Kỹ Thuật Nâng Mũi Hiện Đại: Góc Nhìn Từ Các Bậc Thầy Hàn Quốc (Man Koon Suh, 2021)

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© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. K. SUH (ed.), State of the Art Rhinoplasty Techniques,

Nasal Tip Techniques (1): Tip
Augmentation Techniques
Moo Hyun Paik and Lo Shui Chu
Tip Augmentation (Correction
of Low Tip)
Most of the rhinoplasty performed in East Asians
is to raise the nasal bridge and the nasal tip.
However, what cannot be overlooked in tip plasty
is that it is hard to obtain satisfactory results by
merely increasing the height of the nasal tip. For
successful tip plasty, not only the height of the
nose tip is raised, but to achieve a natural and
beautiful nose, the shape, width, and position of
the nasal tip must be adequately maintained or
changed. Therefore, the suture technique and the
cartilage graft, which are the two most commonly
used tools in nasal tip surgery, should be appro-
priately applied.
Suture Techniques
If the patient has well-developed alar cartilages,
tip projection can be made by suture techniques
alone. But most of the patients who want to get
tip augmentation in the East Asian population
have underdeveloped alar cartilages. Tip aug-
mentation by suture techniques alone can be used
in limited cases. In most instances, suture tech-
niques and ear cartilage graft are used in combi-
nation. Although the suture technique is a
valuable way to solve many problems in tip
plasty, it has been undervalued and ignored a lot
due to the complex algorithm and nomenclature
that confuse us. To simplify the various suture
techniques, it is classified into three categories by
the three fundamental components of the nasal
tip, the left and right alar cartilage, and the sep-
tum. The suture was classified into three types by
dividing the left and right cartilage and the sep-
tum, which are the basic three components of the
tip of the nose.
(A) Suture on each alar cartilage
• Transdomal suture
• Lateral crural mattress suture
(B) Suture between alar cartilages
• Interdomal suture
• Intercrural suture
• Lateral crural spanning suture
(C) Suture between septal cartilage and alar
cartilages
• Medial crural septal suture
• Lateral crural septal suture
• Columellar septal suture
In using the suture techniques for tip plasty,
several sutures can be used in combination. The
precise location of the suture point and proper
M. H. Paik (*)
Department of Plastic and Reconstructive Surgery,
Ulaanbaatar Agape Christian Hospital,
Ulaanbaatar, Mongolia
L. S. Chu
Gok Saem Aesthetic Plastic Surgery Clinic,
Seoul, South Korea

44
tension is very important to get a successful
result. A 5-0 or 6-0 PDS or Nylon with a round or
cutting needle can all be used according to the
surgeon’s preference. The method and function
of each suture are as follows.
Transdomal Suture
Transdomal suture is a mattress suture at the dome
area of each alar cartilage, which makes a more
acute dome angle to get more tip projection and tip
definition (Fig. 1). This suture also can be used for
shifting the dome position cephalically or caudally
to control the nasal tip position (Fig.  2).
Overzealous narrowing of the dome angle can
make pinched tip deformity and acute angle of
nostril apex (Fig.  3). To avoid suture material
exposure, injection of local anesthetics on under-
lying mucosa or undermining the underlying
mucosa is helpful before suture placement (Fig. 4).
Lateral Crural Mattress Suture
This suture is for changing the convexity of lat-
eral crura to correct the bulbosity and pinched
deformity of nasal tip as well as asymmetrical
convexity of lateral crura (Fig. 5).
Interdomal Suture
It is a suture between both domes for tip narrow-
ing by decreasing the interdomal distance.
Intercrural Suture
The intercrural suture is a suture placed between
both medial crura for stabilization of columella
and tip support (Fig. 6b). The flaring angle of the
medial crura can be controlled by modifying the
location of the suture site. In East Asian people
who need tip augmentation, the development of
the medial crura of alar cartilages is often not
enough to support the tip only by intercrural
suture, resulting in distortion of medial crura
over time (Fig. 7). A columellar strut instead of
the intercrural suture is needed in most cases.
Lateral Crural Spanning Suture
It is a mattress suture between both lateral crura
for narrowing of the tip and supratip area (Fig. 8).
This suture also supports the nasal tip from the
cephalic portion of the dome (Fig.  9).
Overtightening of this suture may cause narrow
and pinched tip deformity as well as retracted ala.
Medial Crural Septal Suture
This suture is performed between the medial
crura and the caudal border of the septum for tip
rotation, tip projection, and correction of hanging
columella (Fig.  10). The degree of rotation,
­projection, and the correction amount of hanging
columella can be controlled by the location and
tension of the suture.
a
b
Fig. 1  Transdomal suture. The wide dome angle was narrowed. Before (a) and after (b) suture tightening
M. H. Paik and L. S. Chu

45
Original dome
Caudal dome shfting
Cephalic dome shfting
a
b
c
d
e
Fig. 2  Transdomal suture. Dome position can be shifted
cephalically or caudally. (a) If the original dome position
is caudally shifted, the tip height is lowered and elon-
gated. If the dome position is cephalically shifted, the tip
is projected and upturned. Before (b) and after (c) cephalic
dome shifting using transdomal suture. The original tip
(d) was upturned and projected (e)
a
b
Fig. 3  (a, b) Overtightening of transdomal suture causes acute dome angle
Nasal Tip Techniques (1): Tip Augmentation Techniques

46
Lateral Crural Septal Suture
This is a suture between lateral crus and septal
dorsum for tip rotation or derotation.
• Lateral crural septal suspension suture
If this suture is placed with cephalically
rotated alar cartilage, it is called lateral crural
septal suspension suture, which makes the
cephalic rotation of the tip (Fig. 11).
• Lateral crural septal derotation suture (Tip
extension suture)
Fig. 4  Separation of underlying mucosa and vestibular
skin before suture placement
a
b
c
d
e
f
Fig. 5  Lateral crural mattress suture. (a) Concave Lt.
later crus before suture. (b) Convex lateral crus after
suture. (c, e) This patient had an asymmetric tip caused by
left side pinching. (d, f) Postoperatively, she has a sym-
metric tip without pinching deformity
M. H. Paik and L. S. Chu

47
a
b
Fig. 6  Interdomal suture and intercrural suture. (a, b) Transdomal suture, interdomal suture, and intercrural suture nar-
rowed the dome angle, interdomal distance, and intercrural space
a
b
Fig. 7  Distorted medial crura (a, b). If alar cartilages are weak, only the suture technique cannot maintain the stability
of the medial crura for tip support
a
b
Fig. 8  Lateral crural spanning suture. (a, b) This suture narrows supratip and tip
Nasal Tip Techniques (1): Tip Augmentation Techniques

48
Fig. 9  Suture technique for tip plasty. (a, c, e, g, i) The patient had a broad ill-defined tip. (b, d, f, h, j) Postoperatively,
the tip was projected, narrowed, and more defined
a
b
c
d
e
f
g
h
i
M. H. Paik and L. S. Chu

49
If the suture is placed with caudally released
alar cartilage, it is called lateral crural septal der-
otation suture, also known as tip extension suture,
which moves the nasal tip in a caudal direction
(Fig. 12).
Columellar Septal Suture
This is a modification of the medial crural septal
suture. It is placed between the caudal border of
the septum and columellar unit consisting of col-
umellar strut and both medial crura (Fig. 13). The
functions of this suture are the same as the medial
crural septal suture, resulting in cephalic rotation
of the tip, tip projection, and correction of hang-
ing columella.
Ear Cartilage Graft
In general, three different autogenous cartilage
can be used in nasal tip plasty: septal cartilage,
ear cartilage, and costal cartilage. And for the
methods, septal extension graft and columella
j
Fig. 9  (continued)
a
b
c
d
e
f
g
h
Fig. 10  Medial crural septal suture. (a, b) The medial
crura of alar cartilages are sutured to the anterior septal
angle and caudal border of the septum for suspension of
the tip and columella. (c, d) Mediral crural septal suture is
being tied. (e, g) This patient showed tip drooping and
hanging columella. (f, h) Postoperatively, the tip was
rotated and projected, and hanging columella was
corrected
Nasal Tip Techniques (1): Tip Augmentation Techniques

