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Part X  Rhinoplasty

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1974
Part X  Rhinoplasty

Tip Grafting
for Nasal Contouring

WILLIAM D. LOSQUADRO, DEAN M. TORIUMI
CHAPTER 56

1976
Part X  Rhinoplasty
N
asal tip contouring is perhaps the most difficult rhinoplasty skill to master. Seem-
ingly isolated maneuvers can simultaneously affect multiple parameters on both
the frontal and lateral views. The degree of difficulty is compounded by the relentless
contraction of the skin–soft tissue envelope and the resultant potential for late com-
plications. Early techniques in tip rhinoplasty were primarily reductive. The lower lat-
eral cartilages were trimmed, scored, or divided to create smaller, albeit weakened,
noses. Current techniques in tip rhinoplasty emphasize conservative lower lateral car-
tilage excision, suture reshaping, cartilage repositioning, and cartilage grafting.
One of the earliest reports of nasal tip cartilage grafting was by Peer in 1945. Through
his histologic studies of grafts, he refuted the prevailing belief that septal cartilage
was resorbed after transplantation, and he specifically described lengthening a re-
tracted columella with septal cartilage. Hage in 1964 detailed the correction of dy-
namic alar collapse using auricular cartilage through, presciently, an open transcol-
umellar approach. Modern tip grafting techniques were first described by Sheen after
he keenly observed that polly-beak deformities resulted from an overreduced nasal
structure that was unable to accommodate a large skin–soft tissue envelope; his so-
lution was to augment the tip with cartilage grafts placed through an endonasal ap-
proach. These techniques were later popularized through the external approach by
Johnson and Toriumi.
Tip grafting is often performed in conjunction with conservative reduction of the
lower lateral cartilages and suture contouring. Grafting significantly increases sur-
gical complexity and the potential for postoperative complications and thus should
not be used indiscriminately. A graded surgical algorithm may effect modest tip
changes, such as narrowing and slight increases in projection, with conservative car-
tilage trimming and suture reshaping alone. Tip grafting can be used for greater
changes, and grafting alone can lengthen or enhance the projection of a short nose,
straighten a severely crooked tip, and reposition retracted alae. When used properly,
cartilage grafting is a powerful tool for nasal tip contouring.
Indications and Contraindications
Indications for tip grafting in primary rhinoplasty include the increase of tip pro-
jection, prevention of postoperative loss of tip projection, nasal lengthening, straight-
ening of tip deviations, and correction of cephalically positioned lower lateral car-
tilages. Mild increases in tip projection may be successfully achieved with suture

contouring (such as dome-binding sutures, lateral crural steal, and so on); increases
greater that 1 or 2 mm frequently require tip grafts. The degree of augmentation and
refinement, the anatomy of the existing nasal framework, and the skin thickness will
further dictate the type of tip grafting employed.
Patients with weak lower lateral cartilages, short medial crura, and a deficient cau-
dal septum are at risk for postoperative loss of tip projection. Extended columellar
struts, caudal septal extension grafts, and caudal septal replacement grafts can each
be used to stabilize the tip. These same grafts can also be used to lengthen short noses
and correct persistent caudal septal deviations. Costal cartilage may be needed when
lengthening a short nose to withstand the force applied by the stretched, contract-
ing skin–soft tissue envelope.
Cephalically positioned lower lateral cartilages are another indication for grafting
techniques. Aesthetically, cephalically positioned cartilages contribute to tip bul-
bosity, the parentheses tip deformity, and alar retraction. Functionally, they facilitate
lateral wall collapse and decreased nasal valve patency. After dissection from both
the nasal skin and vestibular mucosa, only very strong, flat lateral crura permit suture
repositioning alone. Most cartilages lack adequate strength to support the lateral
wall and will require placement of lateral crural strut grafts to prevent postoperative
alar collapse and retraction.
No absolute contraindications to tip grafting exist, although grafting is sometimes
unnecessary. Primary rhinoplasty patients with adequate projection, proper rotation,
and minimal tip bulbosity may successfully be treated with conservative trimming
of the cephalic lateral crura and suture contouring. Overly long noses may be better
addressed by setting the medial crura back on the caudal septum in a tongue-in-
groove fashion. Desired aesthetic changes must be balanced against the increased
risk of complications posed by grafting.
Pertinent Anatomy
The nasal tip proper is one of the nine aesthetic subunits of the nose. Within the con-
text of nasal tip contouring, the term tip more accurately reflects the lower third of
the nose, specifically the tip, ala, soft tissue triangle, and columellar subunits. The
transition points between these subunits contribute substantially to tip highlights
and shadows.
1977
Chapter 56  Tip Grafting for Nasal Contouring

The external appearance of the nasal tip is dictated primarily by the anatomy of the
lower lateral cartilages and the caudal septum. Projection and rotation are the pri-
mary metrics analyzed when viewing the tip profile. Other important parameters are
the alar-columellar relationship, the columellar-lobular angle or double break, and
the supratip break. Ideal tip projection has been quantified by assorted mathemati-
cal equations and anatomic relationships. Yet adequate projection is often best de-
termined by simple observation of each patient’s anatomy—particularly dorsal height,
nasal length, and chin projection. Ideal rotation in males is approximately 90 to 100
degrees and 100 to 120 degrees in females. The perceived rotation is affected by the po-
sition and contour of the nasolabial angle. A gentle curve is desirable; a sharp tran-
sition makes the angle appear more acute and unnatural.
The alar-columellar relationship can significantly affect the perceived harmony of
the tip profile. Alar retraction creates a snarled appearance that mars an appropri-
ately projected and rotated tip. Approximately 2 to 4 mm of columellar show is gen-
erally considered aesthetic. Greater show may result from alar retraction or a hang-
ing columella; less show may be caused by hanging alae or retracted columella. The
alar rim contour should approximate a gentle curve. Whereas alar retraction is char-
acterized by a more uniform arc of elevation, alar notching describes an acute, fo-
cal retraction that interrupts the ideal contour.
The double break and supratip break are other important components of an aes-
thetic tip. The double break is formed by the natural divergence of the intermediate
crura. The cephalic break point corresponds to the tip-defining points on the frontal
view and represents the transition from the domes to the lateral crura. The caudal
break point represents the initial divergence of the medial crura into the domes and
can be difficult to appreciate on frontal view. The area between these two points
forms the infratip lobule. The transition from the tip-defining point to the dorsum
forms the supratip break. The dome height over the anterior septal angle and the
skin thickness draping over it creates the break. A 1 or 2 mm supratip break is es-
pecially desirable in females, whereas males may tolerate less or no supratip break.
1978
Part X  Rhinoplasty

The tip profile is primarily a two-dimensional relief against a uniform background;
subtle shadows and highlights compose the frontal view. When using a single mid-
line light source, the tip highlight predominates. Ideally, it is a horizontally oriented
ellipse formed by the divergence of the intermediate crura and the paired domes. The
paired tip-defining points are more prominent when two light sources are used. The
average width between tip-defining points is reportedly 8 mm, although this distance
should be individualized based on overall facial width, base width, and cultural norms.
1979
Chapter 56  Tip Grafting for Nasal Contouring
Cephalic to the tip highlight there should be a subtle shadow that represents the
supratip break. Greater supratip breaks cast darker shadows. The tip highlight should
gradually transition to the alae without a deep shadow. A concave transition between
the tip and alae isolates the tip with shadows and creates the so-called parentheses
deformity; this may be caused by bulbous or cephalically positioned lower lateral
cartilages. An unnatural, single midline tip highlight may be seen in patients whose
domes have been pinched together. On the basal view, a pinched tip will exhibit
marked alar concavity.

