-term stability is low if the columella and subnasale are extensively manipulated, with thick tip skin/soft tissue,
weak and/or twisted medial crura, and excessive onlay graft. It is important to remember the fact that scar contracture is more
severe in Asian patients with thicker skin than in Caucasian patients.
For strong and stable medial crura, the columellar strut graft should be performed in a cautious manner. At times, the dis-
section in the intercrural space can result in scar contracture that places greater posterior force than the anterior force pro-
vided by the columellar strut graft, for a net posterior vector. For a nose with thick skin and soft tissue, a columellar strut
graft must be rigid and firm enough to withstand the weight of the soft tissue as well as the contractile force of the scar tissue
(Fig. 10.35).
a
c
b
Fig. 10.35 Previously, this patient had undergone columellar strut graft but reported loss of tip height after 1 year. This was most likely due to the
floating-type columellar strut graft not being strong enough to withstand the force of scar contracture
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Problems of Thick Skin
As previously mentioned, thick skin provides significant resistance to tip graft, compresses the medial crura, and is likely to
undergo significant contraction with scarring. In addition, tension and pressure from the thick skin envelope tend to cephali-
cally rotate a shield graft. They can also buckle the lateral crura, which will cause cephalic rotation of the dome of lower
lateral cartilage. This can subsequently lead to infratip blunting and appearance of short nose. Avoidance of these problems
requires lateral crural onlay graft or derotation graft, in combination with columellar strut graft (Fig. 10.22).
Septal extension graft can be an alternate option. Septal extension graft must be adequately strong. A septal extension
graft prepared from weak septal cartilage can easily collapse over time under the weight of thick skin and scar contracture,
which is a common cause for tip drooping (Fig. 10.36). Because of this, a strong septal extension graft is required, which can
result in rigid nasal tip.
With thick skin and short columella, tip onlay/shield graft can easily lead to loss of tip projection and will require rigid
structural graft, such as septal extension graft or fixed columellar strut graft.
a
b
Fig. 10.36 Tip drooping after septal extension graft. (a) Preoperative photograph of a patient with drooping nasal tip. This patient underwent
septal extension graft to project the nasal tip. (b) After 1 year, the nasal tip has lost the projected height from the prior operation, which was due to
the fact that a thin septal cartilage was used as the extension graft
Problems of Thick Skin

484
Management of Supratip and Infratip Lobules
An aesthetically pleasing tip requires careful management of supratip and infratip lobule. The creation of a natural supratip
break requires two things: adequate tip projection and prevention (or correction) of supratip bulging.
Most Asian men do not want a supratip break, and excessive supratip break is a cause of complaint even among Asian
women. Instead of creating an exaggerated supratip break for a curved dorsal profile, it is better to create a smooth profile
from the radix to the tip. For female patients, it is better to create a tip projection that is slightly higher than the height of the
dorsum.
There are a number of pointers for prevention of supratip bulging. First, the transition between the implant tip and tip
cartilage graft should be delicate. The implant tip should be carved very thinly to allow for a natural supratip break. Second,
the operator must avoid creating a groove between implant tip and tip cartilage graft, which can occur if the implant tip is too
thick or if the gap is large between the implant tip and tip graft. Third, lateral crura of lower lateral cartilages can cause
supratip bulging. In this case, the lateral crura can be sutured to the dorsal septal angle to create a concavity in the lateral
crura. Fourth, a supratip skin-to-cartilage suture (SQ approximation suture) can be used to eliminate dead space in the supra-
tip area. When employing this suture, it is important not to interrupt the blood supply to the skin with excessive suture tension
(Figs. 9.46 and 9.47). Fifth, a supratip bulging that is discovered after an operation should be managed with triamcinolone
injection from 1 to 2 weeks after an operation. Supratip taping should be maintained for about 2 months (Fig. 3.8).
The infratip lobule should be proportionally sized for the overall nasal tip to appear natural. A nose without infratip lobule
can appear too “sharp” and operated. In male patients, lack of infratip lobule is not a significant problem, but a slight forma-
tion of infratip lobule will appear to be natural in female patients (Fig. 10.37). However, an infratip lobule should not be
confused with a hanging columella. A naturally appearing infratip lobule can be created with the use of shield graft.
a
b
Fig. 10.37 Infratip lobule. (a) This patient has a drooping tip and hanging columella. (b) Postoperatively, the nasal tip is adequately projected,
with correction of hanging columella and development of infratip lobule
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Factors Involved in Tip Drooping After Long Term
With time, it is not rare to observe nasal tip drooping after a tip-projection surgery, which is a source of significant distress
for the patient and the surgeon both. Tip drooping is a natural part of the aging process and is often unavoidable. However,
tip drooping that occurs within 2 years of an operation is to be avoided. In Asian rhinoplasty, it is important to appreciate the
factors that contribute to tip drooping in the preoperative setting and to address them during the operation. These factors
include retruded columella, short columella, hanging columella, thick and tight tip skin, and strong DSN muscle.
Short and Retruded Columella
A nose with short and retruded columella can easily have tip drooping after a tip-projecting operation. Such a nose is often
accompanied by maxillary or ANS hypoplasia (Fig. 10.38). This type of nose is relatively common among Asians, and has
weak and short medial crura. In this context, simple cartilage onlay graft is insufficient in obtaining a good result. Medial
crural reinforcement and caudal projection of columella are basic requirements for tip projection. For medial crural rein-
forcement, the strut graft should be of long fixed type. Otherwise, the medial crura and strut can be depressed with tip droop-
ing (Fig. 10.39). At the same time, the retracted columella should be sufficiently addressed to prevent tip drooping.
Excessive dissection and manipulation of the space between medial crura in a nose with thick skin and short columella
can induce scar contracture and subsequent tip drooping. Because of this, the dissection between the medial crura should be
minimized as much as possible while performing rigid columellar strut graft or septal extension graft.
Congenital absence of medial crura (partial or complete) will also require fixed columellar strut graft or septal extension
graft (Fig. 10.40).
Fig. 10.38 A short retruded columella is usually accompanied by maxillary or ANS hypoplasia
a
b
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486
Fig. 10.39 Floating type of strut
graft can result in depression of
short retruded columella
c
Fig. 10.38 (continued)
10 Optimal Tip Projection in Asian Noses