50
strut are the two most commonly used techniques
for tip plasty. We have to decide which method
and cartilage to use for nasal tip plasty. Usually,
septal extension graft with septal cartilage may
be the most commonly used technique that
enables tip projection and length control at the
same time. Moreover, it is simple and easy to
apply.
However, a septal extension graft has many
possible shortcomings. First, the medial crura of
the alar cartilage are fixed to the septal extension
graft, which leads to an uncomfortably rigid
nasal tip and columella, especially in cephalic
direction, and subsequently results in unnatural
facial animation (Fig. 14). Second, it is often dif-
ficult to harvest a sufficient amount of septal car-
a
b
c
d
Fig. 11  Lateral crural septal suspension suture. (a, b) The cephalic borders of the lateral crura are sutured to the
cephalic portion of the septal dorsum. (c, d) The patient’s drooping tip was rotated and projected
M. H. Paik and L. S. Chu

51
tilage from the noses of East Asians. Overzealous
harvesting of septal cartilage may cause saddle
deformity or deviation caused by weakening the
remaining septal framework (Fig. 15). Third, in
patients with a low tip or upturned tip and a prior
septal extension graft using septal cartilage, a rib
cartilage graft is the only viable option for addi-
tional tip lengthening and projection as it pro-
duces a relatively stiff nasal tip and leaves a chest
wall scar. Fourth, a septal extension graft usually
gathers the lateral crura to the midline, which, in
turn, increases the possibility of a narrow, pinched
tip and retracted ala. Fifth, it is hard to predict the
amount of septal cartilage available accurately in
preoperative planning.
The priority of our choice of material and
method for tip augmentation is to provide a beau-
tiful and natural nasal tip with fewer complica-
tions and less discomfort to the patients. The
most protruding parts of the human face, the
nasal tip and ears, are composed of elastic carti-
lage that is physically soft, flexible, and movable.
They are less vulnerable to external forces.
Considering these characteristics of the human
face, we prefer suture techniques and ear carti-
lage graft in tip augmentation to make the nasal
tip as soft as possible. Septal cartilage is used
only in limited cases. To maintain natural physi-
cal properties, I try not to fix the alar cartilage to
the fixed unit (bony and septal cartilage frame-
work) with a rigid graft such as a septal extension
graft or rigid structural graft preserving the func-
tion of the membranous septum for mobile and
less rigid nasal tip.
To overcome the disadvantages of septal
extension graft, we have devised a procedure
called derotation graft, which uses ear cartilage.
In the past decade, we have performed more than
1000 derotation grafts for tip plasty. This method
makes possible accurate pre-/intraoperative esti-
mation of the amount of ear cartilage to be har-
vested. The flexibility of the ear cartilage graft
results in a less rigid nasal tip and avoids interfer-
ence with the function of the membranous
septum.
Surgical Techniques
Ear Cartilage Harvesting and Fabrication
The incision is made along the hidden area of the
inner surface of antihelix using a separate inci-
sion on cymba area and cavum area to avoid a
visible scar on the exposed area (Fig. 16).
The skin flap is elevated above the perichon-
drium on both anterior and posterior surfaces.
For proper strength, both layers of the perichon-
drium were included in all grafts harvested from
the ear. Two pieces of cartilage from cymba and
cavum choncha are harvested (Fig. 17). To avoid
auricle collapse, the bridge area between cymba
and cavum concha must be saved at least 7–8 mm
in width. The round shape of the cut edge is safer
than the angular shape to prevent ear deformity
(Fig. 18).
a
b
c
d
Fig. 12  Lateral crural septal derotation suture (Tip extension suture). (a, b) Caudally moved alar cartilages are fixed to
the caudal dorsum of the septum. (c, d) A slightly upturned tip was downwardly moved
Nasal Tip Techniques (1): Tip Augmentation Techniques

52
It is recommended to harvest ear cartilage
after exploring the nose, which allows for collect-
ing just as much cartilage as you need. After
wound closure of the donor site, a compressive
dressing with Vaseline gauze and wet cotton is
maintained for 1 week and replaced with a
rubber-­hard putty for 1–2 months to prevent ear
deformity (Fig. 19).
The straight portion of the graft from cymba
concha is used to make a double-layered colu-
mellar strut, and the remaining boat-shaped piece
is used to make a derotation graft (Fig. 20). A
a
b
c
d
e
f
g
h
i
Fig. 13  Columellar septal suture. (a) An anchoring
suture at the septal angle or caudal border of the septum is
done for suspension. (b, d) Before tightening the suture.
(c, e) After tightening the suture, the tip complex was
moved up. (f, h) This patient had a long nose with a
drooping tip. (g, i) Postoperatively, the tip is rotated and
projected
M. H. Paik and L. S. Chu

53
a
b
Fig. 14  (a) This patient
shows an unnatural
appearance with a rigid
immobile tip caused by
a septal extension graft
with rib cartilage. (b)
After removing the rigid
rib graft and replacing it
with the ear cartilage
graft, her tip became
soft, movable, and
natural
a
b
c
Fig. 15  (a) Saddling deformity caused by overzealous
harvesting of septal cartilage. (b, c, d, e) In this old
patient, it was corrected with ear cartilage grafts (multi-
layered grafts on depressed area, columellar strut, derota-
tion graft, tip graft) due to calcification of the rib cartilage.
(f) As a result, she has a straight dorsal line
Nasal Tip Techniques (1): Tip Augmentation Techniques

54
d
e
f
Fig. 15  (continued)
a
b
Fig. 16  Ear cartilage harvesting. (a, b) Separated incisions at the hidden area to avoid a visible scar
M. H. Paik and L. S. Chu

55
graft from cavum concha can be used as onlay
graft, shield graft, and additional derotation graft
for tip plasty (Fig. 21).
Application of Cartilage Graft
Columellar strut
Two layers of mirror-imaged cartilage from
cymba concha are sutured with several 6-0 PDS
mattress sutures to make a bilayered columellar
strut (Fig. 22). In most cases, it is used as a float-
ing type to support and project the tip (Fig. 23).
This columellar strut is also useful for correcting
long nose and drooping tip (Fig. 24).
The amount of tip projection and cephalic
rotation can be controlled by the length of the
strut and the fixation point between the strut and
medial crus. To correct pinched tip deformity, the
columellar strut can be used as an umbrella shape
for reinforcement of the dome of the nasal tip to
correct pinched tip deformity (Fig. 25).
The deeper the pocket for this graft on the
columellar base, the more columellar base retrac-
tion can be augmented and corrected (Fig. 26).
a
b
Fig. 17  Ear cartilage harvesting. (a, b) Two pieces of cartilage from cymba and cavum concha area
Fig. 18  Round shaped cut edge is safer for the stability of
remaining cartilage at the donor site
Nasal Tip Techniques (1): Tip Augmentation Techniques

56
a
b
c
d
Fig. 19  (a) A compressive dressing for donor site with
vaseline gauze and wet cotton packing for 1 week. (b)
After 1 week, an ear mold with rubbery hard putty is
applied for 2 months to minimize the ear deformity. (c, d)
Cut a wedge out of the putty adjacent to the ear canal for
hearing
M. H. Paik and L. S. Chu

57
Fig. 20  Cartilage from cymba concha. The straight por-
tion is used to make a double-layered columellar strut, and
the remaining part is used to create a derotation graft
a
b
Fig. 21  Cartilage from
cavum choncha. (a, b)
This cartilage can be
used for onlay graft,
shield graft, or
additional derotation
graft
a
b
Fig. 22  Columellar strut. (a, b) Two layers of mirror-­
imaged cartilage are sutured together
Nasal Tip Techniques (1): Tip Augmentation Techniques