Overall tip shape and size are crucial to tip aesthetics. A bulbous tip interrupts a
smooth brow-tip aesthetic line. Bulbosity may result from both enlarged and cephal-
ically positioned lateral crura. The ideal lateral crura position can range from 35 to
45 degrees off the midline; more simply, they should point towards the lateral can-
thus as opposed to the medial canthus.
1980
Part X  Rhinoplasty
Even after performing a cephalic trim, cephalically positioned lateral crura can leave
residual tip fullness that tends to obliterate the subtle sidewall inflection at the con-
fluence of the sidewall, tip, and ala.
The relationship of the infratip lobule to the ala is another important component of
the frontal view, and the ideal contour is a gently curving V, or “gull in flight.” Promi-
nence of the infratip lobule, tip rotation, and alar position all contribute to this con-
tour. It is exaggerated by a prominent, “hanging” infratip lobule and reduced by a
hidden, flattened infratip lobule. An underrotated tip also creates an unsightly shadow
at the nasolabial angle.

Preoperative Assessment
The surgeon begins the preoperative assessment by eliciting the patient’s functional
and aesthetic concerns. Understanding the patient’s surgical goals is crucial to a suc-
cessful surgeon-patient relationship. Some patients request correction of obvious de-
formities, such as a dorsal hump or bulbous tip, whereas others provide annotated
photographs detailing a multitude of changes. Some want to address a single defor-
mity, such as male patient who wants a less bulbous tip but is unconcerned with a
slight dorsal convexity. Ethnic patients may ask for subtle changes that maintain
their ethnicity, or they may desire a more refined nose.
Identifying patients with unachievable aims or goals beyond the surgeon’s aesthetic
range is paramount. Patients with goals that are unattainable rarely have body dys-
morphic disorder; they more commonly request changes that are not anatomically
feasible. For instance, a finite reduction is achievable in a patient with thick skin, a
large dorsal hump, and overprojected nasal tip without developing a polly-beak de-
formity; however, a small, petite nose is unrealistic. Other patients may desire changes
that are displeasing to the surgeon’s aesthetic sensibilities, such as a scooped dorsum
or arched alae. These goals may be surgically attainable, and the patient may indeed
be happy postoperatively. However, a dissatisfied patient is both unhappy and aes-
thetically worse. All of these patients are poor candidates, and the surgeon should
politely decline to operate on them.
The patient’s past surgical history should be obtained. The timing and number of
prior septoplasties, rhinoplasties, and cartilage-harvesting procedures are recorded.
Proper preoperative counseling requires that the surgeon be aware of available graft-
ing material and whether alloplastic implants or injectable fillers have been used pre-
viously. Operative reports may detail implants unknown to the patient, although the
accuracy may be unreliable. Many surgical decisions will thus require direct intra-
operative inspection.
The patient’s past medical history should also be elicited, particularly rhinologic
complaints such as nasal obstruction, congestion, epistaxis, and rhinorrhea. Patients
with allergic rhinitis should be counseled that medical intervention will be necessary
to alleviate their symptoms rather than surgery. A history of bleeding diatheses,
asthma, chronic obstructive pulmonary disease, diabetes, and immune disorders is
also important, because these will have an impact on intraoperative management
and postoperative healing. The patient’s medication usage should be recorded, par-
ticularly nasal decongestant sprays.
For most primary and secondary rhinoplasties, smoking is not a contraindication,
although the increased risk of infection, tissue necrosis, and prolonged healing should
be discussed. Complex revisions of skin–soft tissue envelopes damaged by infection,
1981
Chapter 56  Tip Grafting for Nasal Contouring

1982
Part X  Rhinoplasty
fillers, or alloplastic implants are at a much higher risk for complications and should
be delayed until the patient stops smoking completely. Ideally, all patients should
quit smoking 6 to 8 weeks before surgery.
The physical examination begins with visual inspection of the frontal, lateral, and
basal views. The external manifestations of various anatomic irregularities were dis-
cussed in the previous section. Palpation helps to assess the strength of the lower lat-
eral cartilages and caudal septum. In revision patients, palpation will aid in differ-
entiating soft tissue from structural abnormalities and assessing the elasticity of
damaged skin.
Anterior rhinoscopy with a nasal speculum can identify caudal septal deviations, in-
ternal nasal valve collapse, and inferior turbinate hypertrophy. It is prudent to per-
form nasal endoscopy in any patient who complains of nasal obstruction. A rigid
zero-degree scope can be introduced under direct visualization or with a camera and
monitor. The presence of a septal perforation, synechiae, polyps, concha bullosa, or
mucopurulent drainage necessitates additional rhinologic workup.
Photography is an integral component of the rhinoplasty consultation. Standard
views include frontal, lateral, oblique, and basal views. Photographs are taken with
two umbrella lights each positioned behind the camera at a 45-degree angle to the
patient. A frontal photograph with a single midline umbrella light positioned behind
the camera improves the contrast between light and shadow and provides better vi-
sualization of nasal contours. Additional views include closeups of all standard views,
an inspiratory basal view to assess external valve collapse, and smile views. Patients
with vertically oriented smiles (that is, the corner of the mouth goes up instead of
moving laterally) who will be undergoing placement of an extended spreader graft
may develop a transverse upper lip crease when they smile.

