92
overlapping each other along the cephalo-medial
border of the lateral crus fixed to the caudal
septum, and a spanning suture is performed on
them to increase the extension force of the tip
while completing the tip rebuilding structure of a
strong and ideal shape that can transfer the out-
ward eversion force of the lateral crus from the
septum to the lateral crus caudal borders that
b
a
Fig. 22 Lateral crural spanning suture. Bulbosity may be reduced by mattress suture on both lateral crus to reduce
convexity
a
b
Fig. 23 Illustration of tip extension suture. Advancement and projection can be achieved at the same time by using a
columellar strut
S. W. Park
93
constitute the lateral limbs of the tip tripod
(Fig. 24). At the same time, the convexity of the
lateral crus, which is the cause of the bulbosity,
decreases, and the cephalic border of the lateral
crus is lowered, and the caudal border becomes
more prominent to make the highlight and
shadow of the external tip contour clearly distin-
guished for effective bulbous tip correction
(Fig. 25).
Understanding the anatomical characteristics
of the Asian nose related to rhinoplasty is a pre-
requisite for performing tip extension sutures.
For nasal hinge release, a broad dissection of the
LLC lateral crus is required, and this step plays a
very important role.
Even in the tip tripod concept, the free move-
ment of the two limbs formed by the lateral crura
is possible only when the nasal hinge and the
pyriform ligament are sufficiently separated.
Rohrich et al. and Han et al. also mentioned the
usefulness of releasing supporting structures
such as the scroll area and the nasal hinge for cor-
recting short noses in Asians.
Tip extension suture can be said to be a variation
of the lateral crural spanning suture method. The
lateral crural spanning suture provides slight tip
projection improvement and caudal rotation of the
lateral crus by pulling and connecting both lateral
cruses using horizontal mattress sutures without
damaging the surrounding structural support. On
a
b
c
d
Fig. 24 Tip extension suture. Rebuilding of the nasal tip is completed after applying tip extension suture with a colu-
mellar strut, minimal cephalic trimming, and lateral crural spanning suture
Nasal Tip Techniques (2): Bulbous Tip Correction
94
the other hand, tip extension suture is a powerful tip
extension and expansion procedure that can effec-
tively achieve the outward eversion of the lateral
crus, which is implemented after complete release
of the lateral crus and can effectively reduce bul-
bosity while creating a new nasal tip complex.
The following requirements must be satisfied
to perform the tip extension suture: (1) sufficient
durability of the alar cartilage, (2) sufficient lat-
eral crural width, and (3) sufficient nasal septal
height and length. The lateral crus of the alar car-
tilage should be strong enough to withstand the
fixation suture, a sufficient width to minimize the
risk of pinched tip deformity or external valve
collapse should be ensured, and the nasal septal
length and height should be sufficiently devel-
oped to be suture-fixed while extending after the
release of the alar cartilage (Fig. 26).
If the above conditions are not satisfied, it is
not easy to transfer supportive force from the
caudal septum to the caudal border of the lateral
crus, and gap-spacing with an interpositional
graft is required for indirect transmission.
Performing a tip extension suture without bridg-
a
c
b
Fig. 25 (a, b) Ideal tip contouring using tip extension suture. (c) The bulbous tip is corrected as the tip tripod and dorsal
line have clear highlights, and as the cephalic border of the convex lateral crus is lowered resulting in a shadow
S. W. Park
95
a
c
b
Fig. 26 In order to perform tip extension suture without
complications, the necessary requirements must be met.
(a, b) Sufficient durability of the alar cartilage and lateral
crural width. Comparison of small and weak alar cartilage
with wide and strong alar cartilage. (c) Sufficient nasal
septal height and length
ing the gap may result in various problems. If the
width or strength of the lateral crus is insufficient,
overmedialization caused by central fixation or
buckling of the lateral crus caudal border due to
excessive concavity may result in complications
such as pinched tip deformity, alar retraction, and
external valve collapse. If the septal length and
height are insufficient, appropriate tip lengthen-
ing and projection cannot be obtained, upturned
tips, pinched tip deformities, and alar retraction
are likely to occur (Fig. 27). In addition, it should
always be noted that fixing the convex lateral
crus to the lower caudal septum can cause or
exacerbate the internal valve problem, and that
the tip may also be deviated by deviated caudal
septum.