58
Derotation graft
Unlike septal extension grafts that can control the
projection and length of the tip simultaneously,
the tip projection with suture techniques and col-
umellar strut tends to rotate the tip to the cepha-
lad and require another graft or procedure to
adjust the tip position.
Derotation graft is a piece of ear cartilage
placed between the septal dorsum and lateral
crura of alar cartilages, which is used for down-
ward rotation of the nasal tip to control the tip
position at the ideal location, minimizing the
limitation of cephalic movability (Figs.  27 and
28). In addition to the caudal rotation of the tip in
short nose correction, derotation graft also can be
used for cephalic rotation of the tip as a tip sus-
pension graft (Fig. 29). In patients with supratip
depression, it is a useful graft to augment the
Fig. 23  This columellar strut between medial crura is
used as a floating typed strut to support the tip
a
b
c
d
e
f
g
h
Fig 24  Tip plasty using columellar strut and suture technique. (a, c, e, g) This patient had a long nose with a broad
drooping tip. (b, d, f, h) Postoperatively, she has a shortened nose with a well-defined, projected tip
M. H. Paik and L. S. Chu

59
a
b
c
d
e
f
Fig. 25  Umbrella-shaped columellar strut. (a) Too close
interdomal distance and acute dome angle. (b) Widened
interdomal distance and round dome angle. (c, e) This
patient had a narrow, pinched tip and acutely angled nos-
tril apices. (d, f) Postoperatively, she has a widened tip
with natural round nostrils
a
b
c
Fig. 26  (a) Long columellar strut for correction of the retracted columellar base. (b) This patient had a bulbous tip and
retracted columella base. (c) Postoperatively, she has a well-defined tip and augmented columellar base
Nasal Tip Techniques (1): Tip Augmentation Techniques

60
depressed area and adjust the tip position simul-
taneously (Fig. 30).
When applying the derotation graft, the height
of the caudal septum is important. If the caudal
septum is high, a reduction of caudal septal
height will be needed in advance to prevent
supratip bulging. On the contrary, when the
height of the caudal septum is low, augmentation
of this portion is required before setting a derota-
tion graft. One of the most favorable aspects of
derotation graft is that it can be modified as an
alar spreader typed derotation graft for correction
of narrow, pinched tip and retracted ala using a
variety of sizes and shapes (Figs. 31, 32, and 33).
In cases with pinched tip caused by vertically
oriented lateral crura, the fixation sutures between
derotation graft with alar cartilage passed more
laterally through lateral crura can lead to the
splay effect of converting vertically arranged lat-
eral crura to the horizontal arrangement (Fig. 34).
Additional tip graft
Compared to septal or rib cartilage, relatively soft
and convoluted ear cartilage is more suitable for
tip grafts such as only or shield grafts (Fig. 35).
The margin of the graft must be carefully tapered
and trimmed to prevent noticeability afterward. It
is advisable to use a broader graft on the bottom
when using it in multiple layers to prevent visible
cartilage margin postoperatively.
Tip Lengthening (Correction
of the Short Nose)
Lengthening the short nose is one of the most
challenging procedures in rhinoplasty. The length
of the nose is described as the distance between
the nasion and the nasal tip. But the apparent
nasal length is influenced by many other factors,
including tip position, nasolabial angle, and con-
vexity of profile dorsal line.
In the short nose with an upturned nasal tip,
caudal rotation of the tip position is required. For
caudal shifting of the nasal tip, three conditions
must be satisfied. First, lengthening of the inner
lining (nasal mucosa) and caudal movement of
alar cartilages, second, maintaining the caudally
moved alar cartilages, that is to say, lengthening
of the cartilage framework, and third, lengthen-
ing of the skin and soft tissues to cover the
extended skeletal framework without tension.
There are several techniques for maintaining
downwardly relocated alar cartilages. Septal
extension graft using septal cartilage may be the
most frequently used technique. The derotation
graft using ear cartilage, structural graft, or canti-
lever graft using costal cartilage and tip extension
suture can also be applied. Each technique has its
advantages and disadvantages. Among them, I
will describe my preferred method using the der-
otation graft.
Derotation Graft
Alar Cartilage
Upper Lateral
Cartilage
a
b
Fig. 27  Derotation graft is placed between the caudal
portion of the septum and lateral crura of alar cartilages.
(a) Schematic drawing. (b) intraoperative view
M. H. Paik and L. S. Chu

61
a
b
Fig. 28  (a) This patient had a broad ill-defined tip, short
nose, and retracted columella. (b) Six years after the oper-
ation using ear cartilage as a columellar strut, tip graft,
derotation graft, and silicon implant for dorsal augmenta-
tion. Postoperatively, he has a nose with a well-defined tip
and proper length
a
b
Fig. 29  (a, b) Derotation graft can be used as a suspension graft for cephalic rotation of the nasal tip
Nasal Tip Techniques (1): Tip Augmentation Techniques

62
a
b
Fig. 30  (a, b) The supratip depression was corrected by derotation graft
a
b
c
Fig. 31  (a) Derotation graft as an alar spreader graft. (b) This patient shows a narrow tip and short nose. (c) Her nasal
tip was widened and downwardly moved using an alar spreader typed derotation graft with ear cartilage
M. H. Paik and L. S. Chu

63
Surgical Techniques
Flap Elevation
The open approach is more suitable to obtain the
maximum extension of the nasal length. In the
primary cases, the degloving plane is supraperi-
chondrial from the nasal tip to the cartilaginous
vault, and subperiosteal or supraperiosteal over
the nasal bones.
In the secondary cases with an alloplastic
implant and/or adhesion between the skin and the
scar tissue, a dual-plane dissection is performed.
The first plane is created between the skin and
the underlying inelastic scar tissue to maximize
the skin release for lengthening. The separation
of the skin flap from the underlying scar tissue
with tedious dissection is one of the most impor-
tant steps for successful lengthening in secondary
a
b
c
d
e
f
Fig. 32  Modification of alar spreader typed derotation
graft for correction of the medial type of retracted ala.
(a–d) Retracted alar domes are released and moved in the
lateral and caudal direction, and this new position is main-
tained with a modified alar spreader typed derotation
graft. (e) This patient shows a narrow tip with a medial
typed retracted ala. (f) Postoperatively, she has a widened
tip without retracted ala
Nasal Tip Techniques (1): Tip Augmentation Techniques

64
cases. The second plane is made between the alar
cartilage and the scar tissue to allow for caudal
rotation of the mobile unit structure. If dorsal
augmentation was necessary, the first plane, sur-
rounded by the vascularized tissue, is used for a
dermofat graft. For a dorsum implant, a subperi-
osteal plane extended from the second plane is
utilized (Fig. 36).
a
b
c
d
e
f
i
j
g
h
Fig. 33  Intercartilaginous typed derotation graft for cor-
rection of the lateral typed retracted ala. (a) Umbrella-­
shaped columellar strut. (b) Intercartilagenous typed
derotation graft and columellar septal suture at the base of
columella. (c) Before the procedures, the lateral crus is
retracted upwardly. (d) After the procedures, the lateral
crus is caudally repositioned. (e, g, i) This patient had
retracted ala, hanging columellar base, and short nose
deformity. (f, h, j) Retracted ala, short nose deformity, and
hanging columella were corrected
M. H. Paik and L. S. Chu

65
Caudal Release of Alar Cartilage
The soft tissue and ligamentous structure between
the alar cartilages and the upper lateral cartilage
are released using scissors, leaving the mucosal
inner lining intact for a tension-free caudal rota-
tion of the alar cartilages (Fig. 37).
If adequate caudal rotation could not be
achieved, further dissection between the mucosa
and the perichondrium beneath the upper lateral
cartilages is attempted for additional lengthen-
ing. In secondary cases with a preexisting septal
extension graft, the medial crura are released
from the adherent scar on the membranous sep-
tum to allow for caudal movement. In either a
severely retracted columella or an insufficient
caudal advancement of the medial crura, a wide
dissection is extended on the septal mucosa to
facilitate the caudal release of the columella.
a
b
c
d
e
f
Fig. 34  Splaying effect of a wide derotation graft. (a)
Vertically arranged lateral crura make a deep alar crease,
it causes a pinching appearance. (b) A broad derotation
graft has a splay effect on lateral crura, so convert verti-
cally arranged lateral crura to the horizontal arrangement.
(c, e) This patient had a bulbous tip with a pinching
appearance caused by a deep alar crease and shows an
hourglass appearance in submental view. (d, f)
Postoperatively, the alar creases were shallowed, and her
pinching appearance was disappeared
Nasal Tip Techniques (1): Tip Augmentation Techniques

