Atlas of Asian Rhinoplasty

488
Hanging Columella
In patients with hanging columella or in those whom hanging columella can be induced with tip compression test, simple tip
onlay graft can worsen the hanging columella and lead to tip height loss. Because of this, a hanging columella should be
addressed prior to the placement of an onlay graft (Fig. 10.41).
Fig. 10.41 Hanging columella can become worse after a cartilage onlay graft and
can become a cause for tip drooping
10 Optimal Tip Projection in Asian Noses

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Thick and Tight Skin Over the Tip
Thick and tight skin will resist tip projection from suture technique and cartilage graft. The shape of lower lateral cartilage
does not easily change due to the thick skin. Because of this, thick skin is just as important of a factor in determining tip
projection as the size and shape of the lower lateral cartilage.
To overcome the tension and contracture of thick and tight skin, the medial crura should be supported with strong struc-
tural grafts, along with the onlay graft. Either a long columella strut graft or a septal extension graft will be necessary.
Strong DSN Muscle
In patients with smiling tip, the action of depressor septal nasi (DSN) muscle can cause tip drooping over time after a tip
plasty operation. Columella strut graft is necessary to withstand the pulling power of the muscle, and the depressor muscle
may need to be cut and repositioned.
Through the open rhinoplasty access, the DSN muscle can be excised, and the surrounding connective tissue is released.
Once this is done, the lower lateral cartilage will seem to suspend easier (Fig. 10.42). However, aggressive manipulation
between and below the medial crura will result in postoperative scar contracture and subsequent tip drooping. Because of
this, the author recommends resection of DSN muscle through an intraoral approach (Fig. 10.43).
Fig. 10.42 Resection of the left DSN muscle and release
of fibrous tissue allow easier mobilization of the left lower
lateral cartilage, compared to the untouched right side.
This can, however, induce severe scar tissue formation
and contracture, which can become a cause for tip
drooping
a
b
Fig. 10.43 Repositioning of the depressor septi nasi (DSN) muscle through the buccal sulcus incision. (a) Exposed DSN m. of right side. (b)
Muscle is cut from its origin (alveolar bone). This muscle will be sutured to the cut end of opposite-side muscle
Factors Involved in Tip Drooping After Long Term

490
Surgical Maneuvers to Decrease the Tip Projection
Scroll area release, removal of cephalic margin of lateral crura, and interruption of the soft tissue between medial crura can
result in minimal reduction of the tip projection.
The scroll area should be considered in two ways. First, the scroll area supports the nasal tip and should not be released
if tip onlay graft is to be performed. Second, the scroll area limits the advancement of lower lateral cartilages in short-nose
correction and suspension of lower lateral cartilage. In this case, the scroll area should be released.
For septal cartilage harvest, dissection between medial crura and mucoperichondrial elevation will disrupt the attachment
between medial crura and caudal septum. This will lead to deprojection of the tip and require a counter-procedure that will
re-project the tip. Such procedures include the elevation of mucoperichondrial flap and quilting suture. Upon harvesting the
septal cartilage and placing the strut graft, quilting suture of the membranous septum will assist in preventing deprojection
and retraction.
For optimal tip projection, the factors which decrease tip projection must be recognized and addressed.
Further Reading
1. Fred GB. The nasal tip in rhinoplasty: use of the invaginating technique to prevent secondary drooping. Ann Otolaryngol. 1950;59:215–23.
2. Kriedel RWH, Scott BA, Foda HMT. The tongue-in-groove technique in septorhinoplasty. A 10-year experience. Arch Facial Plast Surg.
1999;1(4):246–56.
3. Toriumi DM. Rhinoplasty. In: Park SS, et al., editors. Facial plastic surgery: the essential guide. New York: Thieme; 2005. p. 223–53.
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© Springer Nature Singapore Pte Ltd. 2018
M. K. SUH, Atlas of Asian Rhinoplasty,
Tip-Reduction Surgery: Bulbous Tip
Correction and Long-Nose Correction
The appearance of nasal tip is determined by tip height, length, rotation, and tissue volume. This chapter addresses excess
volume of the tip (bulbous tip) and excess length of the tip (long nose).
Bulbous Tip
The volume of a nasal tip is determined by the size of lower lateral cartilages, the interdomal distance, domal width, domal
divergence angle, and thickness of soft tissue. Among these, the soft-tissue thickness is the most important factor in Asians.
An aesthetically pleasing nasal tip is not determined by either the cartilage or the soft tissue but by the harmony between the
two components.
Ideal Shape of the Tip
According to Rohrich, the ideal nasal tip shape in Caucasians is described as having domal arch of 4 mm, 30° of domal
divergence angle, and roughly 5 mm between the two tip-defining points (TDPs) (Fig. 11.1). However, these standards can-
not be applied to Asians because the skin and soft tissue of the nasal tip are much thicker with smaller lower lateral cartilages.
In addition, the tip-defining points are not clearly delineated into two points in Asian patients. Because of these anatomic
differences, the nasal tip operations designed for Caucasian patients are not employed for Asian patients. For Asian
11
Fig. 11.1 Ideal shape of the nasal tip. The ideal
nasal tip has a domal arch of 4 mm, 30° of domal
divergence, and roughly 5 mm between the two
tip-defining points (TDPs)