Nasal Tip Techniques (2): Bulbous Tip Correction
96
a
b
c
d
Fig. 27 Various complications. (a, b) Pinched tip defor-
mity. (c) Intraoperative findings of pinched tip defor-
mity—excessive cephalic excision, overmedialization
using lateral crural spanning suture and prominent buck-
ling of lateral crus. (d, e) Alar retraction. (f, g) External
valve collapse
S. W. Park
97
e
g
f
Fig. 27 (continued)
Nasal Tip Techniques (2): Bulbous Tip Correction
98
Overcoming Obstacles of Tip Extension
Suture with Dorsal Batten Graft
In a limited situation where the width and strength
of the lateral crus are insufficient for tip exten-
sion sutures, and the septal height and length are
insufficient, the dorsal batten graft for reinforcing
the height and length of the caudal septum may
be used not only to prevent overmedialization
and buckling of the lateral crus, but also to trans-
mit the force from the septum to the tip indirectly
through the lateral crus (Fig. 28).
The dorsal batten graft generally originates
from the derotation graft introduced by Baek
et al. and the alar spreader graft for correcting
alar retraction, as designated by Gunter et al. It
can be grafted by emphasizing the role of derota-
tion for tip lengthening. It can also be applied in
the form of an alar spreader graft that acts as a
gap spacer when strengthening and outward ever-
sion cannot be achieved sufficiently, as the lateral
crus is too pliable to extend with central fixation.
Besides, it can be applied when the size of the
lateral crus is small, or the septum is small and
short while advancing the lateral crus, or when
the gap is wide from the position of the cephalic
border of the lateral crus for fixation to the caudal
septum. Even in this case, the bulbosity can be
corrected by forming an outward eversion-type
tip tripod made by a strong tip projection method
using a central tip extension force and a columel-
lar strut, same as the tip extension suture.
The dorsal batten graft can raise the caudal
septal height. Therefore, if the caudal septal
height is higher than the original tip, or if the tip
projection is insufficient, the cephalic border of
the lateral crus connected with the dorsal batten
graft by suture becomes higher than the tip posi-
tion. In such cases, sufficient lengthening can be
achieved, but projection and bulbous tip correc-
tion may be insufficient or pollybeak deformity
may occur due to the outward inversion of the
lateral crus. It is desirable to apply a dorsal batten
graft after lowering the caudal septal height.
Septal Extension Graft
For tip plasty using a septal extension graft, bul-
bous tip correction can be performed in the simi-
lar way. The septal extension graft is a method
that can facilitate tip projection and lengthening
by caudal septal support. However, it is an intui-
tive and simple method in which the position of
the tip is designated according to the shape and
size of the graft (Fig. 29).
In order to obtain sufficient tip projection and
lengthening, tension-free, extensive, and com-
plete release of alar cartilage is also required.
Even at this time, the position of the cephalic bor-
der of the lateral crus plays an essential role in
reducing the bulbous tip contour. The fully
released lateral crus should be sutured with the
septal extension graft lowered toward the fixed
caudal septum, and the bulging part where the
a
b
Fig. 28 Using a dorsal batten graft, the ideal nasal tripod shape was created to obtain sufficient lengthening of the tip
and reduce bulbosity
S. W. Park
99
Fig. 29 Septal extension graft. Batten-type septal exten-
sion graft is preferable for bulbous tip correction because
cephalic border of lateral crus can be lowered
cephalo-medial border of the lateral crura gath-
ered toward the center overlap, should be made
into a shape with a flat or slightly concave lateral
crus by minimal cephalic trimming and lateral
crural spanning suture connecting through the
septal extension graft. Therefore, it is better to
design the septal extension graft as a batten type
in which the supratip area does not increase in
height and the caudal septum fixed with suture is
low.