66
Fig. 35  Convoluted shape of the ear cartilage is useful
for the tip graft as onlay graft, shield graft
Fig. 36  Dual plane dissection in secondary rhinoplasty
for short nose correction. The skin flap and the cartilage
framework must be separated from inelastic scar tissue for
lengthening
a
b
Fig. 37  (a, b) Alar cartilages were released from upper lateral cartilages and septum to move them caudally
M. H. Paik and L. S. Chu

67
a
b
c
Fig. 38  Derotation graft application. (a, b) Alar carti-
lages are released from upper lateral cartilages and cau-
dally moved. (c) Derotation graft was placed between the
caudal portion of the septal dorsum and lateral crura of
alar cartilages to maintain the new caudal position of the
tip
a
b
c
d
e
i
f
g
h
Fig. 39  Derotation graft maintains tip length and tip
movability. (a, d, g) This patient had severely contracted
short nose deformity. (b, e, h) One year after the opera-
tion, using multilayered derotation graft, a columellar
strut, dermofat graft for dorsal augmentation. This graft
maintains nasal length. (c, f, i) This graft enables the tip
movement without resistance
Nasal Tip Techniques (1): Tip Augmentation Techniques

68
a
b
c
d
e
f
g
h
i
j
m
n
k
l
Fig. 40  Multilayered derotation grafts are used to correct
the severe form of a short nose. (a, b) Alar cartilages were
severely deformed and adhered to the surrounding scar
tissue. (c) Alar cartilages were completely released from
the scar tissue and upper lateral cartilages. (d) A columel-
lar strut was used for tip support. (e, f, g) Alar cartilages
were symmetrically rearranged at the caudal position and
maintained with a multilayered derotation graft. (h)
Dermofat graft was used for dorsal augmentation. (i, k,
m) The patient had a severely contracted short nose defor-
mity with asymmetric nostrils. (j, l, n) Postoperatively, he
has a nose with normal length and symmetric nostrils
M. H. Paik and L. S. Chu

69
After all these release procedures, a sufficient
release of the alar cartilage can be attained with-
out the necessity of a composite graft. The com-
plete release of both alar cartilages from the
surrounding scar tissue with careful dissection
not to injure the nasal mucosa is also a time-­
consuming and vital step to lengthen the inner
lining resulting in caudal rotation of the nasal tip.
Fixation of Caudally Released Alar
Cartilage
To maintain the nasal tip in a new caudal posi-
tion, a supporting structure is needed in the gap
between released alar cartilage and upper carti-
lage frameworks, such as septal cartilage and
upper lateral cartilages. As mentioned in this
chapter, derotation graft using ear cartilage is my
preferred method and material in correcting the
short nose. This flexible cartilage graft can main-
tain the alar cartilage at a new caudal position
(Fig. 38).
Derotation graft between the dorsum of cau-
dal septum and alar cartilages is a simple and
very effective technique for maintaining the cau-
dally repositioned nasal tip with movability in
correction of the short nose (Fig. 39). If a piece of
derotation graft is not strong enough to keep the
tip position, more derotation grafts can be added
for reinforcement (Fig. 40). When the short nose
deformity is combined with a retracted ala or
pinched tip deformity, a derotation graft can be
used as an alar spreader graft (Fig. 41). In terms
of tip projection, a derotation graft tends to lower
the tip and is commonly used along with a colu-
mellar strut to maintain or project the height of
the tip.
a
b
c
d
e
f
g
h
Fig. 41  Alar spreader typed derotation graft. (a, b) Alar
cartilages were released from upper lateral cartilages and
septum so these can be moved down easily. (c) A wide alar
spreader typed derotation graft was used for widening
domes and lateral crura. (d) This new position of alar car-
tilages was maintained with multilayered derotation
grafts. (e, g) This patient shows a short nose, retracted
columella, and pinched tip. (f, h) Postoperatively, he has a
nose with proper length, well-expanded tip without pinch-
ing appearance, and no retracted columella
Nasal Tip Techniques (1): Tip Augmentation Techniques

70
Although a derotation graft is a very useful way
of correcting a short nose, it also has its ­limitations
in application. It is difficult to effectively elongate
the nose if the caudal septum is considerably short
and/or if the distance between the caudal septal
margin and the new alar cartilage position is too
far to allow the graft to bridge the gap, maintaining
the tip elongation. Even if the tip lengthening is
sufficient, the derotation graft cannot resist the
tension after closure in patients with tight skin and
a short septal length. Therefore, for patients with a
short nose and severely retracted columella, a sep-
tal extension graft is necessary to appropriately
push down the columellar base.
In patients having a short nose with a short
septal length and/or severely retracted columella,
a septal extension graft is a good solution, as it
allows the dome to move caudally and pushes
down the columellar base. Fixing the medial
crura of the alar cartilages to a septal extension
graft leads to an uncomfortably rigid nasal tip
and columella, resulting in unnatural facial ani-
mation (Fig. 42).
Further, because of the relatively small and
weak septal cartilage in the East Asian popula-
tion, the under-correction of a short nose is not
uncommon. To overcome these shortcomings,
the combination of septal extension graft and
derotation graft enables to avoid over resection of
septal cartilage and help to maintain tip mobility
(Fig. 43).
a
b
c
d
e
f
g
h
Fig. 42  Comparison between a rigid immobile tip and a
soft mobile tip. (a–d) This patient underwent the septal
extension graft, resulting in a rigid immobile tip resulting
unnatural looking in animation. (e–h) After replacing the
septal extension graft with a columellar strut and derota-
tion graft using ear cartilage, the tip became movable, and
she recovered her natural-looking in animation
M. H. Paik and L. S. Chu

71
a
b
c
d
e
f
g
h
i
Fig. 43  Combination of septal extension graft and dero-
tation graft. (a) Schematic drawing of combination tech-
nique. (b) Moderated lengthening of the septum. (c) A
derotation graft was placed between the septal extension
graft and lateral crura. (d, f, h) This patient shows a short
nose and retracted columella. (e, g, i) Postoperatively, her
nose was elongated, retracted columella was corrected,
and she can maintain tip softness and movability
Nasal Tip Techniques (1): Tip Augmentation Techniques

72
Further Reading
Byrd HS, Andochick S, Copit S, Walton KG.  Septal
extension grafts: a method of controlling tip projection
shape. Plast Reconstr Surg. 1997;100(4):999–1010.
Deva AK, Merten S, Chang L. Silicone in nasal augmen-
tation rhinoplasty: a decade of clinical experience.
Plast Reconstr Surg. 1998;102(4):1230–7.
Dingman RO, Walter C. Use of composite ear grafts in
correction of the short nose. Plast Reconstr Surg.
1969;43(2):117–24.
Gruber RP.  Lengthening the short nose. Plast Reconstr
Surg. 1993;91(7):1252–8.
Gruber RP. Surgical correction of the short nose. Aesthetic
Plast Surg. 2002;26 Suppl 1:S6.
Gruber RP, Kryger G, Chang D.  The intercartilaginous
graft for actual and potential alar retraction. Plast
Reconstr Surg. 2008;121(5):288e–96e.
Gunter JP, Rohrich RJ.  Lengthening the aesthetically
short nose. Plast Reconstr Surg. 1989;83(5):793–800.
Guyuron B, Varghai A.  Lengthening the nose with a
tongue-and groove technique. Plast Reconstr Surg.
2003;111(4):1533–9.
Ha RY, Byrd HS. Septal extension grafts revisited: 6-year
experience in controlling nasal tip projection and
shape. Plast Reconstr Surg. 2003;112(7):1929–35.
Kang JG, Ryu J. Nasal tip Surgery using a modified septal
extension graft by means of extended marginal inci-
sion. Plast Reconstr Surg. 2009;123(1):343–52.
Lee Y, Kim J, Lee E. Lengthening of the postoperative
short nose: combined use of a gull-wing concha com-
posite graft and a rib costochondral dorsal onlay graft.
Plast Reconstr Surg. 2000;105(6):2190–9.
Paik MH. Correction of short nose. Arch Aesthtic Plast
Surg. 2005;11(1):22–6.
Paik MH, Chu LS.  Correction of the short nose
using derotation graft. Arch Aesthetic Plast Surg.
2012;18(1):35–44.
Paik MH, Chu LS.  Correction of short nose deformity
using a septal extension graft combined with a derota-
tion graft. Arch Plast Surg. 2014;41(1):1–7.
Palacin JM, Bravo FG, Zeky R, Schwarze H. Controlling
nasal length with extended spreader grafts: a reliable
technique in primary rhinoplasty. Aesthetic Plast Surg.
2007;31(6):645–50.
Toriumi DM, Swartout B. Asian rhinoplasty. Facial Plast
Surg Clin North Am. 2007;15(3):293–307.
M. H. Paik and L. S. Chu