492
rhinoplasty, the parameters mentioned above, such as domal divergence angle, dome arch width, and TDPs, are less impor-
tant than obtaining the desired external shape of nasal tip through the manipulation of thick skin and soft tissue. To accom-
plish this, the parameters developed for Caucasian patients should be used as a reference, with a separate set of standard
parameters for Asian patients. However, obtaining such a standard is difficult in Asians, as the parameters vary widely
depending on the thickness of the skin and soft tissue.
In this context, the definition of ideal tip shape by Toriumi might be more appropriate for Asian patients. Toriumi described
ideal tip, bulbous tip, and pinched tip by the concept of highlights and shadows. According to him, attractive tips are not
always narrower, but have favorable placement of light reflection and shadowing to create a more graceful transition from tip
lobule to alar lobules. Aesthetically pleasing highlights and shadowing around the nasal tip region are mandatory for overall
balance of a truly refined nasal appearance. On the frontal view, a preferable contour of nasal tip has a horizontal orientation,
with shadow in the supratip area that continues into the supra-alar regions. The transition from the tip lobule to the alar lobule
is smooth, without a line of demarcation. The tip-defining points are seen as a horizontally oriented highlight with shadows
above and below (Fig. 11.2). From the oblique perspective, 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
(Fig. 11.3). The base view shows a triangular shape with no notching between the tip lobule and the alar lobule (Fig. 11.4).
A nasal tip with nontrivial bulk can still be attractive if the shadow and highlight exist in a harmonious relationship. If a
bulbous tip in an Asian patient is managed purely in terms of volume reduction, the resulting nasal tip can appear pinched.
To create a non-bulbous nasal tip that remains attractive, the nose should be considered in terms of 3-dimensional structure
with shadow and highlight. Therefore, the important factor in bulbous tip correction is to achieve harmonious shadow and
highlight of the nasal tip. The bulk of soft tissue should not be reduced to the detriment of this harmony while obtaining a
supratip area that is narrower than the nasal tip.
In Asian patients, bulbous tip is defined as large nasal tip regardless of the underlying etiology. There is not clear distinc-
tion between bulbous tip and boxy tip, and boxy tip can be considered as a type of bulbous tip. A boxy tip is a large nasal tip
that has a broad and rectangular lobule from basal view (Fig. 11.5).
For Asian rhinoplasty surgeons, bulbous tip correction is a common yet challenging procedure, with frequent disappoint-
ments. The bulbous tip in Asians is not the simple problem of large and/or separated lower lateral cartilages. Instead, the
bulbosity is often a problem that arises from thick skin and soft tissue. Correction of bulbous tip is less satisfactory over a
long term, if the bulbosity results from soft tissue than from lower lateral cartilages.
It is not difficult to obtain a satisfactory lateral profile in Asian rhinoplasty, but this does not always translate to a satisfac-
tory look from the frontal view. Small contour asymmetry, disrupted transition of the concave-convex surface, and pinched
appearance are more readily apparent in the frontal view.
Many patients will say “my nose tip is bulbous” when the nose actually is small. This most commonly happens with
pinched tip or with a nasal tip that lacks shadow. In many situations, patients will describe the nasal tip of a model or a celeb-
a
b
Fig. 11.2 Favorable nasal tip
contour has a horizontal
orientation, with a shadow in
the supratip area that
continues into the supra-alar
regions. (a) The transition
from the tip lobule to the alar
lobule is smooth, without a
line of demarcation. The
tip-defining points are seen as
a horizontally oriented
highlight with shadows above
and below. (b) Two opposing
curves 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 alar
lobule (from New Concepts in
Nasal Tip Contouring by
Toriumi)
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Fig. 11.3 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 (from New Concepts in Nasal Tip Contouring by Toriumi)
Fig. 11.4 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 (from New Concepts in Nasal Tip
Contouring by Toriumi)
Bulbous Tip

494
a
b
d
e
c
Fig. 11.5 Bulbous tip and boxy tip. (a) Comparisons across the shape of nasal tip. (b, c) A patient with bulbous tip. (d, e) A patient with boxy tip
11 Tip-Reduction Surgery: Bulbous Tip Correction and Long-Nose Correction

495
rity as being “slim,” but these examples often do not represent slim nasal tips. Ultimately, the perception of an attractive nasal
tip is not an issue of volume but of harmonious transition and shadows.
Indiscriminate resection and excessive spanning of lower lateral cartilages are not ideal. To prevent pinched tip, the transi-
tion between nasal tip and ala should be smooth, which maintains an appropriate domal divergence angle and prevents
deformation of lateral crura.
The idea tip should not have tip-defining points that are too close together, and the volume of supratip area should be
lesser than the volume of tip-defining point (Fig. 11.6). An operation that contradicts these proportions will result in pinched
a
b
c
d
e
f
g
h
i
Fig. 11.6 Correction of bulbous tip. (a–c) This patient has a slightly long nose and bulbous tip with the supratip being wider than the width of
tip-defining points (TDPs). (d) The widths of lateral and medial crura are wide. (e) The design for cephalic trimming of lateral crura and strip
resection of medial crura. (f) Interdomal suture and lateral crural spanning suture are performed. (g–i) At 6 months, the nasal tip volume appears
reduced. However, the width of TDPs has not decreased. The supratip area has lost volume, and the shadow in the supratip area continues into the
supra-alar regions. The transition from the tip lobule to the alar lobule does not have any pinched appearance. The tip-defining points are seen as
a horizontally oriented highlight
Bulbous Tip