Imaging software is an excellent tool for demonstrating operative goals. Modified
photographs can help patients communicate their goals more effectively and provide
the surgeon with a visual surgical template. It is imperative, however, that realistic
imaging of an obtainable outcome be shown. In the senior author’s practice (D.M.T.),
preoperative digital imaging is performed, and copies of these simulated results are
provided for the patient to take home. He or she is encouraged to review the photo-
graphs and schedule another visit if modifications or clarification is necessary. How-
ever, producing virtual results with the patient present should only be performed af-
ter considerable experience, because it requires deft use of the software and
knowledge of what is surgically achievable. Likewise, photo imaging should not be
performed by ancillary staff, who may not have knowledge of realistically achiev-
able results. If used properly, photographic imaging can be a powerful tool in the
surgical practice.
1983
Chapter 56  Tip Grafting for Nasal Contouring

1984
Part X  Rhinoplasty
Preoperative Planning
Patients are positioned supine on the operating room table with the head supported
by foam. Operative frontal, lateral, and basal photographs are taken after intubation.
Convexities and concavities are marked before local anesthetic is injected so that de-
formities can continue to be identified despite the inevitable edema from the injec-
tion and operative manipulation. Local injection of the tip, nasal spine, dorsum, side-
walls, septum, and vestibular mucosa incision lines is then performed with 1%
lidocaine with 1:100,000 epinephrine. Vigorous injection of the septum facilitates
hydrodissection of the mucoperichondrial flaps.
An inverted-V incision is outlined midway between the superior extent of the col-
umella and the medial crural footplates. A straight-line columellar incision should
be avoided to prevent scar contracture and columellar notching. In patients whose
noses will be deprojected, the incision should be outlined slightly higher to accom-
modate its eventual inferior movement.
Operative Technique
Incision and Dissection
The various benefits and drawbacks of endonasal and open rhinoplasty are a fre-
quent topic of debate. Many advanced tip-grafting techniques require suture fixation
and are best accomplished by the open approach. Flap elevation and closure war-
rants close attention and meticulous technique.

The anterior columellar portion of the incision is performed with a No. 11 blade.
For precise incision placement, the blade is moved in a sawing motion. The lateral
limbs are incised very superficially to avoid transecting the medial crura. The vestibu-
lar portion of the columellar incision is more easily completed with a No. 15 blade.
Grasping and turning the tip with the left hand exposes the columella. The incision
is extended up toward the vestibular apex, but not blindly into it.
The marginal incisions are performed next. Using a wide double-pronged skin hook,
the lateral crura are exposed. Gentle palpation with the scalpel can help identify the
caudal edge of the lateral crura. The incision is then performed from lateral to me-
dial but is stopped short of the vestibular mucosa beneath the dome. At this point
the marginal incision has not yet been connected to the columellar incision.
Elevation of the skin–soft tissue envelope over the medial crura begins using Con-
verse scissors, exercising care to avoid transecting the medial crura. As the dissection
approaches the intermediate crura, it is important to dissect within the supraperi-
chondrial plane. This plane is often identified by its wispy connective tissue and lack
of bleeding.
Once the skin flap has been elevated over the intermediate crura, the marginal inci-
sions can be completed. A wide double prong skin hook is used to expose the vestibu-
lar apex and the incision is completed with the Converse scissors. Direct visualiza-
tion permits precise incision placement. Dissection over the domes is facilitated by
simultaneous caudal lower lateral cartilage retraction and cephalad skin flap re-
traction. Careful dissection over the lateral crura ensures that the caudal margin is
not inadvertently transected.
Dissection continues in the supraperichondrial plane onto the anterior septal angle
and over the upper lateral cartilages; a Converse retractor facilitates visualization be-
neath the flap. Once the rhinion is encountered, the nasal bone periosteum is incised
with the sharp edge of a Joseph periosteal elevator. The periosteum is raised off the
nasal bones with the Joseph elevator.
1985
Chapter 56  Tip Grafting for Nasal Contouring

Septal cartilage is the first choice for grafting material because of its location, strength,
and flexibility. There are multiple approaches for septal cartilage harvest; the choice
depends on the work to be undertaken. A Killian incision may be used for rhino-
plasties in which repositioning of the tip, columella, or nasal base is not necessary.
If more extensive work is needed and the nose requires shortening, lengthening, ro-
tation, or deprojection, dissection between the medial crura to expose the caudal
septum may be beneficial. The interdomal space is divided, and dissection is carried
onto the anterior and posterior septal angles; extended dissection requires division
of the upper lateral cartilages from the dorsal septum. Entering the interdomal space
and separating the upper lateral cartilages allow maximal septal exposure and pre-
cise control of nasal base and tip position.
Mucoperichondrial flap dissection in the subperichondrial plane ensures a relatively
bloodless dissection. The proper plane is entered by scoring the septum with a No.
15 blade and then dissecting the flap with a Freer elevator. Dissection is carried back
to the bony-cartilaginous junction bilaterally. If the bony septum is deviated, flap ele -
vation continues posteriorly and the deviated portion is resected.
In harvesting septal cartilage, it is important to leave a 1 to 1.5 cm L-strut intact to
provide nasal support. Additional cartilage may be left beneath the keystone area of
the upper lateral cartilages to ensure dorsal support, particularly in patients with
short nasal bones. Careful dissection of posterior septal cartilage between the per-
pendicular plate of the ethmoid bone and the vomer will ensure maximal length to
the septal graft.
1986
Part X  Rhinoplasty
Septal Cartilage Harvest

Costal Cartilage Harvest
Details of costal cartilage harvesting and carving are presented in Chapter 59. It is
worth reiterating, however, that postoperative warping can be avoided by early and
sequential intraoperative graft carving. Somewhat counterintuitively, bent pieces are
often preferred to straight pieces, because the warping has commenced in the oper-
ating room and can be used to the surgeon’s advantage.
Nasal Base Stabilization
The nasal base is the foundation of the lower third of the nose and maintains tip po-
sition; anatomically, it is composed of the caudal septum and its soft tissue attach-
ments to the lower lateral cartilages. Stabilization of the nasal base is a prerequisite
for tip contouring. A weak nasal base requires overcorrection of projection and ro-
tation in anticipation of postoperative loss of projection. Consistent results require
precise intraoperative tip positioning on a stable base that is resistant to postopera-
tive skin–soft tissue envelope contraction.
A graduated approach to nasal base stabilization is prudent. Patients at risk for post-
operative loss of tip projection are those with weak lower lateral cartilages, a short
caudal septum, and short medial crura. The nasal base of patients with long, strong
medial crura can be stabilized with a columellar strut placed into a pocket dissected
between the medial crura. In patients requiring rotation or shortening, the medial
crura can be fixed to the midline caudal septum in a tongue-in-groove fashion.
1987
Chapter 56  Tip Grafting for Nasal Contouring
Patients requiring nasal lengthening or significant projection need strong support to
resist the skin–soft tissue envelope contractile forces. Lengthening is accomplished
with a caudal septal extension or replacement graft. Caudal septal extension grafts
can be placed end-to-end or overlapped, depending on the position of the caudal
septum. End-to-end grafts are stabilized with two sets of bilateral splinting grafts su-
tured with 5-0 PDS sutures. A slightly deviated caudal septum can be lengthened