73
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. K. SUH (ed.), State of the Art Rhinoplasty Techniques,

Nasal Tip Techniques (2): Bulbous
Tip Correction
Sung Wan Park
Introduction
Definition
A bulbous tip of the nose, along with a low dor-
sum, is the chief complaint of Asians. Correcting
the bulbous tip of the nose accounts for most tip
plasty in Asians. However, the bulbous tip of the
nose has not yet been clearly defined. It is charac-
terized by tip defining points that are poorly
defined and a wide gap between the tip defining
points. Jeong et al. arbitrarily defined the case in
which the tip width was wider than 0.6 of the alar
width as a bulbous tip. A low dorsal height may
also contribute to the lower third to appearing
wider in the frontal nasal view, and a wide alar
lobule area may also make the tip appear bul-
bous. Therefore, even patients who want to have
a bulbous tip correction may not be able to clearly
distinguish between a nose with a bulbous tip or
a nose with a broad tip and wide alar base. The
boxy tip is defined as a convex lateral crus, wide
dome arc, and interdomal distance with a rectan-
gular shape in the basal view and is known to be
different from the bulbous tip, but a similar cor-
rective strategy can be adopted in Asians.
Etiology and Types
Advancements in modern tip plasty for
Caucasians have been made through various
attempts to correct bulbous tips, especially the
cartilaginous tissues of bulbous, broad, boxy, and
bulky tips. Tip plasty for Asians has also made a
lot of progress based on modern tip plasty using
autologous cartilage tissues, breaking away from
the method relying on alloplastic material in the
past. Nevertheless, it is important to consider that
Asians have many different anatomical aspects
compared to Caucasians. The bulbous tips of
Asians are largely divided into two categories
depending on the thickness of the skin and soft
tissue envelope (SSTE), and the degree of carti-
lage development: the types with a large and
wide cartilaginous structure, resulting in a bul-
bous nose despite a thin or adequate SSTE simi-
lar to that of a Caucasian, and the types with
thicker SSTE than Caucasians, with a small and
weak lower lateral cartilage and a low and short
nasal bone and septal cartilage. Jeong et al. have
further subdivided the latter types into those with
denser dermal fibrotic tissues and those with
loose fibro-fatty tissues. Suh has classified bul-
bous tip into cartilage predominant, soft tissue
predominant, mixed type as well. As such, Asians
tend to have thick SSTE and lack cartilaginous
development. Therefore, to overcome these ana-
tomical disadvantages and obtain a clearly
defined nasal tip with an acceptable nasal tip
S. W. Park (*)
April31 Plastic Surgery Clinic,
Seoul, South Korea

74
shape, sufficient projection through the cartilagi-
nous tip plasty, and proper management of SSTE
of the nasal tip, which is highly difficult, is essen-
tial. This section describes the nasal tip SSTE
management and cartilaginous modifications
reflecting the anatomical characteristics of Asians
to correct a bulbous tip, which is a challenging
procedure.
Preoperative Analysis
The formation of a bulbous tip contour by the
underlying cartilaginous structure and overlaying
SSTE is complex. Preoperative evaluation is very
important for correcting this. Aesthetic and func-
tional assessments related to structural rhino-
plasty should also be performed. The operator
can establish an operation plan by comparing the
underlying anatomic structure and the external
contour through visual assessment, palpation,
and preoperative analysis while determining the
cause of the underlying anatomy, the changes
required to make the nose look less bulbous, and
the limit for these changes. This information
should be conveyed to the patients for their
understanding of the cause of the bulbous nose as
well as the limitations of the bulbous tip correc-
tion, to convince them about the results.
Visual Analysis
First, the overall nasal proportion should be
observed. If the dorsal height is too low, the tip of
the nose may appear more bulbous than it actu-
ally is. The potential of a relatively wide alar lob-
ule making the nose look wide should also be
considered. It is important to evaluate the bul-
bous tip from the front. While the tip defining
point is unclear and appears wide, the region
between the two supra-alar grooves separated
from the tip lobule and the alar lobule each other
are seen as amorphous as if they were combined
as a single tip (Figs.  1 and 2). Toriumi et  al.
emphasized the highlight and shadow of the
three-dimensional Ideal nasal tip contour, and
Casir et  al. also used polygons to show an in-­
depth model of the ideal shape of the entire nose.
Compared with these, the lateral crus, not the
domal segment of the alar cartilage middle crus,
is higher than the contour of the tip. Depending
on the condition of the soft tissue, sometimes the
alar groove leading from the lateral region to the
medial region is visible, and the cephalic portion
appears wider than the caudal side of the tip as if
pinched.
From the side, the tip defining point is not
clearly apparent because of the thick skin with
less tip projection due to the less developed alar
cartilage characteristic of Asians, especially the
medial crus. The lateral crus along with the cau-
dal end of the dorsal septum, appears higher than
the tip defining the domal segment, while the tip
defining point seems to be missing. In addition,
the thick SSTE on the caudal end of the dorsal
septum may contribute to supratip fullness as
well as pollybeak deformity in some cases
(Figs. 1 and 2).
The smooth transition of the alar margin from
the tip lobule to the alar lobule is emphasized in
modern rhinoplasty. In correcting a bulbous tip, a
pinched tip deformity may occur in cases of over-
correction; therefore, achieving a natural and aes-
thetically pleasing tip is more important than
focusing solely on the narrowing of the bulbous
tip (Fig. 3).
Physical Analysis
Most of the skin at the bulbous tip of the nose of
Asians is thick and oily with well-developed
sebaceous glands and large surface pores. The
dermal component of the skin is thick, and its
elasticity is often limited compared to that of
Caucasians. A pinching test with fingers may be
performed to determine how well it stretches, and
whether the gliding plane can be detected. If the
SSTE is thick, it may not be detected effectively.
The thickness of the dermal layer and the sturdi-
ness of the lower lateral cartilage should also be
examined. If the dermal layer is thick, the extent
to which nasal SMAS can be removed without
injuring the dermal vascular plexus should be
determined during the opening dissection, and it
S. W. Park

75
a
c
d
b
Fig. 1  Bulbous tip. SSTE type. SSTE is thick and dense. However, lower lateral cartilage and septal structure are small
and weak
Nasal Tip Techniques (2): Bulbous Tip Correction

76
a
c
d
b
Fig. 2  Bulbous tip. Cartilaginous type. The alar cartilage is wide and large, and has a convex lateral crus large enough
to be classified as a boxy tip. The SSTE is relatively thin
S. W. Park

77
is recommended to check the dermal layer of the
supratip break portion as well.
It is also important to examine the structural
anatomy. To rebuild the nasal tip tripod, the
required amount of projection, and the method to
achieve it could be planned by palpation using
finger pressure, to determine whether the length
and height of the caudal septum, as well as the
lower-third portion from the caudal septum,
through the membranous septum, to the medial
crus of the columellar portion, can maintain the
projection of the tip appropriately. In addition, it
is possible to make the patient aware of the
change in the tip cartilaginous complex by per-
forming a simulation to reduce bulbosity by
molding certain parts by palpation considering
the underlying anatomical structure.
Operative Consideration
Thinning and Debulking of Skin
and Soft Tissue Envelope
When the SSTE is determined to be thick through
various nasal tip analyses described above, the
SSTE can be surgically thinned and a lot of
efforts are made to reduce bulbosity, however,
thinning of the thick skin of Asians is difficult.
Anatomically, the nasal tip of Asians has a small
a
c
b
Fig. 3  Aesthetically ideal and favorable tip contour. (From Dr. Dean Toriumi)
Nasal Tip Techniques (2): Bulbous Tip Correction