In other words, regardless of the material or
method of tip extension suture, dorsal batten
graft, or septal extension graft is used, the ideal
nasal tip tripod shape for bulbous tip correction
should be aimed at the shape of tip extension and
expansion with lateral crural eversion form and
the caudal border of the lateral crus maintaining
continuity without buckling (Fig. 30).
Other Considerations of Bulbous Tip
Correction
Supratip Deformity
For the ideal aesthetic line, a natural supratip
contour line with a tip slightly higher than the
dorsum is desirable, and the tip may appear more
bulbous with pollybeak deformity or supratip
deformity (supratip fullness). Most bulbous and
thick skins tend to exist more widely than the tip
lobule subunit. Although the skin and dermal
layer are thick to the supratip area, it is difficult to
perform sufficient SMASectomy as electrocau-
tery is not easy because of frequent bleeding in
this area, including the dorsal nasal artery branch
in the SMAS layer and dorsal skin is relatively
thin on cephalic to the supratip area, which
requires careful dissection for smooth efface-
ment. This thick dermal layer results in supratip
fullness with slight bulging in the supratip area.
Also, when the tip projection is lost, this phe-
nomenon tends to become more obvious.
To prevent this, scoring or hedging on the
supratip area may be performed to some extent,
but defatting and thinning procedures at the
supratip area should be performed very carefully,
with caution with respect to skin injury due to
vascular insufficiency. If necessary, it is also pos-
sible to eliminate dead space and create a supra-
tip break point by suture approximation to the
dermis layer of the undersurface of the supratip
skin flap and the caudal dorsal septum (Fig. 31).
Structurally, it is desirable to slightly exagger-
ate the cartilaginous supratip break caused by the
height difference between the tip, including the
tip graft and the caudal septal angle or the caudal
end of the silicone implant. It has been recom-
mended that this height difference should be
approximately 6–8 mm for redraped thin skin,
and 8–10 mm distance should be secured for
thick skin (Fig. 32). However, it is important to
consider that the supratip break may be worsened
in thin skin.
Tip Graft
For tip projection and definition, the onlay tip
graft of various cartilages is essential for the
bulbous tip of Asians with thick skin. Tip defini-
tion is planned in the form of a cap graft or
shield graft. Cap onlay grafts minimize mor-
selization and may be effective for aggressive
multilayer applications. A shield graft may be
effectively used by forming a tip definition with
the upper margin (Fig. 33). Several primary
Nasal Tip Techniques (2): Bulbous Tip Correction
100
a
c
b
Fig. 30 Regardless of the method or graft material used for tip plasty, the ideal nasal tip tripod should be achieved in
the form to reduce bulbosity. (a) Tip extension suture. (b) Dorsal batten graft. (c) Septal extension graft
Fig. 31 Supratip approximation suture. It is desirable to
perform it with minimal bite and appropriate tension that
is not excessive because of tension necrosis
S. W. Park
101
clinical examples are shown in Figs. 34, 35, 36,
37, 38, 39 and 40.
Secondary Bulbous Tip Correction
For the secondary rhinoplasty, the overall carti-
laginous tip rebuilding procedure for bulbous tip
correction was not different from the primary rhi-
noplasty. The potential of the tip extension that
can be projected or lengthened should be deter-
mined by releasing the alar cartilage sufficiently.
While observing the degree of deformation and
damage that occurred in the previous surgery and
correcting them, careful attention should be paid
to achieve the ideal tripod shape of the tip as
much as possible by using appropriate tip exten-
sion procedures and techniques (Figs. 34, 35, 36,
37, 38, 39 and 40).
However, often in secondary rhinoplasty for
Asians, reduction of the bulky soft tissue is often
difficult when the implant is placed at the tip or
near the tip with untouched original thick skin
and soft tissue envelope, as well as the hypertro-
phy of the capsules and scar tissues occurs around
the tip. Even if it takes time, soft tissue around
the capsules and scars near the tip must be care-
fully removed without skin injury. In this case, it
is useful to perform flap elevation through dual
plane dissection through the supracapsular plane.