1988
Part X  Rhinoplasty
Patients with a severe caudal septal deviation, deficient septum, or nasal cant may
benefit from a caudal septal replacement graft. In these cases, the caudal septum is
removed while a strong dorsal strut is left intact. Spreader grafts are inserted up to
the osteocartilaginous junction and extend beyond the end of the dorsal strut to sta-
bilize the caudal septal replacement graft. Dissection is carried down through the in-
terdomal space onto the nasal spine. After removal of the caudal septum, a straight
5 mm osteotome is used to make a notch in the nasal spine and set the midline of
the nasal base. Creation of a wedge-shaped notch acts as a graft fixation point and al-
lows precise and stable graft placement. The nasal spine may not be centered, such
as in deviated noses, and the notch may need to be set off of the nasal spine midline.
Before graft placement, two 4-0 PDS sutures are placed through the periosteum on
each side of the notch and left untied. If no tissue is available for suture placement,
a hole can be drilled through the nasal spine with a 16-gauge needle. Once the graft
is placed within the notch, the suture is passed back through the graft and tied.
Cartilage from the septum or rib is preferred for caudal septal replacement and ex-
tension grafts. Equivalent strength with auricular cartilage requires thicker grafts,
which can excessively widen the columella and block the airway. Costal cartilage is
strong enough to resist postoperative contractile forces in complex revisions where
scarred skin–soft tissue envelopes need lengthening and projection.
with an overlapping graft if the caudal margin of the graft is midline. The graft is se-
cured with horizontal mattress 5-0 PDS sutures. The overlapping cephalic edge of
the graft is beveled so the airway is not obstructed. End-to-end grafts are preferred
because they are less likely to cause deviation or airway obstruction.

1989
Chapter 56  Tip Grafting for Nasal Contouring
Lower lateral
cartilage
Interdomal
suture
Caudal septal
extension graft
Dome-binding
sutures
Tip Projection
Multiple techniques are available to increase tip projection. Minor increases in pro-
jection can be obtained with suture contouring alone. Dome-binding sutures can
be placed within the native domes or used to recruit lateral crura. The lower lateral
cartilages may also be advanced on a stable nasal base and fixed with transeptal
4-0 plain gut sutures. This technique will blunt the nasolabial angle, which may or
may not be a beneficial change. When these techniques prove insufficient, tip grafting
is required.
Mild increases (1 or 2 mm) in tip projection can be attained with tip onlay grafts.
These grafts are trimmed into a rectangular or elliptical shape to simulate the ideal tip
highlight and are sutured directly over the domes in a horizontal orientation. Any
type of cartilage may be used, although the cephalic trim of the lateral crura is ideal
for mild increases, because its soft edge blends easily with the native cartilages. For
greater increases in projection, thicker or multiple pieces of septal cartilage or soft
tissue may be necessary.

Larger increases in projection can be obtained with shield tip grafts. The graft shape
simulates the divergent intermediate crura and paired tip-defining points. Beveled
edges facilitate graft camouflage. The shield tip graft is sutured to the intermediate
crura and projects above the domes. The additional projection carries an increased
risk of graft visibility, particularly in patients with thin skin. However, the graft’s
leading edge stretches and thus refines the thick-skinned tip. Slight graft flexion, of-
ten caused by compression from the skin–soft tissue envelope, helps preserve the dou-
ble break. Support grafts (cap or buttress grafts) can be placed behind the shield graft
to resist excessive cephalic pressure.
1990
Part X  Rhinoplasty
Lower lateral
cartilage
Shield tip graft
Lateral
crural graft
Lateral
crural graft
Upper lateral
cartilage
Smoothing the transition from the shield graft to the lateral crura is crucial to pre-
serving a smooth tip–alar lobule junction and preventing shadows that isolate the
tip. Lateral crural grafts extend from the existing lower lateral cartilages to the pos-
terosuperior aspect of the shield graft and are secured with 6-0 PDS suture. They are
used primarily when the shield graft projects more than 3 mm above the existing
dome structures.

Skin thickness dictates the amount of camouflage necessary to prevent graft visibility.
Thick skin may require none, whereas thin skin requires several layers. Perichon-
drium is an excellent tissue for this purpose, especially thick, fibrous, costal peri-
chondrium. Gently crushed septal cartilage, auricular cartilage, or scar tissue is also
useful. These materials can be sutured over or around the leading edge of the shield
graft to prevent graft visibility.
Greater tip projection increases the distance between the domes and anterior septal
angle, thus increasing the supratip break. The visible supratip break reflects the skin
thickness draped over this height. In a projected tip on a stable base, 4 to 6 mm be-
tween the dome and anterior septal angle is appropriate for thin skin, whereas 8 to
12 mm may be needed for thick skin. Too large a supratip break may appear as a
scooped dorsum or mild saddle deformity. Supratip grafts can be sutured to the car-
tilaginous dorsum to ease the transition and improve the overall nasal profile.
Tip Rotation
Smaller degrees of tip rotation can be achieved simply by placing a columellar strut
and dome-binding sutures. This maneuver will increase tip projection and often pro-
duce moderate tip rotation; the amount of rotation depends on the prominence of
the caudal septum and its contribution to the ptotic tip. Trimming the caudal sep-
tum can result in tip rotation but is unreliable. Tip rotation can also be achieved by
shortening the lateral crura or by performing a lateral crural division and overlay
(the lateral crural steal technique described by Kridel and colleagues). Alternatively,
tip rotation can be controlled by setting the medial crura into position about the na-
tive or extended caudal septum.
1991
Chapter 56  Tip Grafting for Nasal Contouring

When excessive nasal length is caused by a redundant caudal septum, tip rotation
can be achieved by dissecting between the medial crura and suturing them to the ex-
isting caudal septum. This maneuver will result in shortening of the nose and rotation
of the nasal tip. The caudal septum is not trimmed but rather used as a fixation point
to create tip rotation. The degree of rotation can be increased by moving the domes
more cephalad than the lower segment of the medial crura. Once rotation is achieved
using this method, there may be redundancy of the lateral crura that may require
dissection of the lateral crura and repositioning. Maneuvers used to rotate and pro -
ject the tip may also flatten the infratip lobule. Lack of a double break on tip profile
will give the nose an unnatural, beaklike appearance. Infratip grafts can be sutured
to the medial crura to recreate the ideal contour.
1992
Part X  Rhinoplasty

Lateral crural strut grafts can be used effectively to reposition the lower lateral carti-
lages, refine the tip, and enlarge the nasal airway. Lateral crural strut grafts are su-
tured to the undersurface of the lateral crura to position the cartilages in a flatter,
stiffer orientation; they can then be effectively narrowed without bulging laterally. The
lateral crura are freed from the underlying vestibular mucosa; local anesthetic is in-
jected to facilitate the dissection. Septal cartilage is strong and flexible but not always
available. The strength of costal cartilage permits reduced graft thickness at the ex-
pense of increased tip rigidity. Auricular cartilage is often too thick for this applica-
tion. Grafts are generally 1 to 1.5 mm thick, 5 mm wide, and 25 to 30 mm long, al-
though the exact length depends on the degree of airway collapse and alar retraction.
1993
Chapter 56  Tip Grafting for Nasal Contouring
Tip Refinement
Tip refinement refers to the overall size, shape, and definition of the tip. The shape
and width of the domes and the size and position of the lateral crura determine
whether the tip is aesthetically pleasing. Large lateral crura should be trimmed cephal-
ically; leaving behind 8 to 10 mm of width is advisable, although the precise amount
resected depends on the shape and intrinsic strength of the cartilages. Dome-binding
sutures refine and narrow the tip. Residual tip bulbosity after trimming and suture
contouring is often caused by cephalically oriented lateral crura or residual defor-
mity of the lateral crura. Dome-binding sutures may also deform the lateral crura
by leaving an unnatural bulge lateral to the dome sutures or near the alar groove.