78
cartilage, and even with a lot of cartilage modifi-
cation, the tip definition is insufficient. Even if
nasal SMAS is sufficiently removed, the skin rich
in dermal components and dense fibrotic tissue is
firm and lacks elasticity. Even with sufficient car-
tilaginous tip defining shaping through the tip
plasty, the external tip contour is not well demar-
cated because of the immediate shuffle effect and
insufficient redraping of the skin. If the dermal
component of such dense skin is removed forci-
bly, the subdermal plexus, which is responsible
for most of the blood supply to the nasal tip, may
be damaged and cause vascular problems.
Therefore, it should be noted that there is a limi-
tation of bulbous tip correction for patients with
nasal tip skin with the above characteristics.
However, compared to Caucasians, the fact
that the tip graft has less demarcation and visibil-
ity in tip contour could be the advantage of thick
Asian skin.
Dual Plane Dissection and Debulking
The skin and soft tissue of the nasal tip consist of
an epidermis layer, a dermis layer, a muscle layer,
and a nasal submuscular aponeurotic system
(SMAS) layer. In the preoperative analysis, con-
sidering the plane for dissection is very important
for opening and uncovering according to the type
after examining the thickness of the SSTE.
In general, if the SSTE is adequate or rather
thin, supraperichondrial dissection should be per-
formed while preserving the skin and soft tissue
as much as possible to prevent excessive external
demarcation of the underlying cartilaginous
structure. It is better to avoid bare exposure of the
alar cartilage. Unlike the alar cartilage of
Caucasians, the bare cartilage of Asians is very
thin and fragile, and cheese wire cutting of the
alar cartilage by suture material often occurs
while performing various suture techniques.
Since there is a possibility that the structure
retention of the nasal tip complex by tightening
the suture is reduced in the long term, it is desir-
able to perform supraperichondrial dissection
with a small amount of soft tissue attached.
For a thick SSTE, dual plane dissection with
the subdermal SMAS and supraperichondrial
planes is a way to debulk the nasal SMAS
between the dermis layer and perichondrium as
much as possible (Fig. 4). First, dissection should
be performed by attaching soft tissue, including
the nasal SMAS, to the cartilage structure as
much as possible through the nasal SMAS and
subdermal planes. The amount of nasal SMAS to
be removed can be controlled by adjusting the
depth of the plane according to the degree of bul-
bous tip or the amount of soft tissue to be deb-
ulked. Dissection may be performed while
checking the dermis layer by palpation using fin-
gers on the outer skin and visually through direct
vision. During dissection, the subdermal plexus
tends to bleed significantly, requiring frequent
cauterization. When transitioning to the bound-
ary of the dorsal septum and upper lateral carti-
lage after crossing the cephalic margin of the tip
and lateral crus by subdermal dissection, it must
proceed to the supraperichondrial plane again. If
necessary, excision of the soft tissues on the lat-
eral side of the upper lateral cartilage may be per-
formed (Fig. 5). However, excessive soft tissue
excision should be avoided as dorsal nasal artery
branches can be encountered at the supratip and
paramedial sides. After placing enough soft tis-
sue above the cartilage, the soft tissue including
nasal SMAS may be excised carefully with scis-
sors, or SMASectomy may be performed en bloc
by elevation of the nasal SMAS flap through
supraperichondrial dissection. With the suprap-
erichondrial plane dissection, the elevated nasal
SMAS flap can be used for soft tissue reinforce-
ment in the required area as a superior-based flap,
or as a soft tissue-free graft (Fig. 6). If the SSTE
is not very thick, rather than en bloc excision, it is
more desirable to preserve the soft tissue at the
tip defining point and only reduce the bulkiness
of the lateral side of the tip by soft tissue partial
excision of the geographic pattern on the cephalic
border of the lateral crus to reduce the bulbosity
seen in the external contour while maintaining a
natural transition of caudal alar margin and pre-
venting the tip of the thinned skin from becoming
sharp (Fig. 7).
Defatting Procedure
First, dissection is performed through supraperi-
chondrial dissection, attaching the nasal SMAS
S. W. Park

79
a
b
Fig. 5  (a) During Nasal SMAS dissection, some excision
of soft tissue can be performed by dissecting to the upper
lateral cartilage area through the lateral crus. However,
caution must be taken for bleeding at all times. (b) If
SSTE is not thick, supraperichondrial plane dissection can
be proceeded in most cases. Yellow line: dissection plane
a
c
d
b
Fig. 4  (a) Dissection to the nasal SMAS plane. (b–d) Elevation of nasal SMAS flap for excision after dual plane
dissection
Nasal Tip Techniques (2): Bulbous Tip Correction

80
and the soft tissue to the uncovered skin flap, and
then after turning it inside out defatting or deb-
ulking procedure is done using Metzenbaum
scissors (Fig. 8). In most cases, this is done in
addition to the excision of soft tissue performed
en bloc, or it is the method of performing a small
amount of debulking or geographic pattern par-
tial thinning after supraperichondrial plane dis-
section for SSTE of moderate thickness. Defatting
with scissors should be performed to the extent
by which the whitish dense and firm dermis layer
is visible while palpating the thickness of the skin
with fingers. Damage to the subdermal plexus
may occur while forcibly removing the dermis
layer, and thermal damage may occur when elec-
trocauterizing small blood vessels. At this time,
local infiltration and topical dripping of
tranexamic acid are useful. Partial necrosis of the
tip and its surroundings tends to occur, so care
should be taken to avoid circular problems and
followed depressed scars. In particular, smokers
or those with a thick dermis layer, larger pores,
a
b
Fig. 7  Geographic pattern SMASectomy. If the SSTE is
not thick throughout the entire tip, performing partial geo-
graphic pattern SMASectomy according to the perop.
external nasal contour rather than en bloc resection helps
to maintain the smooth transitional continuity of the cau-
dal border of the lateral crus
a
b
Fig. 6  Elevated nasal SMAS can be used as a soft tissue flap, or excised nasal SMAS can be used where necessary as
a soft tissue-free graft
S. W. Park