496
Fig. 11.7 Bialar angle
tip and will often lead to reoperation. The operation should not focus solely on bringing the lower lateral cartilages together.
Rather, the nasal volume should be reduced while maintaining an appropriate balance between the shadow and highlight. The
volume ratio between supratip area and tip-defining points can be controlled with cephalic trimming of lateral crura, supratip
debulking of soft tissue, and spanning suture of lateral crura. The alar groove should be present but not be deep. The line
connecting between the tip and ala base should be smooth without demarcation, with an angle not more than 60° (Fig. 11.7).
This will sometimes require alar base reduction. A narrow domal separation angle can lead to pinched tip, but this is some-
times not avoidable in significant amount of tip reduction and tip projection. Such a case may require alar rim graft, which
is employed frequently in addressing bulbous tip correction in Asian patients.
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Classification of Bulbous Tip
The volume of a nasal tip is determined by the size, convexity, and divergence of lower lateral cartilage as well as by the
soft-tissue thickness. Ideal shape of nasal tip is formed by the harmony between the lower lateral cartilage and soft-tissue
covering. If either the cartilage or the soft tissue becomes the more predominant component, the nasal tip will be bulbous.
Externally, bulbous tip refers to large or broad nasal tip. However, bulbous tips can be classified into several types accord-
ing to the etiology of underlying internal structure, with the corrective operation varying according to the underlying etiol-
ogy. As such, accurate assessment of a bulbous tip is important for operative planning.
Causes of bulbous tip include thick skin and soft tissue, excess width of lateral crura, excess length of lateral crura, bifidity
of the domes, vertical convexity of the lateral crura, and horizontal convexity of the lateral crura. Constantian has reported
that bulbous tip is related to cephalically malpositioned lateral crura, which creates a vertical fullness of the nasal tip that
interrupts the brow-tip aesthetic line (Fig. 11.23).
In Asian patients, the bulbous tip does not always contain large lower lateral cartilages. At times, the lower lateral carti-
lages can be normal or even diminutive, with the bulk of nasal tip more often coming from the excess in soft tissue.
Nagarkar et al. classified bulbous tip according to the shape of lateral crura (type I: flat lateral crura, type II: convex lateral
crura, and type III: concave lateral crura) but it is not applicable in Asian rhinoplasty because it does not take soft tissue into
account. Bulbous tip classification in Asian patients has various classifications, but the author uses the following classifica-
tion for a simpler decision-making process.
Type I: Cartilage Predominant
In this type of bulbous tip, the lower lateral cartilages are either too large or convex, or the interdomal space is too wide. The
lateral crura may be too far apart with curled-in cephalic margin. On examination, the skin will be thin with visible contour
of the underlying cartilages, and the height of nostril is usually not low (Fig. 11.8).
a
b
c
Fig. 11.8 Cartilage predominant type of bulbous tip. This type of bulbous tip has large lower lateral cartilages, convex lateral crura, wide inter-
domal distance, and wide separation of the lateral crura. The skin and soft-tissue envelope are relatively thin
Bulbous Tip

498
Type II: Soft-Tissue Predominant
This type of bulbous tip is common among Asian patients. The lower lateral cartilages are usually of normal or small size,
and most of the nasal tip volume comes from the thick skin and soft-tissue envelope (SSTE). The nasal tip is large but the
contour of cartilage is masked by the thick skin and soft tissue. Upon examination, the cartilage will be difficult to palpate
because of the thick soft tissue. The nostrils are usually low in height (Fig. 11.9).
a
b
c
Fig. 11.9 Soft-tissue predominant type of bulbous tip. This type of nasal tip bulbosity has a small or normal lower lateral cartilage, and most of
the nasal tip volume comes from the thick skin and soft-tissue envelope
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Type III: Mixed
This type of bulbous tip is a combination of types I and II. The lower lateral cartilages are large and/or widely separated. At
the same time, the skin soft-tissue envelope is thick (Fig. 11.10).
a
b
c
Fig. 11.10 Mixed type of bulbous tip. The mixed type of bulbous tip is composed of thick SSTE as well as large lower lateral cartilage
Bulbous Tip

500
Several Techniques to Reduce the Tip Volume
Illusion and Harmony
The perceived size of a nasal tip is relative to the remainder of the nose. With low nasal dorsum, the nasal tip can appear
larger, and dorsal augmentation can make a nasal tip appear smaller than it used to be. In the same way, alar base reduction
can make the tip appear larger. An upturned tip can appear more bulbous than it really is. Lengthening the nose can decrease
bulbous shape of the nasal tip (Fig. 11.11).
a
b
Fig. 11.11 The relationship between nasal length and nasal tip bulbosity. In this patient, the dorsal augmentation and tip lengthening make the
nasal tip appear less bulbous
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Soft-Tissue Debulking and Expansion
Tip bulbosity from thick skin and excessive subcutaneous tissue is addressed through debulking procedure (removal of
excessive subcutaneous tissue) (Fig. 11.12). All areas of the nasal lobule are debulked, but the debulking is performed more
meticulously in the midline of supratip area to allow for folding. During the debulking process, it is important to preserve the
subdermal plexus without any disruptions in the blood supply.
Tip onlay/shield graft alone can have tip-narrowing effect, with narrower graft yielding narrow-appearing nasal tip.
Fig. 11.12 Soft-tissue debulking of the tip
Several Techniques to Reduce the Tip Volume

502
Lower Lateral Cartilage Manipulation
Bulbosity due to lower lateral cartilages is addressed by the distance and angle reduction, volume reduction, and convexity
control.
Distance and Angle Reduction
Suture techniques used for bulbous tip correction include interdomal suture, transdomal suture, and spanning suture of lateral
crura.
Interdomal suture is effective for addressing wide interdomal distance and domal clefting. In this technique, the soft tissue
between the domes is removed, and the domes are sutured together (Fig. 11.13).
Transdomal suture is effective for wide domal arches (Fig. 11.14). This suture technique is almost always used for carti-
lage predominant type of bulbous tip. It decreases the domal definition angle and lateral crural convexity (Fig. 11.15).
a
b
c
Fig. 11.13 Interdomal suture. (a) Wide domal separation. (b, c) Placement of interdomal suture has brought the domes closer together
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Fig. 11.14 Transdomal
suture
a
b
Fig. 11.15 Transdomal suture decreases the domal definition angle and the lateral crural convexity. (a) Prior to transdomal suture. (a) After trans-
domal suture
Several Techniques to Reduce the Tip Volume