1994
Part X  Rhinoplasty
Original position
New position
Lateral crural strut graft
Cephalically oriented lateral crura can be repositioned once lateral crural strut grafts
are in place. A pocket is dissected caudally in the alar skin–soft tissue envelope with
Converse scissors. The pocket is typically placed just caudal to the alar groove. Place-
ment of the strut graft within this pocket will decrease the cephalic tip bulbosity and
The position of the domes can be altered with lateral crural strut grafts. This tech-
nique is applied primarily in an overprojected nose to decrease tip projection and
counterrotate the tip. Precise positioning of the medial graft edge creates a new tip-
defining point along the intermediate crura or medial to the original dome. Posi-
tioning the lateral crural strut graft medially moves the old dome lateral to the new
one and deprojects and counterrotates the tip. The new dome’s position is fixed by
placing transdomal 5-0 PDS sutures through the medial margin of the graft and na-
tive lower lateral cartilages; the suture is tied between the new domes to hide the su-
ture knot. A limited increase in tip projection can be obtained by moving the medial
margin of the lateral crural strut graft lateral to the existing dome. Tip projection is
more commonly increased by advancing the nasal base on a stable strut or exten-
sion graft or with a shield tip graft.
Lower lateral cartilage
Old dome
Lower lateral cartilage
New dome
Old dome
Lateral crural
strut graft
Caudal septal
extension graft
Upper lateral
cartilage

1995
Chapter 56  Tip Grafting for Nasal Contouring
Dome
replacement
graft
Lateral crural
strut graft
Dome replacement graft
Lateral crural
strut graft
Caudal septal
extension graft
Upper lateral
cartilage
Dome replacement grafts are first sutured to the existing medial crura; in some cases,
they can be sutured directly to the caudal septal extension or caudal septal replace-
ment graft. Soft, flexible tissue is ideal for the dome grafts. Thin septal cartilage, scar
tissue, and rib perichondrium are good options, although a remnant lateral crural
graft with attached scar tissue is ideal because of its flexibility and strength. Lateral
crural strut grafts can be sutured to the lateral aspect of the dome replacement grafts
to provide lateral wall support. They should measure 25 to 32 mm in length de-
pending on the size of the nose and the amount of lateral wall support needed. Ideal
lateral crural strut grafts are slightly curved, and the concave side is oriented toward
the nasal airway to ensure airway patency. Once the lateral crural strut grafts are in
place, domes can be created by placing 5-0 PDS dome sutures bilaterally.
improve retracted alae. Precise placement of the pockets is critical to producing sym-
metrical alar margins and nostrils. If the nostril shapes or alar margins are asym-
metrical preoperatively, the two pocket locations must be altered to compensate for
these differences.
In complex revision cases, the native domes and lateral crura may be severely de-
formed by scar tissue, multiple grafts, and overresection. If no useable intermediate
or lateral crura exist, new ones can be shaped from dome replacement grafts.

1996
Part X  Rhinoplasty
Nostril Reshaping
In addition to base reduction techniques, nostrils can be reshaped with grafting. Lat-
eral crural repositioning is perhaps the most powerful method of pulling down re-
tracted alae and recreating nostril shape on frontal view. Lateral crural overresec-
tion in traditional reductive rhinoplasties often led to alar collapse that isolated the
tip in circumferential shadows. Alar retraction exaggerates the “gull in flight” con-
tour on frontal view and contributes to the abnormal alar-columellar relationship
on profile. As previously described, lateral crural strut grafts can be used to reposi-
tion the alae more caudally. It is essential to make the pockets for the repositioning
caudally and down to the piriform aperture to ensure adequate alar movement. When
moving the ala caudally, the pocket created for the lateral crura should be even more
caudal and closer to the alar margin. Often this maneuver will result in increased
alar flare, which must be addressed with alar base reductions.
Further improvement in nostril shape can be obtained with alar rim grafts. These
can help recreate and support the tip-alar transition and correct alar concavities.
Alar rim grafts are typically 2 to 3 mm wide and 12 to 15 mm long. A pocket is care-
fully dissected caudal to the marginal incision, and the graft is slid into the pocket.
It is held in place with a single 6-0 Monocryl suture. The medial graft edge should
be gently crushed with Adson-Brown forceps to prevent visibility. Alar rim grafts help
correct the alar concavities seen on the basal view and create a smooth transition
from tip lobule to alar lobule.

1997
Chapter 56  Tip Grafting for Nasal Contouring
Lateral wall splints fashioned from 0.25 mm bivalve septal splints facilitate integra-
tion of lateral crural struts. The bivalve septal splint is cut in half and the edges
trimmed. One piece is placed intranasally and the other across the sidewall and ala.
The splints are sutured in place with a single 3-0 nylon suture placed through-and-
Closure
Closure begins by reapproximating the skin flap with a single deep 6-0 Monocryl
suture. The marginal incisions are then carefully approximated with 5-0 chromic gut;
poor reapproximation can lead to the development of vestibular webs and nasal valve
stenosis. The columellar skin is closed with 7-0 nylon vertical mattress sutures placed
perpendicular to the incision line apices. Precise closure at the columellar edge is cru-
cial to prevent visible contour irregularities. The spaces in between are then filled
with vertical mattress or simple interrupted sutures, depending on the amount of
eversion needed. The vestibular portion of the columellar incision is closed with sin-
gle interrupted 6-0 fast-absorbing gut sutures. Meticulous technique helps to cam-
ouflage the scar.