81
and an abundance of sebaceous glands are more
susceptible to vascular deprivation, warranting
further caution.
Step-by-step excision or hedging and scoring
procedures can be performed using Metzenbaum
scissors or blades if the dermis layer is very thick
on the undersurface of the elevated skin flap as
dual plane dissection is too difficult or if there is
a thick scar tissue during reoperation. The
­procedure itself is difficult because bleeding eas-
ily occurs in the subdermal plexus, and care must
be taken to avoid thermal injury to the subdermal
plexus that may occur during electrocautery.
Nasal Tip Refining and Reduction
for Bulbous Tip Correction
Many of the tip plasty procedures that have been
developed to date are part of the effort to correct
the bulbous tip of Caucasians, which has been
used to define the tip contour through changes in
the underlying cartilage tissue with the suture
technique. In the past, a bulbous, broad, boxy, or
bulky tip was improved by removing some of the
cartilage tissue involving excessive cephalic
trimming and performing destructive and aggres-
sive procedures such as scoring or dome division
of the cartilage. In recent modern rhinoplasty, tip
plasty of alar cartilage has been developed into a
form of nondestructive tip tripod rebuilding using
a suture technique that preserves the original car-
tilage tissue with minimum cephalic trimming,
while achieving a well-defined nasal tip.
Intraoperative Analysis
Intraoperative analysis of alar cartilage after
nasal skin uncovering, plays a very important
role in establishing a tip structuring and grafting
plan. Examining the size and strength of the alar
cartilage, the size and strength of the septal carti-
lage, and the location of the caudal septum are
very important in deciding which method to use
for tip projection. The shape, convexity, plane,
direction, and width of the lateral crus are critical
for determining tip shaping to reduce bulbosity
(Fig. 9). The suture technique should be selected
by considering the underlying structure with the
external tip contour before surgery.
Suture Technique and Procedures
for Correction of Bullous Tip
Unlike Caucasians, Asians have a very fragile and
small alar cartilage and a thick and heavy skin, so
tip defining is not easily accomplished with suture
technique alone, and the amount of change in car-
tilage shape is not much compared to that of
Caucasians. There are suture techniques that may
not be necessary depending on the situation, as
more effective changes can be made with the help
of a graft. Nevertheless, suture techniques are the
most basic cornerstones for inducing projection,
rotation, and tip definition by changing the shape
of the alar cartilage. Therefore, it is very impor-
tant to understand the change on the alar cartilage
by each suture technique to create an ideal tip tri-
pod structure. Among various suture techniques,
procedures involved in bulbous tip correction
should be reviewed, and how it can be applied to
small and weak cartilages in Asians should always
be considered.
Medial and Middle Crural Suture
The most important key for the medial and middle
crural sutures in Asian rhinoplasty is that it is used
with the columellar strut to reinforce the support
of the nasal tip projection (Fig. 10). There is also a
Fig. 8  Defatting and debulking procedure. It is recom-
mended to proceed while feeling the thickness of the skin
with your fingers. At all times, care must be taken not to
cause skin necrosis and depressed scars around the tip and
its surroundings caused by subdermal plexus vascular
injury during debulking procedure and electrocauterization
Nasal Tip Techniques (2): Bulbous Tip Correction

82
function of adjusting the asymmetry of the medial
and middle crus or reducing the columellar width.
If the medial crus is strong or the projection of the
tip is sufficient, requiring no additional projection,
it would be possible to use only the suture without
the columellar strut. In Asians, the medial crus is
very weak and short, and the tip can be properly
defined only when the projection through rein-
forcement of the medial crura is sufficiently
achieved using the columellar strut.
Interdomal Suture
It is a suture technique that reduces the width
between domes by narrowing the domal diver-
gence angle, which can reduce the overall width of
the tip and correct asymmetry (Fig. 11). In Asians
a
b
c
d
Fig. 9  Boxy tip. Operative and corrective plans should be determined from Intraoperative findings. Convex lateral crus,
wide domal arc and wide interdomal distance can be seen, and SSTE is relatively not thick
S. W. Park

83
with low convexity of the alar cartilage, ambiguous
boundary between the medial crus and the dome,
and thick skin, it is often regarded as a suture per-
formed at the apex of the tip of the columellar strut
along the added extension of the medial crural
suture. Because onlay grafts such as cap grafts and
shield grafts are placed on top of them, reinforce-
ment of projection using columellar struts is often
the most important purpose. If the alar cartilage is
bulbous and large, the domal anterior separation
angle (alar flare angle) is also distinct. Therefore,
the stronger the caudal interdomal suture, the more
severe the bulging of the lateral crus. In this case, a
lateral crural spanning suture is essential for bul-
bous tip correction.
a
c
b
d
Fig. 10  (a) Medial crural suture. (b) Middle crural suture. (c, d) Various columellar strut. Medial and middle crural
suture is mostly used with columellar strut
Nasal Tip Techniques (2): Bulbous Tip Correction

84
Transdomal Suture and Hemitransdomal
Suture
Transdomal suture induces a change in the dome
shape and tip definition through the horizontal
mattress suture to the domal segment. It reduces
the convexity of the lateral crus and enables
slight caudal rotation or cephalic rotation
depending on the position of the suture with a
slight projection (Fig. 12). However, in Asians,
the cartilage is small and an onlay tip graft is
mostly used, hence, it may not be as effective. It
is desirable to perform this after accurately judg-
ing the condition and state of the alar cartilage as
it may cause a pinched tip, soft triangle notch-
ing, alar collapse, etc.
The hemitransdomal suture was mentioned
by Tardy et  al. as a modificated transdomal
suture performed on the cephalic end of the
dome. It allows the caudal border of the lateral
crus to be changed by eversion while narrowing
the dome and reducing lateral crural convexity
(Fig. 13). The eversion and expansion of the lat-
eral crus caudal border are very important for
changing the alar cartilage shape of the bulbous
tip and complete the nasal tip tripod structure. If
the conventional transdomal suture is performed
in the form of inversion of the lateral crus cau-
dal border, bulbosity can worsen. Therefore, a
hemitransdomal suture should be performed
with attention to the cephalocaudal plane of the
lateral crus.
Lateral Crural Spanning Suture
The lateral crural spanning suture has been men-
tioned by Tebbett and is also referred to as the
lateral crural suture. It is an effective method
widely used for bulbous tip correction as it
reduces lateral crural convexity by suturing in the
form of a horizontal mattress in the middle por-
tion of the cephalic side of the lateral crura, and
also has an effect of narrowing the interdomal
distance by narrowing the distance between the
lateral crura (Fig. 14). It can be adjusted accord-
ing to the degree of suture tension. Care must be
taken to adjust the tension; alar buckling by sig-
nificantly tight sutures may cause pinched tip
deformity, requiring alar rim graft, or worsening
medialization of the lateral crus after excessive
cephalic trimming, resulting in alar retraction. To
prevent these alar retractions or pinched tip
deformity, alar spreader-type dorsal batten grafts
can be used.
In recent modern Western rhinoplasty, a lat-
eral crural strut graft technique has been widely
used for the correction of cephalic malposition of
the lateral crus to reduce bulbosity as well as
complete reshaping of the nasal tip tripod struc-
ture. In such cases, the lateral crural spanning
a
b
Fig. 11  Interdomal suture
S. W. Park

85
suture, which is highly likely to medialize the lat-
eral crus, has limited use.
Cephalic Trimming of Lateral Crus
Cephalic trimming is a procedure that enables
various suture techniques while actually reducing
the convexity of a boxy or bulbous tip by excision
of the cephalic end of the lateral crus. It has long
been regarded as a routine procedure for reducing
nasal tip plasty. Since cephalic trimming is a
destructive procedure that cannot be reversed, it
is necessary to control the amount and degree
clearly by intraoperative assessment, as well as to
carefully determine the relationship with other
grafting
procedures
or
suture
techniques
(Fig.  15). Recently, in modern tip plasty for
Caucasians, cephalic malposition correction of
the lateral crus using a lateral crural strut graft
has been performed for bulbous tip correction.
Nevertheless, aggressive cephalic trim increases
the risk of complications such as pinched tip
deformity, alar retraction, and external valve col-
a
b
Fig. 12  Transdomal suture
a
b
Fig. 13  Hemitransdomal suture. This tip defining suture enables outward eversion of caudal border of lateral crus. This
plane of lateral crus can make the nasal tip less bulbous and less pinched as well
Nasal Tip Techniques (2): Bulbous Tip Correction

86
lapse, especially in thin-skinned patients with a
weak alar cartilage.
Similarly, cephalic trimming should be per-
formed conservatively in tip plasty in Asians. If
cephalic trim is performed on the severely con-
vex part routinely, the width of the lateral crus
decreases and the lateral crus strength required
for tip projection is weakened. When the scroll
and hinge areas are sufficiently released and sep-
arated, the connection with the upper lateral car-
tilage is broken, and some of the convexity
memory of the lateral crus is lost, making it eas-
ier to transform into a flat or concave lateral crus
even without routine cephalic trimming. If the
width of the alar cartilage to be used for the pro-
jection and tip extension is lost or reduced by
routinely performed cephalic trimming, the tip
projection becomes difficult, and the effect of
the tip extension achieved from the strengthen-
ing of the alar cartilage is greatly reduced, result-
ing in a high risk of complications such as rotated
upturned tip, alar retraction, alar notching, and
pinched tip. Therefore, it is recommended to
trim or excise only the excess parts based on a
thorough assessment of the desired gain after
improving the convexity of the lateral crus by
sufficient release of the scroll area and nasal
hinge (Fig. 16).
Rebuilding of Nasal Tip Tripod
with Tip Refinement in Asian
Rhinoplasty
Complete Release of Alar Cartilage
In rebuilding the tip structure, the nasal tip tripod
concept plays a very significant role. Anderson
described the conjoined medial crus and both
lateral crura as the three limbs of a tripod
(Fig. 17). Tripod theory has been used to explain
nasal tip dynamics and allow the conceptualiza-
tion of maneuvers that will alter tip projection,
rotation, nasal length, and width. The complete
release and rebuilding of the alar cartilage can
achieve the desired result through sufficient alar
cartilage lengthening and projection. For Asians
who need tip projection, extensive release of tip
supporting structures such as the scroll area,
nasal hinge, and membranous septum is required
(Fig.  18). Tip supporting structures generally
play a role in maintaining the projection of the
tip, but because they are rather restrictive to
a
b
Fig. 14  Lateral crural
spanning suture
S. W. Park