504
Spanning suture of lateral crura is the horizontal mattress suture between both lateral crura of the lower lateral cartilages
to reduce the distance between both crura and reduce the convexity of the lateral crura (Fig. 11.16). This suture can induce
alar rim retraction or pinching and should not be employed in a nose with retracted ala to decrease the distance between
lateral crura. For a bulbous tip with retracted ala, the distance between lateral crura should not be modified. Instead, the lat-
eral crural convexity can be reduced (Fig. 9.38), or a derotation suture should be used to reduce the lateral crural convexity
and to avoid alar retraction (Fig. 9.39).
a
b
c
d
f
e
Fig. 11.16 Spanning suture of lateral crura. (a, b) Before spanning suture. (c) Release of scroll area. (d) Placement of interdomal suture. (e, f)
After two spanning sutures, the lateral crura have been brought closer to each other, with decreased convexity of each crus
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Volume Reduction
Too wide of lateral crura (excess vertical height) can lead to supratip bulbousness. Decreasing the lateral crural width can
also decrease the supratip fullness. Cephalic trimming (partial removal of cephalic portion) of the lateral crura decreases the
width of lower lateral cartilage, and this can induce cephalic rotation of nasal tip (Fig. 11.17).
There are several mechanisms for how cephalic trimming decreases nasal tip volume. First, cephalic trimming decreases
horizontal width of lateral crura. Second, the distance is decreased between lateral crura. Third, the increased stress on
remainder of lateral crura decreases the convexity of lateral crura.
According to Rohrich, cephalic trimming has several variations (Fig. 11.18). The area of resection is determined by the
size, convexity, and strength of lateral crura. It is safe to keep the resection to a minimum for lateral crural that is concave
and weak. Even for a voluminous tip, the cephalic trimming should be minimal if the volume is due to soft-tissue bulk.
Extended cephalic trim medializes tip-defining points, and is applicable for wide domal arches and large domal divergence
angles.
a
b
Fig. 11.17 Cephalic trim of lateral crura
a
b
c
Fig. 11.18 Types of cephalic trim (Rohrich). (a) Limited cephalic trim (scroll area only). (b) Standard cephalic trim. (c) Extended cephalic trim
Several Techniques to Reduce the Tip Volume

506
The cartilage is scored using No. 15 blade. The excess cartilage is dissected and resected using Metzenbaum scissors. A
minimum of 6–7 mm cartilage should be left behind. Otherwise, over-resection can lead to pinched ala, alar retraction, exter-
nal valve collapse, and nasal tip asymmetry. More of the cartilage should be preserved if the cartilage is thin or weak.
Resection of cephalic margin of lateral crura can result in minimal reduction of tip projection.
The resected portion of lateral crura can be used as diced cartilage for correction of dorsal irregularities. If the cartilage is
large, it can even be used as alar rim graft. Cephalic trimming can be employed along with spanning suture (Fig. 11.19).
Even with minimal resection, the remaining portion of lateral crura can buckle and collapse over time, due to scar con-
tracture and weakening of the cartilage secondary to aging. Because the degree of scar contracture is difficult to predict, the
cephalic trimming of lateral crura should be performed in conservative manner for Asian patients, among whom the tech-
nique is usually not effective enough to bring significant reduction in tip volume. The technique can often lead to pinched
tip, external valve collapse, retracted ala, and nasal tip asymmetry, all of which are causes for revisional operation.
b
c
d
a
Fig. 11.19 Cephalic trim and spanning suture of lateral crura. (a) Design for the cephalic trim. (b) Cephalic trim has been performed. (c, d)
Spanning suture of lateral crura is being performed
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Convexity Control
In the past, morselization or cross-hatching of the lateral crura was favored for satisfactory outcomes in the early postopera-
tive period but is not recommended these days for a couple of reasons. First, lateral crura become weaker with aging. Second,
scar contracture and activation of tip muscle can gradually deform the lateral crura. Because of these factors, the lateral crura
can gradually fail as a structure and result in depression or collapse of alar wall.
Mattress suture on lateral crura (convexity control suture) can flatten out the convexity in lateral crura (Fig. 11.20).
a
b
c
d
e
Fig. 11.20 Convexity control suture on the lateral crura. (a, b) Bulbous tip with long convex lateral crura. (c) Cephalic trimming of lateral crura
and columella strut graft has been performed. (d) Transdomal suture was done. (e) Double-mattress sutures have been performed to flatten the
convex lateral crura
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508
Excessive length or vertical convexity of lateral crura requires division and overlapping suture (Fig. 11.21). The lateral
crura are cut and the medial portion is made to overlap the lateral portion and secured in place with sutures. The vestibular
skin underlying the overlapped area should be elevated from the undersurface of lateral crura.
If the convexity control suture does not flatten or buckles the lateral crura, a lateral crural strut graft can be considered
(Fig. 11.22). Lateral crural strut graft is prepared as a rectangular piece of septal cartilage and inserted in a pocket created
between lateral crura and underlying vestibular skin. This graft acts as a splinting graft to flatten convex lateral crura, and can
decrease lateral crural convexity.
Fig. 11.21 Lateral crural
division and overlapping
Fig. 11.22 Lateral crural strut graft to flatten the
convex lateral crus
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Reorientation of Cephalically Positioned Lateral Crura
Cephalically positioned lateral crura can have a “parentheses” appearance from frontal view (Fig. 11.23). This lateral crural
malposition was first described as a parenthesis-shaped deformity by Sheen, in which the lateral crura are oriented 30° from
midline and directed towards the medial canthus, instead of the normal orientation of 45° from midline towards the lateral
canthus of the eye (Fig. 11.24). A nasal tip with cephalically positioned lateral crura can have supratip bulbousness, and
pinched appearance or external valve collapse in the area of ala without cartilage support. In such a nose, resection of lateral
crura and lateral crural spanning suture can cause or worsen a pinched deformity. Cephalic positioning of the lateral crura
requires a totally different approach from the usual techniques of bulbous tip correction. The lateral crura are repositioned
caudally to decrease supratip fullness and to increase the volume below the TDPs. The lateral crura are elevated from vestibu-
lar skin. The lateral crural strut graft is fixed, and the lateral crura are repositioned into caudal pockets. The derotation suture
can also be used, as described below.
a
b
Fig. 11.23 Cephalically positioned lateral crura
Several Techniques to Reduce the Tip Volume