1998
Part X  Rhinoplasty
through the sidewall, and the knot is tied intranasally. To account for the lateral wall
edema and prevent skin ulceration or necrosis, the knot should be loose enough to
allow passage of a needle-holder tip. Folded, nonadherent gauze packs are placed
bilaterally, depending on the quantity of intraoperative bleeding. Vestibular splints
also fashioned from 0.25 mm bivalve septal splints may be placed to stent constricted
airways and to help preserve the lateral position of lateral wall grafts.
A narrow strip of nonadherent gauze is placed over the dorsum from the radix to
the supratip. The nose is then taped with ¼-inch reinforced paper tape, and a ther-
moplastic cast is applied to the dorsum. Bacitracin in applied to all suture lines. A
gauze drip pad is placed across the nose. Nonadherent gauze and a transparent dress-
ing are used to cover the chest incision at the harvest site.
Postoperative Care
A broad-spectrum antibiotic is prescribed postoperatively for up to 2 weeks. Patients
are encouraged to take acetaminophen for pain, although hydrocodone/acetaminophen
pills are prescribed for more severe pain. Nonadherent gauze packing and vestibu-
lar splints are removed on postoperative day 1. The chest dressing is removed on
postoperative day 2. The columellar and chest sutures, nasal cast, and lateral wall
splints are removed on postoperative day 7. Alar base reduction sutures are removed
on postoperative day 14. Patients return to the office for two additional visits the
first month, monthly for the next two visits, and then bimonthly for two visits.
Correction of minor asymmetries with compression maneuvers can begin 3 weeks
after surgery. Patients are directed to apply pressure to specific areas for 1 minute
10 times daily. Silicone sheeting is provided for chest wounds 3 weeks after surgery.
Patients are instructed to tape the sheeting over the scar nightly and clean it with al-
cohol in the morning; sheets are changed monthly.
Walking may begin on postoperative day 1, but patients are asked to refrain from stren-
uous physical activity for 6 weeks. Swimming is restricted for 4 weeks; afterward pa-
tients may swim in chlorinated pools only for the next 2 months. Patients may wear
glasses while their cast is still in place. Thereafter, patients are asked to bring glasses
to the office so that their resting position on the nasal bridge can be assessed.

1999
Chapter 56  Tip Grafting for Nasal Contouring
Problems and Complications
The most common complication after surgery is residual asymmetries, especially in
difficult revisions or congenital or traumatic cases. The likelihood that asymmetries
may develop is strongly correlated with the patient’s skin thickness. Thick skin re-
mains edematous for much longer after surgery and will tend to hide many irregu-
larities; even minor irregularities will show through thin skin.
Nostril asymmetry can be one of the most difficult problems to correct in revision
patients. Preference is given to aligning nostrils on frontal view. An appropriate alar-
columellar relationship on lateral view is the next goal in nostril reshaping. Symme-
try on the basal view is the most difficult to achieve, but fortunately the least visible.
Additional complications include bleeding, infection, and scarring. Epistaxis is un-
common after surgery and can often be treated with oxymetazoline spray. Recalci-
trant bleeding may require application of hemostatic agents, packing, or operative
intervention. The risk of infection is very low but increases substantially in patients
who have had multiple procedures. Any suspicion of nasal cellulitis should be treated
quickly and aggressively. A low threshold for incision and drainage in the operating
room is prudent, since chronic abscesses can smolder and destroy nasal cartilage
grafts or, in the worst cases, irreparably damage the skin envelope.
Careful attention to closure of the transcolumellar incision can maximize scar cam-
ouflage. Poor scars can be treated with dermabrasion or revision. Improper closure
of marginal and intracartilaginous incisions can lead to vestibular scarring. Even the
smallest scars or webs can compromise the internal nasal valve and drastically de-
crease nasal airflow. Repair often requires placement of an auricular composite graft.
Base reduction and chest incisions can be especially troublesome, particularly in
thick-skinned ethnic patients, such as Asians and mestizos. Silicone sheeting, steroid
injections, and dermabrasion can all be used to improve the appearance of hyper-
trophic scars.

2000
Part X  Rhinoplasty
Results
This 17-year-old patient requested nasal refinement. She reported nasal dyspnea dur-
ing exercise. On frontal view, she had a narrow dorsum, lateral wall pinching, and
a bulbous tip with a typical parentheses deformity. On lateral view, she had a dor-
sal hump, underprojected tip, and an obtuse nasolabial angle. Additionally, she had
an underprojected chin. On basal view, she had flared medial crura, a wide columella,
and a trapezoidal configuration secondary to her wide tip and lateral wall collapse.
Intranasal examination revealed a septal spur along the floor of the left nasal cavity.
She also exhibited external valve collapse on inspiration.

2001
Chapter 56  Tip Grafting for Nasal Contouring
Nasal
Lower lateral cartilage
Septum
Lateral
Lower lateral cartilage
Upper and lower lateral cartilages
Alar rim
grafts
Lateral crural
strut graft
Tip graft
Caudal septal
extension graft
Caudal septal
extension graft
Lateral crural
strut grafts
Lateral crural
strut grafts
Spreader
graft
Spreader
graft
Excised
septum
Caudal septal
extension
graft
Surgical Plan
Correction of the patient’s nasal airway obstruction required repositioning the cephalically posi-
tioned lateral crura. A small caudal septal extension graft was placed to support the nasal base.
Spreader grafts were placed to correct the middle vault pinching. The lateral crura were dissected
from the vestibular skin and supported with lateral crural strut grafts. The lateral crura were then
positioned caudally to correct the cephalically oriented cartilages. A small, soft cartilage graft was
placed over the domes to provide some additional tip projection and narrowing. Alar rim grafts
were used to create a smooth transition from the tip lobule to the alar lobule. The rhinoplasty work-
sheet demonstrates the maneuvers performed during her surgery.

2002
Part X  Rhinoplasty
Surgical Steps
 Inverted-V midcolumellar incision connected to bi-
lateral marginal incisions
 Open septoplasty and septal cartilage harvest
 Bilateral spreader grafts
 Caudal septal extension graft overlapping left septum
 Bilateral cephalic trim of lateral crura
 Bilateral lateral crural strut grafts, dome sutures, and lateral crura caudal reposi-
tioning
 Bilateral alar rim grafts
 Bilateral alar batten grafts
 Crushed cartilage placed over domes

2003
Chapter 56  Tip Grafting for Nasal Contouring
One year postoperatively, she has smooth brow-tip aesthetic lines, improved dorsal
width, and a narrower tip. She no longer has a parentheses shape to her nasal tip,
and the shadowing of her tip is more favorable. On lateral view, she has a smooth
dorsum, increased projection, and an improved nasolabial angle. The basal view re-
veals a triangular configuration, lateral wall support, and increased nostril size.

2004
Part X  Rhinoplasty
This 19-year-old patient requested rhinoplasty. On frontal view, she had a wide tip
and a hanging infratip lobule. On lateral view, she had a slight dorsal hump, an un-
derprojected tip, and an underprojected chin. Her nose appeared dependent because
of the downward cant to the nostrils. On basal view, she had flared medial crural
footplates and a trapezoidal shape consistent with her wide tip lobule.