87
obtain additional projection and lengthening, the
supporting
structure
must
be
sufficiently
released.
Rebuilding Nasal Tip Tripod
The most commonly used methods for tip plasty
in Asians are the columellar strut graft and the
septal extension graft. Both methods require a
supportive force of the caudal septum. Unlike the
septal extension graft, in which the direct tip
position is determined, the method of using the
columellar strut graft is based on the strong tip
extension or tip expansion force of the alar carti-
lage complex in which tip projection by columel-
lar strengthening and derotation are combined. In
other words, the projection of the tip can be max-
imized by the centralizing caudal rotation vector
transmitted indirectly by the lateral crus while
a
d
b
c
Fig. 15  Various types of cephalic trim. (a) Separation of upper and lower laterals (scroll incision). (b) Limited cephalic
trim (scroll area only). (c) Standard cephalic trim. (d) Extended cephalic trim
Nasal Tip Techniques (2): Bulbous Tip Correction

88
a
b
Fig. 16  The conventional cephalic trim of the lateral crus
is not needed in most Asians. While preserving the lateral
crus as much as possible, only the bulging cephalo-medial
portion due to overlapping of both lateral crura requires
minimal excision. After excision, it is possible to reduce
bulbosity and strengthen tip lengthening with lateral cru-
ral spanning suture
Fig. 17  Anderson’s tip tripod concept
Fig. 18  Tip supporting structure. These structures should
be released to rebuild the ideal nasal tip tripod complex
S. W. Park

89
restraining and preventing cephalic rotation in
the caudal septum, and by the cephalic rotation
vector of the strengthened columellar strut
(Fig. 19). Choi et al. have described this form as
a qaudripod concept by adding septal support to
the tripod. For nasal tip rebuilding through tip
extension or expansion concept in Asian nose
surgery, it is desirable to perform both the projec-
tion and the bulbous tip correction simultane-
ously, while various suture techniques and grafts,
which have been known for many effects and
functions, form a complex and systematic rela-
tionship to achieve contouring of the tip cartilagi-
nous framework.
Ideal Nasal Tip Refinement of Alar
Cartilage for Bulbous Tip Correction
The nasal tip definition that creates an aestheti-
cally ideal nasal tip contour for bulbous tip cor-
rection is not achieved by simply trimming the
alar cartilage and narrowing the wide interdomal
width. Many authors have pointed out that the
bulbous tip contour can be corrected only by
reshaping or remodeling in a shape as close as
possible to the ideal nasal tip framework. Bulbous
tip narrowing without considering nasal tip
reshaping causes more immediate and late
complications.
When it comes to the refinement of the ideal
nasal tip, the most essential factor is the shape of
the lateral crus of the alar cartilage. The shape of
the lateral crus includes the anteroposterior rela-
tionship, plane, and direction of the lateral crus.
In particular, the most important point is that the
lateral limbs of the nasal tip tripod concept should
be composed of the caudal border, not the
cephalic border of the lateral crus (Fig. 20). The
lateral crus showing a bulbous contour may be
convex, but if the projection is weak, the cephalo-­
medial border is high and the caudal-lateral bor-
der is low as it is at the same or higher position
than the dome. It has a more vertical direction,
and it can be observed that the plane of the lateral
crus is in the form of outward inversion.
Eventually, the highlight contour of the bulbous
nasal tip is caused by the convexity of the lateral
crus and the higher position of the cephalic bor-
der. To reshaping tip and reduce bulbosity, the
cephalic border of the lateral crus should be low-
ered to create a shadow contour, and the tip defin-
ing point should be achieved to the most projected
highlight contour, while the plane of the lateral
crus is in the form of an outward eversion
(Fig. 21). The cephalic portion of the lateral crus
should be lowered toward the caudal septal angle,
and sufficient tip projection of the medial crus
and the middle crus portion should be performed
at the same time to make the convex lateral crus
a
b
Fig. 19  Illustration of tip extension force. The caudal
rotation force is supported by the caudal septum and
transmitted indirectly by the lateral crus, and the cephalic
rotation force generated by the columellar strut, generates
the tip extension force that causes both tip advancement
and projection
Nasal Tip Techniques (2): Bulbous Tip Correction

90
flat or slightly concave and to fully expand the
caudal border of the lateral crus. This can be a
method of shaping an aesthetically pleasing tip
by correcting a bulbous tip through a tip exten-
sion procedure.
Tip Extension Suture
The tip extension suture concept introduced by
Kim et al. is a single suture technique concept,
which is a multifunctional and simple yet power-
ful tip extension procedure in which sufficient
caudal advancement can be performed on the lat-
eral crus of the completely released alar cartilage
to fix it to the caudal septal angle to promote the
derotation and projection of the low and upturned
tip in Asians. As mentioned above, a strong nasal
tip tripod can be formed by the tip extension
suture, and the nasal tip complex made in this
way plays an important role in forming the ideal
nasal tip contour.
The most common sutures involved in bul-
bous tip redefining include the cephalic hemi-
transdomal suture, which can contribute to the
slight rotation of the tip and convert the lateral
crus into an outward eversion form, and the lat-
eral crural spanning suture which can reduce the
convexity of the lateral crus (Fig. 22). However,
the small and weak domal segment of Asians
often does not allow precise transdomal suture at
the desired location, unlike that of Caucasians,
and it is often difficult to change the entire lateral
crus, which is fragile and flexible, with only
transdomal suture. Although the lateral crural
spanning suture can slightly reduce the tip width,
it is difficult to lower the height of the lateral crus
cephalic border, which is higher than the caudal
border of the lateral crus. Moreover, these sutures
only transform the shape within the frame of the
alar cartilage, and they do not play a major role in
the projection or strengthening of the entire nasal
tip complex required for Asian rhinoplasty.
At this time, the tip extension suture can be
used to achieve the two purposes of tip projection
and bulbous tip correction. The bulbous tip cor-
rection in thick-skinned patients is not obtained
simply by changing the shape of the cartilage, but
by achieving ideal rebuilding of the entire nasal
tip complex. The lateral crus can be sufficiently
advanced by fully releasing the alar cartilage, and
the cephalic border of the lateral crus is fixed and
lowered on the caudal septum to allow sufficient
tip projection with a strong columellar strut based
on the septal support, and to effectively obtain
the ideal plane and concavity of the lateral crus. It
can be used alone or with various suture tech-
niques and graft techniques, and can be main-
tained by stable scar casting (Fig.  23). After
applying the tip extension suture and columellar
strut graft, minimal cephalic trimming is per-
formed only on the lateral crura that bulge upward
a
b
Fig. 20  In the tip tripod concept, the lateral limbs must be the most prominent portion of the caudal border, not the
cephalic border of the lateral crus, for correction of the bulbous tip and rebuild ideal nasal tip tripod
S. W. Park

91
a
b
c
e
d
Fig. 21  (a, b) Illustration of outward eversion of lateral crus. (c, d) Intraoperative demonstrative findings of outward
eversion of lateral crus. (e) Intraoperative finding of outward eversion of lateral crus
Nasal Tip Techniques (2): Bulbous Tip Correction