510
Fig. 11.24 Direction of lateral crura. (a, b) The usual direction of lateral crura towards the lateral cantus. (c, d) More cephalically oriented lateral
crura point towards the medial canthus
c
d
a
b
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Role of the Derotation Suture in the Bulbous Tip Correction
Displacing the lateral crura caudally through derotation suture is very effective for supratip fullness.
In many Asian patients, it is common to observe bulbous supratip area from soft tissue, thick skin, and lateral crus, while
the infratip/ala area is pinched (Fig. 11.25). Derotation suture displaced the lateral crura caudally, which decreases the supra-
tip volume and increases the infratip/ala volume (Fig. 11.26). The nasal tip lengthening due to the derotation can be coun-
tered by the tip rotation suture, which prevents the dome from being displaced caudally (Fig. 9.33).
Fig. 11.25 In this patient with bulbous tip, the
supratip is relatively full, but the infratip/ala appears
to be pinched
Several Techniques to Reduce the Tip Volume

512
a
c
d
e
b
f
g
h
Fig. 11.26 Role of derotation suture in the correction of bulbous tip. (a–d) Bulbous tip having cephalically oriented lateral crura. (e, f) Along with
interdomal suture and spanning suture, the lateral crura are displaced caudally using derotation suture. (g, h) Eight months postoperatively, supratip
volume decreased without formation of ala pinching
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Operative Techniques According to the Types of Bulbous Tip
The techniques for reducing nasal tip volume can be used in various combinations to address the different types of bulbous tip.
Type I: Cartilage Predominant
A single procedure that manipulates lower lateral cartilage is usually insufficient, and several techniques are usually
necessary.
The operation begins with open access to the lower lateral cartilage. Visual inspection of the cartilage should reveal the
etiology contributing to the bulbosity of the nose. If needed, columellar strut graft is performed before any of the suture
techniques. Then the operation proceeds in the order of interdomal suture, transdomal suture, cephalic trimming with/with-
out spanning suture, and derotation suture. Some recommend cephalic trimming of lateral crura prior to any suture tech-
nique, but the author finds that the cephalic trimming should be performed after columella strut graft, and interdomal and
transdomal sutures. This is to allow reevaluation of the nasal tip volume and cephalic rotation after these procedures, which
is useful in determining the amount of trimming required (Fig. 11.27). The lateral crural convexity control suture is per-
formed after transdomal suture. The transdomal suture can reduce the lateral crural convexity, and the lateral crural mattress
suture should be placed after evaluating the change in convexity.
The supratip fullness on profile view can be reduced by cephalic trimming. If this is not adequate, however, the lateral
crura can be sutured to the dorsal septal cartilage (Fig. 11.28).
Bulbous tip with thin skin and weak lower lateral cartilage should be managed using only tip suture techniques without
any cephalic trimming.
Operative Techniques According to the Types of Bulbous Tip

514
a
b
c
d
e
f
g
h
Fig. 11.27 Operative
procedures of cartilage-
predominant bulbous tip. (a)
Large lower lateral cartilages
having convex lateral crura.
(b) Columellar strut graft is
performed in case of low tip.
(c) Cephalic trimming of
lateral crura has been
performed. (d) Spanning
suture and convexity control
sutures on the lateral crura
have been performed. (e, f) A
patient having a cartilage
predominant type of bulbous
tip. (g, h) Two years
postoperatively after dorsal
augmentation (silicone
implant) and bulbous tip
correction
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a
b
c
d
e
f
Fig. 11.28 Correction of supratip bulging. (a, b) Bulbous tip with supratip bulging. (c) The lateral crura are very wide. (d) Cephalic trimming. (e,
f) During the placement of lateral crural spanning suture, the suture is passed through the dorsal septal cartilage, which helps to decrease supratip
bulging
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Type II: Soft-Tissue Predominant
Thick skin and soft-tissue envelope is a significant obstacle in bulbous tip correction. Structural changes using suture tech-
niques and cartilage grafts are often masked by the thick soft tissue, with minimal external change.
A nose with thick soft tissue usually experiences prolonged edema and requires more than a year to observe the final
outcome following an operation. Therefore, a nose with thick soft tissue is not only challenging to operate on but also
requires patience on the part of the patient. In addition, long-standing edema induces fibrosis, which can lead to post-rhino-
plasty fibrosis syndrome and increased nasal tip volume. Because of this, the operator should try to minimize intraoperative
edema and to decrease the postoperative edema as much as possible. To accomplish this, tissue trauma should be minimized
by accurate dissection and gentle handling of tissue, as well as maintaining excellent hemostasis. Preoperative steroid injec-
tion and intraoperative application of cold wet gauze to the nose are helpful. For significant amount of postoperative edema,
dexamethasone (IV or IM) can be administered at the first follow-up visit. Patients should be instructed to apply tape dressing
for 2 months during the time spent at home. Edema around the nasal tip can be decreased by triamcinolone injection into the
supratip area around 1–2 weeks after the operation.
A bulbous tip with thick skin and soft tissue cannot be addressed with trimming the lower lateral cartilage and various
suture techniques. The soft-tissue predominant type of bulbous tip requires soft-tissue debulking along with expansion of
skin envelope by rigid structural cartilage graft.
Soft-tissue debulking is an important procedure but is limited in how much it can address tip bulbosity. This is because
the thick skin is not as elastic and does not shrink wrap onto the cartilage framework as much. As such, adequate tip projec-
tion is necessary to fully expand the skin envelope, which will compensate for the lack of elasticity in the thick skin. The tip
can be projected using cartilage onlay/shield graft, columella strut graft, and sepal extension graft. The soft-tissue predomi-
nant type of tip bulbosity is often accompanied by weak medial crura, and the weak medial crura usually cannot withstand
the heavy soft tissue and cartilage graft. The compression and twisting of the medial crura can lead to loss of tip height, and
this should be prevented with a firm rigid structural graft like fixed-type columellar strut graft or septal extension graft
(Fig. 11.29).
To further minimize the edema in soft-tissue envelope, the debulking procedure should be performed as the last step. If
the soft-tissue debulking is performed first, the soft-tissue edema will continue to develop through the duration of operation.
It is important to minimize this edema, especially in the thick soft tissue, which can more easily lead to edema-induced
fibrosis.
One must recognize that tip reduction will produce less than optimal outcomes for a nasal tip that is high from having a
thick soft tissue with small lower lateral cartilages because a rigid structural graft cannot be used for the tip projection or tip
skin expansion.
Upon debulking, the supratip suture may be required to eliminate the dead space between skin and underlying cartilage
structure (Chap. 9). If the supratip volume still needs to be reduced after the debulking procedure, a suture can be placed in
the subcutaneous tissue across the midline (Fig. 11.30).
In a nose with preexisting pinching at the ala-lobule junction, bulbous tip correction can aggravate this pinching, which is
obviously undesirable. To avoid this problem, the following operative techniques are helpful:
1. The interdomal suture is placed in the cephalic margin of the dome, which prevents the caudal margins of domes from
coming too close to each other.
2. The spanning suture should not be tied with excessive tension. The derotation suture is helpful in pushing the lateral crura
in the caudal direction.
3. The alar rim graft is performed at the ala-lobule junction, as needed.
A tip reduction surgery for a nose with thick skin and soft-tissue envelope will sometimes have satisfactory appearance in
the early postoperative period, but can be followed by nasal tip bulbousness due to scar tissue formation several months later.
This can sometimes benefit from triamcinolone injection every 2–3  weeks (Fig.  11.31). However, this is not always
successful.
A wide alar base will appear relatively wider after the reduction of a bulbous tip. As such, it is sometimes necessary to
reduce the alar base to maintain an appropriate ratio between the tip and base (Fig. 11.32).
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a
e
c
d
h
Fig. 11.29 Bulbous tip of soft-tissue predominant
type. (a–d) This patient has a broad nasal bone and
bulbous tip. She underwent hump reduction,
osteotomy, radix augmentation with implant (1.5 mm
in height), and tip reduction via columellar strut graft
and soft-tissue debulking. (e–h) After 6 years, the
nasal tip remains defined and less bulbous despite the
thick skin
Operative Techniques According to the Types of Bulbous Tip