2005
Chapter 56  Tip Grafting for Nasal Contouring
Nasal
Lower lateral cartilage
Septum
Lateral
Lower lateral cartilage
Upper and lower lateral cartilages
Alar rim
grafts
Lateral crural
strut grafts
Lateral crural
strut graft
Tip
grafts
Caudal septal
extension graft
Lateral
osteotomy
Rasp
Peri-
chondrium
Lateral crural
strut grafts
Alar batten
grafts
Medial and lateral osteotomy sites
Alar batten
graft
Excised septum
Caudal septal
extension
graft
Spreader
graft
Surgical Plan
The primary goal was to increase the patient’s nasal tip projection. Stabilization of the nasal base
using a caudal septal extension graft was an important step in the surgery. The extension graft over-
lapped the septum slightly and was stabilized with splinting grafts. A dorsal hump reduction was
performed and lateral crural strut grafts were placed. The lateral crura were then moved caudally
to correct their cephalic position. Onlay tip grafts were placed horizontally over the domes to pro-
vide additional tip projection. Bilateral medial and lateral osteotomies were performed. Alar rim
grafts contributed to proper tip contour. The rhinoplasty worksheet illustrates the steps performed
during her surgery.

2006
Part X  Rhinoplasty
 Inverted-V midcolumellar incision con-
nected to bilateral marginal incisions
 Dorsal hump rasping
 Bilateral medial and lateral osteotomies
to narrow the upper third
 Open septoplasty and septal cartilage
harvest
 Bilateral spreader grafts
 Caudal septal extension graft overlap-
ping the left side of the septum and sta-
bilized with right splinting graft
 Bilateral cephalic trim of lateral crura
 Bilateral lateral crural strut grafts, dome
sutures, and lateral crura caudal repo-
sitioning
 Crushed cartilage on domes
 Bilateral alar batten grafts
Surgical Steps
 Submental incision with submental liposuction and placement of a small Silastic ex-
tended chin implant

2007
Chapter 56  Tip Grafting for Nasal Contouring
Two years postoperatively, she has a more refined tip and an improved alar-columellar
relationship. On lateral view, she has a straight dorsum, increased tip projection, and
more favorable angulation of her nostrils. The refined tip and increased projection
is reflected in the triangular shape of her nasal base.

2008
Part X  Rhinoplasty
This 46-year-old female patient requested rhinoplasty. On frontal view, she had a
narrow dorsum, bulbous tip, and hanging infratip lobule. On lateral view, she had
a prominent dorsal hump, overprojected tip, hanging columella, and short upper lip.
The basal view revealed a wide, bifid tip and short medial crura.

2009
Chapter 56  Tip Grafting for Nasal Contouring
Nasal
Lower lateral cartilage
Septum
Lateral
Lower lateral cartilage
Upper and lower lateral cartilages
Alar rim
grafts
Peri-
chondrium
Crushed cartilage
Lateral crural
strut graft
Tongue-in-groove
setback
Dorsal hump
reduction
Alar batten graft
Lateral crural
strut grafts
Alar batten grafts
Lateral crural
strut grafts
Excised septum
Trim caudal
septum
Surgical Plan
This patient underwent an external rhinoplasty approach and reduction in the overall size of her
nose. Fortunately, she had relatively thin skin that was able to contract over time. (If she had had
thick skin, there would have been a limitation to the amount of skin shrinkage that could occur, and
this would have limited the degree of deprojection and downsizing that her nose would have toler-
ated.) She had a very large, harvestable segment of septal cartilage. After conservatively trimming
the caudal septum, the medial crura were set back and sutured to the septum in a more inferior po-
sition to decrease tip projection. This maneuver relaxed the upper lip and created a more favorable na-
solabial angle. Dorsal hump reduction was performed and spreader grafts were placed. The lateral
crura were dissected from the underlying vestibular skin. Lateral crural strut grafts were sutured to
the undersurface of the lateral crura, medial to where the original domes were located, to move the
new domes medially and further deproject the tip. Dome sutures were placed to narrow the tip. The
lateral crura were then repositioned caudally to correct their cephalic positioning. Additional cartilage
was needed, so auricular cartilage was harvested and used for alar batten grafts and alar rim grafts.
Alar base reductions were performed to decrease the excess nostril size caused by deprojecting the
tip. The rhinoplasty worksheet illustrates the maneuvers performed during her surgery.

2010
Part X  Rhinoplasty
Surgical Steps
 Inverted-V midcolumellar incision connected to bi-
lateral marginal incisions
 Examination of lower lateral cartilages reveals cephalic
positioning of the lateral crura
 Dorsal hump reduction
 Open septoplasty and septal cartilage harvest
 Bilateral spreader grafts with two on the right side
 Tongue-in-groove setback of medial crura onto cau-
dal septum with deprojection
 Bilateral cephalic trim of lateral crura
 Bilateral lateral crural strut grafts, dome sutures, and lateral crura caudal reposi-
tioning; domes moved medially to decrease tip projection
 Right auricular cartilage harvest through postauricular incision
 Bilateral auricular cartilage alar batten grafts
 Bilateral alar rim grafts
 Auricular perichondrium and crushed
cartilage over domes.

2011
Chapter 56  Tip Grafting for Nasal Contouring
Downsizing the patient’s nose left redundant skin, which caused tremendous swelling
and a very wide nose in the early postoperative period. It took many months for the re-
dundant skin to shrink. After 18 months, she has smooth brow-tip aesthetic lines and
a narrower, more refined tip. On lateral view, she has a straight dorsum, decreased pro-
jection, a shorter nose, and a softer nasolabial angle. Shortening her nose has resulted in
a longer upper lip. The basal view reveals a rounder tip lobule without bifidity.

2012
Part X  Rhinoplasty
This 51-year-old woman complained of nasal deformities and obstruction. She had
undergone a primary rhinoplasty 13 years before and a revision 1 year thereafter.
On frontal view, her nose was deviated to the right. She also had collapse of the left
upper lateral cartilage and pinching of the tip. On lateral view, her nose was under-
projected with a mild polly-beak deformity. The basal view revealed left lateral wall
collapse and nasal deviation to the right. Intranasal examination revealed a high left
septal deviation obstructing the nasal valve and a right posterior septal deviation.