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a
b
c
d
e
f
g
h
Fig. 11.30 Supratip skin-to-skin suture. (a, b) This patient has a flat dorsum and round bulbous tip. (c) The skin and soft tissue are thick. (d, e)
The patient underwent tip plasty with soft-tissue debulking, transdomal suture, spanning suture of lateral crura, conchal cartilage onlay graft on
the tip, and dorsal augmentation using silicone (3 mm in height). (f) The supratip suture is placed in the subcutaneous tissue on either side of the
midline, after debulking procedure. (g) After 2 years, the nasal tip remains defined and slimmer than the preoperative state
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a
b
c
d
Fig. 11.31 Triamcinolone injection for the bulbous tip. (a) This patient with bulbous tip underwent debulking of tip soft tissue, columellar strut
graft, transdomal suture, and spanning suture of lateral crura. (b) Postoperative outcomes are satisfactory at 1 year. (c) However, the nasal tip
volume increased over time. (d) The patient underwent eight injections of intralesional triamcinolone, which was helpful in reducing the nasal tip
volume (4 years after the operation)
Operative Techniques According to the Types of Bulbous Tip

520
a
b
c
d
e
Fig. 11.32 Alar base reduction combined with bulbous tip correction. (a, b) Bulbous tip and wide ala base. (c) Design for the alar base reduction.
(e, f) Five months after tip plasty with debulking procedure, columellar strut graft, spanning suture of lateral crura, septal cartilage onlay graft, and
alar base reduction
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Type III: Mixed
The mixed type of tip bulbosity requires both cartilage manipulation and soft-tissue debulking. In this type, pinching or
notching of the tip-ala margin also requires alar rim graft to recreate a smooth margin (Fig. 11.33).
a
b
c
d
Fig. 11.33 Bulbous tip correction and alar base reduction of mixed type of bulbous tip. (a, b) This patient with bulbous tip and wide alar base
underwent dorsal augmentation with silicone implant (5 mm), tip plasty with soft-tissue debulking, septal extension graft, alar rim graft, and alar
base reduction. (c, d) At 5 years, the nose has retained the defined and non-bulbous tip from the operation. The tip-ala margin has retained a smooth
contour
Operative Techniques According to the Types of Bulbous Tip

522
Manipulation of Curled-In Cephalic Margin of Lateral Crura
The convexity of lateral crus creates a dome-shaped elliptical appearance on the cephalic border and descends medially to
join to the upper lateral cartilage in a considerable number of bulbous tips (Fig. 11.34). Hafezi referred to this curled-in
cephalic margin as inward limb, which results in 3-dimensional hemispheric form for the lateral crura. If the cephalic margin
is trimmed in the conventional manner without inclusion of the curled-in margin, the remaining portion of medial wall of
lateral crura becomes a source of elastic recoil force.
To avoid this, the scroll area should be released, and the curled-in margin is flattened with spanning suture or trimmed.
Placement of spanning suture without proper trimming can induce pinched tip or can result in widening of the supratip lobule
due to the elasticity of curled-in cephalic margin. The release of curled-in cephalic margin should incorporate not only the
scroll area but also the middle crura area. The flattened cephalic margin of lateral crura should be prevented from re-curling
by suturing the margins together (Fig. 11.35). This step is effective in decreasing the lateral crural convexity and improves
alar retraction. Lateral crural convexity can be further decreased using spanning suture, which will decrease the tip volume
and rotate the tip caudally. This prevents the formation of alar retraction or can even correct a preexisting problem. Derotation
suture should be employed as necessary (Fig. 11.36).
a
b
Fig. 11.34 Dome-shaped
elliptical appearance on the
cephalic border with curled-in
margin. (a) Normal
appearance of lateral crura.
(b) Lateral crura having
curled-in margin of cephalic
border
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a
b
c
d
e
f
g
h
i
j
k
Fig. 11.35 Spanning suture in lateral crura with curled-in cephalic margins. (a, b) A patient with bulbous tip. (c) Upon exploration, the cephalic
margins of lateral crura were found to be curled in. (d) Scroll area release on the left side. (e) The cephalic margin of left lateral crus is flattened.
(f) Both cephalic margins have been flattened. (g) The cephalic margins are sutured together. (h) Spanning suture is placed to decrease lateral crural
convexity. (i) The spanning suture has been placed. (j, k) At 2 weeks, the bulbous tip is corrected without any pinched deformity
Operative Techniques According to the Types of Bulbous Tip

524
a
b
c
e
f
d
g
h
i
j
Fig. 11.36 (a–c) This patient has a flat dorsum and bulbous tip. (a–f) The curled-in cephalic margin is flattened by release of scroll area and
placement of spanning suture. (g) Placement of derotation suture. The patient also underwent dorsal augmentation using silicone implant (5 mm)
and alar base reduction. (h–j) Photographs at 6 months show satisfactory correction of bulbous tip
11 Tip-Reduction Surgery: Bulbous Tip Correction and Long-Nose Correction

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Operative Techniques for the Boxy Tip
It is more practical to understand boxy tip to be a subset type of bulbous tip. The term boxy tip is generally used to describe
a tip which has a more squared appearance on the base view.
Rohrich classified boxy tip in the following manner (Fig. 11.37): type I, with a wider intercrural angle (greater than 30°);
type II, with a wider domal arch (greater than 4 mm); and type III, a combination of types I and II.
Type I boxy tip is corrected with interdomal suture. In type II boxy tip, the wide domal arch can be addressed with trans-
domal suture. Type III boxy tip will require both interdomal suture and transdomal suture. However, a boxy tip can contain
not only wide domal divergence angle and domal arch but also convex or concave lateral crura, and thick skin and soft tissue,
which also requires corrective procedures, such as cephalic trimming, convexity control suture, lateral crural strut graft, and
soft-tissue debulking (Fig. 11.38). If the lateral crura are to be trimmed in a boxy tip, the cephalic trimming should be
extended into the cephalic portion of middle crura to allow for the two tip-defining points to be closer. However, cephalic
trimming should be kept to a minimum if the lateral crura are weak and flat. The operative techniques are not different from
those used for bulbous tip, and there is no need to categorize boxy tip as separate from bulbous tip.
> 30°
> 30°
30°
≤4mm
>4mm
>4mm
Fig. 11.37 Types of boxy tip. (Left) Type I boxy tip with wide intercrural angle (greater than 30°) and normal domal arch. (Center) Type II boxy
tip with wide domal arch (greater than 4 mm) and normal angle of divergence. (Right) Type III boxy tip with a combination of wide intercrural
angle and domal arch
Operative Techniques for the Boxy Tip

526
a
b
c
d
e
f
g
Fig. 11.38 Correction of boxy tip. (a, b) A patient with boxy tip. (c) Lateral crura are large and convex. (d) Interdomal sutures are placed. (e–g)
Cephalic margin is trimmed, and spanning sutures are placed
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Long Nose
Nasal length is the distance from the nasion to the tip. The ideal length for a nose will differ across various authors. Byrd
suggested that a nose is of ideal length when it is two-thirds the height of midface (glabella to subnasale). A different stan-
dard is Goode’s 3:4:5 triangle. One side of the triangle is a vertical tangent from the nasion to the alar crease. The second
side is a perpendicular line from this tangent going through the tip-defining point, and the third side is a line from nasion to
the tip-defining point (Fig. 11.39). The ratio of these three sides should exist as 3:4:5.
The ideal length of nose also differs across ethnicities and individuals. The ideal length for a given nose will vary accord-
ing to the overall length and width of the face and by the shape of chins and lips. As such, the static standards cannot be
followed blindly, and each operation should be tailored to each patient.
Long nose is common in Caucasian but is not rare among Asian patients.
Among Asian surgeons, long-nose correction is considered to be easier than short-nose correction. In practice, however,
long-nose correction requires vast amount of rhinoplasty knowledge and experience. The surgeon should know fully about
the nasal tip dynamics and how to alter its position and shape by suture techniques and graft.
In general, long noses have the following characteristics:
1. A long drooping tip
2. An acute columella-labial angle
3. Smiling tip
4. Quite common dorsal hump
Fig. 11.39 Goode’s 3:4:5 triangle. The length of lines B:A:C should be at a 3:4:5 ratio
Long Nose

528
depressor septi nasi m.
levator labii superioris
alaeque nasi m.
Fig. 11.40 Activation of depressor septi nasi and
levator labii superioris alaeque nasi muscles
amplifies the drooping of the tip (e.g., during
smiling animation)
Dynamic forces of the depressor septi nasi muscle and levator labii superioris alaeque nasi muscle worsen the drooping
tip when smiling (Fig. 11.40).
To understand the causes of the long nose and how to correct it, the concept of the tripod of nasal tip should be in mind.
Anderson’s tripod concept is a long-lasting important concept that the nasal tip is supported by three limbs: the central limb
is two medial crura, and the lateral limbs are the lateral crura of the lower lateral cartilages (Fig. 9.7). The operator can adjust
the tip height by manipulating the length of central limb and lateral limbs. For example, shortening of the lateral crura can
shorten and cephalically rotate the tip. Shortening of the medial crura can reduce the tip height, and lengthening of medial
crura can project the tip. For long-nose correction, the manipulation of individual limbs to adjust the position of the nasal tip
is an important operative principle.
Several tip plasty techniques are required in a combination for long-nose correction. Of the various procedures, the fol-
lowing two should be taken into consideration: cephalic rotation of lower lateral cartilages and cephalic retraction of medial
crura. Additional procedures are applied based on the type of long nose.
Among Asian patients, long noses can be classified according to nasal tip height.
1. Type I: Long nose with drooping tip
2. Type II: Long nose with normal tip height
3. Type III: Long nose with overprojected tip
All long noses require cephalic rotation of dome to have the tip shortened, for which partial resection of cephalic margin
of lateral crura and/or shortening of lateral crura will be required. Difference in operative details of each type lies in control
of tip height: project, maintain, or de-project the tip.
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Type I: Correction of Long Nose with Drooping Tip
This is the most common type of long nose in Asians and is characterized by acute columellolabial angle, which becomes
worse when smiling. The following anatomic features are common:
1. Long lateral crura
2. Short medial crura
3. Caudally positioned caudal septum (overdeveloped cartilage septum)
4. Long membranous septum
5. Overactive depressor septi nasi muscle (Fig. 11.41)
Fig. 11.41 Anatomy of long nose. (a, b) This patient with long nose has a low drooping tip, long membranous septum, overdeveloped caudal
septal cartilage, and cephalically positioned long lateral crura. (c) Anatomic features of long nose include caudally positioned septum, long lateral
crura with high abutment, hyperactive depressor septi nasi muscle, and long membranous septum. (d, e) Long lateral crura
M.K.Suh M.D
M.K.Suh M.D
a
c
b
d
e
Type I: Correction of Long Nose with Drooping Tip