Nasal
Lower lateral cartilage
Septum
Lateral
Lower lateral cartilage
Upper and lower lateral cartilages
Tip
grafts
Peri-
chondrium
Lateral crural
strut graft
Caudal septal
replacement graft
Septal cartilage
dorsal graft
Alar batten
graft
Caudal septal
replacement graft
Lateral crural
strut grafts
Alar batten grafts
Lateral crural
strut grafts
Spreader
graft
Spreader
graft
Caudal
septal
replacement
graft
Spreader
graft
Septal cartilage
dorsal graft
Septum resected
during previous
surgery
Septum resected
during current surgery
Alar rim grafts,
smaller one
on right
2013
Chapter 56  Tip Grafting for Nasal Contouring
Surgical Plan
A secondary rhinoplasty was performed using the external rhinoplasty approach. Costal cartilage
was harvested to obtain adequate cartilage for grafting. The patient had significant weakness in the
nasal tip from previous overresection of the lower lateral cartilages. She had a severely deviated cau-
dal septum that required replacement with a caudal septal replacement graft. This graft supported
what remained of the lower lateral cartilages. Spreader grafts were placed to correct the middle
nasal vault collapse. The weak, damaged lateral crura were stabilized with lateral crural strut grafts,
and the lateral crura were repositioned caudally. Harvested septal cartilage was used for the lateral
crural strut grafts to provide a softer nasal tip. Soft cartilage was placed over the domes to provide
additional tip projection. A septal cartilage dorsal graft was placed to increase the dorsal height.
The rhinoplasty worksheet illustrates the steps performed during her surgery.

2014
Part X  Rhinoplasty
 Costal cartilage caudal septal replacement graft sutured to notch in nasal spine
and stabilized with spreader grafts
 Bilateral septal cartilage lateral crural strut grafts to minimize tip rigidity, dome
sutures, and lateral crura caudal repositioning
 Bilateral septal cartilage alar batten grafts
 Bilateral alar rim grafts
 Crushed cartilage and perichondrium over domes
 Septal cartilage dorsal graft and supratip graft
 Bilateral alar base reductions
Surgical Steps
 Right inframammary fold incision and sixth rib harvest
 Inverted-V midcolumellar incision connected to bilateral marginal incisions
 Open septoplasty and removal of caudal septum because of severe caudal septal
deviation
 Bilateral costal cartilage extended spreader grafts

2015
Chapter 56  Tip Grafting for Nasal Contouring
Twenty-six months postoperatively, the patient has excellent nasal respiration. On
frontal view, her nose is straight, and the left upper lateral cartilage collapse has been
corrected. On lateral view, she has a straight dorsum, increased projection, and in-
creased rotation. The basal view reveals a straight, midline columella and supported
lateral walls.

2016
Part X  Rhinoplasty
This 43-year-old woman requested correction of her nasal deformity and left-sided
obstruction. The patient had undergone rhinoplasty 25 years earlier and gradually
developed pinching and nasal obstruction. On the frontal view, she had a narrow
middle vault, a wide, bifid tip, a hanging tip lobule, and retracted alae. Her skin was
very thin, and the outlines of her lateral crura were visible. On lateral view, she had
a hanging columella and retracted alae. The basal view revealed a trapezoidal con-
figuration consistent with her wide tip.

2017
Chapter 56  Tip Grafting for Nasal Contouring
Nasal
Lower lateral cartilage
Septum
Lateral
Lower lateral cartilage
Upper and lower lateral cartilages
Alar rim
grafts
Dorsal graft
Perichondrium
Lateral crural
strut graft
Tongue-in-groove
setback
Lateral crural strut grafts
Buried nylon
footplate suture
Alar rim
graft
Alar rim
graft
Lateral crural
strut graft
Dorsal graft
Perichondrium
Excised septum
Surgical Plan
Significant grafting material was required to correct this patient’s problems. Costal cartilage was
harvested from the right side of the chest. Correction of the hanging columella required setting back
the medial crura and suturing them to the caudal septum. This maneuver lifted the columella and im-
proved the alar-columellar relationship. Complete correction of her deformity required dissecting
the lateral crura from the vestibular skin, placement of lateral crural strut grafts, and reposition-
ing into caudal pockets. This maneuver pulled both alae caudally into a more favorable position.
Longer lateral crural strut grafts were needed to bring the ala down to the proper level. Additionally,
alar rim grafts were placed to increase her nostril symmetry. A small dorsal graft was placed to pro-
vide proper dorsal alignment. Perichondrium was placed over the domes to camouflage any tip
asymmetries.

2018
Part X  Rhinoplasty
Surgical Steps
 Right inframammary incision and seventh rib harvest
 Inverted-V midcolumellar incision connected to bilateral marginal incisions
 Open septoplasty and remaining septal cartilage harvest
 Bilateral spreader grafts, thicker on the left side
 Tongue-in-groove setback of medial crura onto caudal septum
 Bilateral lateral crural strut grafts, dome sutures, and lateral crura caudal reposi-
tioning
 Bilateral alar rim grafts
 Two layers of perichondrium placed over domes
 Septal cartilage dorsal graft
 Bilateral alar batten grafts

2019
Chapter 56  Tip Grafting for Nasal Contouring
Thirty-four months postoperatively, the patient has appropriate dorsal width, a re-
fined tip, and correction of her alar retraction and hanging tip lobule. On lateral
view, she has a shorter nose with less columellar show and a more appropriate alar-
columellar relationship. The basal view shows symmetrical nostrils and a triangular
shape.

2020
Part X  Rhinoplasty
Concluding Thoughts
Refinement of the nasal tip requires control of nasal tip position and shape of the
lower lateral cartilages. Stabilizing the nasal base provides a foundation for the tip
modification. Once the nasal base is stabilized, the nasal tip cartilage can be modi-
fied using dome sutures, cephalic trim, and cartilage grafting. Some of the more com-
mon types of grafting include lateral crural strut grafts, alar rim grafts, and tip grafts.
Using these grafts, the tip structures can be stabilized and the domes modified. Pro-
jection can be controlled using columellar struts, caudal extension grafts, and tip
grafts. Use of cartilage grafting for tip contouring minimizes the need for reduction,
which can weaken the tip structures, resulting in pinching and collapse. The struc-
tural approach to nasal tip refinement provides excellent long-term outcomes and
minimizes the potential for tip deformity.
Clinical Caveats
 Tip grafting is an integral component of nasal tip contouring.
 Indications for tip grafting include increasing tip projection, prevention of post-
operative loss of tip projection, nasal lengthening, straightening tip deviations, and
correction of cephalically malpositioned lower lateral crura.
 Important components of the tip profile are projection, rotation, the supratip
break, the infratip lobular double break, and the alar-columellar relationship.
 Important components of the tip frontal view are the tip highlight, symmetry, a
smooth tip-alar transition, supratip shadow, and the alar-infratip lobule relation-
ship.
 Clear, realistic goals are necessary for a successful surgeon-patient relationship.
 Judicious use of computer imaging by the surgeon is critical to establishing real-
istic patient expectations.
 Careful incision design and meticulous skin–soft tissue envelope elevation facili-
tate a successful result.
 Nasal base stabilization is a crucial first step for all tip grafting techniques.
 Increased projection can be obtained with suture contouring, tip onlay grafts, and
shield tip grafts.
 Tip rotation can be achieved by suture contouring, caudal septal trimming, lateral
crural resection or division and overlay, and fixation to the native or extended cau-
dal septum.