530
Correction of this type of long nose will require simultaneous cephalic rotation of the dome. The first step to long-nose
correction includes cephalic trimming of lateral crura, caudal septal shortening, and depressor septi nasi muscle weakening,
which may be adequate for mild forms of long nose (Fig. 11.42). Severe cases may additionally require lateral crural shorten-
ing. Operative techniques are described below.
a
b
c
d
e
f
Fig. 11.42 Long-nose correction. (a–c) This patient
with long nose underwent hump reduction,
osteotomy, tip plasty with soft-tissue debulking,
cephalic trimming, and columella strut graft. (d–f)
At 2 years, the nose has retained the new appropriate
length without nasal tip drooping. The remainder of
face appears swollen due to a recent fat injection of
the whole face
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Partial Resection of Cephalic Margin of Lateral Crura (Cephalic Trim)
For a wide lateral crura, the dome will be prevented from adequate cephalic rotation because the cephalic margin of lateral
crura will contact the upper lateral cartilage. This will require partial resection of cephalic margin of lateral crura. The dis-
section in the scroll area and resection of cephalic edge of lateral crura induce scar formation and contracture, which is also
actually helpful for reducing the length of nose.
To determine the area to be resected, the nostril apex is rotated in the cephalic direction. This will bring the portions of
lateral crura in touch with the upper lateral cartilage, which is the area that is marked to be trimmed (Fig. 11.43). The carti-
lage is scored using a No. 15 blade, and Metzenbaum scissors are used to cut through the full thickness of resection.
If the resection is too aggressive, the lateral crus might buckle and result in pinched tip or external valve collapse. To
prevent this, the lateral crus should be kept at a minimal width of 6 mm.
a
b
c
Fig. 11.43 Cephalic trimming. (a, b) Cephalic rotation of the lower lateral cartilage reveals the cephalic margin that comes into contact with
upper lateral cartilages and prevents further rotation. This area is marked for trimming. (c) Cephalic margin of lateral crura has been resected along
the design
Type I: Correction of Long Nose with Drooping Tip

532
Shortening of Caudal Septal Cartilage
With a long nose, the septum is usually overdeveloped with the caudal margin more caudally projected than usual.
Overdeveloped caudal septum tends to push the lower lateral cartilage caudally and prevent cephalic rotation of lower lateral
cartilage.
There are three types of caudal septal shortening: an even width of resection, a wider resection of the anterior caudal
septum, and a wider resection of the posterior caudal septum (Fig. 11.44).
a
b
c
Fig. 11.44 Types of caudal septal shortening. The caudal septum can be shortened in three patterns. (a) Strip resection of even width. (b) Wedge
resection with larger anterior section. (c) Wedge resection with larger posterior section
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Shortening of Lateral Crura
Cutting and overlapping the lateral crura (lateral crural overlay) can rotate the tip cephalically (Fig. 11.45).
The cartilage is incised at the junction between the lateral third and medial two-thirds because the alar skin is thicker at
this area and can easily hide the overlapped edges of the lateral crus (Fig. 11.46). The vestibular skin is freed from the under-
surface of lateral crus at the cartilage incision. After cutting the cartilage cut, the anterior segment is then advanced and
placed over the posterior segment in order to shorten the overall length of lateral crus. Lateral crus is then sutured in place
using 5-0 PDS sutures in the horizontal mattress fashion. Two sutures are usually required. This lateral crural shortening will
rotate the domes cephalically.
Fig. 11.45 Lateral crural
shortening
Type I: Correction of Long Nose with Drooping Tip

534
a
b
c
d
e
f
Fig. 11.46 Lateral crural shortening. (a, b) A patient with long nasal tip. (c) Vestibular skin is freed from the undersurface of left lateral crus at
the cartilage incision site. (d) The left lateral crus has been shortened by overlapping. (e) Photograph after shortening both of the lateral crura. (f)
The medial crura are also shortened to reduce the tip projection
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Shortening of Membranous Septum
Strip resection is usually not performed for long membranous septum, except for the extremely long nose (Fig. 11.47).
The membranous septum can be more accurately resected if performed after the tip plasty and closure of the columella
wound. Upon closing of the columella incision, the redundant septal mucosa is measured (Fig. 11.48). If the septal mucosa
is not excessively redundant, the mucosa can be redraped posteriorly and fixed with quilting sutures. However, excessive
redundancy will require strip resection of the membranous septum. The resection, however, should not include any vestibular
skin. To avoid incorporation of vestibular skin, the resection should be performed only on the deep septal mucosa. This is
important for the prevention of weeping nose (wet nasal tip).
Fig. 11.47 Excision of
redundant membranous
septum
Type I: Correction of Long Nose with Drooping Tip

536
a
b
c
Fig. 11.48 Membranous septum shortening. (a) Redundant mucosa is marked. (b) Strip resection has been performed. (c) Primary repair using
absorbable suture has been performed
11 Tip-Reduction Surgery: Bulbous Tip Correction and Long-Nose Correction