However, there are cases where it is necessary to
carefully perform geographical defatting or scar
excision of the undersurface of the skin flap.
Then tip extension and expansion procedure can
be applied (Fig. 41).
a
b
Fig. 32 In order to make a slight and smooth supratip
break without supratip fullness, the height difference
between the dorsal component and the nasal tip dome
should be greater in thick skin than in thin skin. (a) Thick-
skinned tip. (b) Thin-skinned tip
Nasal Tip Techniques (2): Bulbous Tip Correction
102
a
c
b
Fig. 33 Various tip graft
S. W. Park
103
Fig. 34 Cartilage and soft tissue type bulbous tip. After
nasal SMASectomy and fully releasing alar cartilage, tip
extension suture, lateral crusal spanning suture, and colu-
mellar strut (ear cartilage) were applied to reduce bulbos-
ity, correct slightly upturned tip and rebuild the ideal tip
structure
a
b
c
d
Nasal Tip Techniques (2): Bulbous Tip Correction
104
e
f
g
h
Fig. 34 (continued)
S. W. Park
105
a
b
c
d
Fig. 35 Soft tissue type bulbous tip. Nasal SMASectomy, columellar strut (ear cartilage), tip extension suture, lateral
crural spanning suture, and alar base reduction were applied to improve tip projection and reduce bulbosity
Nasal Tip Techniques (2): Bulbous Tip Correction
106
a
b
c
d
Fig. 36 Boxy tip. Septal extension graft and minimal cephalic trimming were applied to improve projection, reduce
boxy contour, and correct retracted columella
S. W. Park
107
a
b
c
d
Fig. 37 Soft tissue type bulbous tip. After soft tissue deb-
ulking, the alar cartilage was too small and fliable for tip
extension suture and caudal septal height and length were
low and short. Therefore, dorsal batten graft with colu-
mellar strut was applied to overcome such obstacles for
tip extension suture
Nasal Tip Techniques (2): Bulbous Tip Correction
108
a
b
c
d
Fig. 38 Cartilage-type bulbous tip. In preoperative findings, bulbous cartilaginous contour was seen. Tip extension
suture with minimal cephalic trimming was applied
S. W. Park
109
a
b
c
d
Fig. 39 Broad tip. Tip extension suture and columellar strut were applied and alar base was reduced
Nasal Tip Techniques (2): Bulbous Tip Correction
110
a
b
c
d
Fig. 40 Cartilaginous type bulbous tip. Bulbous contour and slight external valve collapse were corrected through
rebuilding ideal tip tripod complex using tip extension suture
S. W. Park
111
e
f
Fig. 40 (continued)
Nasal Tip Techniques (2): Bulbous Tip Correction
112
a
b
c
d
Fig. 41 Secondary bulbous tip. Implant between the
domes exacerbated her bulbous and upturned tip.
Capsulectomy, careful debulking of soft tissue and scar
tissue around the tip and removal of implants were done.
Tip extension suture and columellar strut were applied
after adjusting the symmetry of both alar cartilage
S. W. Park
113
e
f
g
h
Fig. 41 (continued)
Nasal Tip Techniques (2): Bulbous Tip Correction
114
i
j
k
m
l
Fig. 41 (continued)
Further Reading
Adamson PA, Morrow TA. The nasal hinge. Otolaryngol
Head Neck Surg. 1994;111(3 Pt 1):219–31.
Anderson JR. A personal technique of rhinoplasty.
Otolaryngol Clin North Am. 1975;8:559–62.
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.
Çakır B, Öreroğlu AR, Daniel RK. Surface aesthetics and
analysis. Clin Plast Surg. 2016;43(1):1–15.
Choi JW, Suh YC, Song SY, Jeong WS. 3D
Photogrammetric analysis of the nasal tip projec-
tion and derotation based on the nasal tip quad-
ripod concept. Aesthetic Plast Surg. 2017;41(3):
608–17.
Cobo R, Camacho JG, Orrego J. Integrated management
of the thick-skinned rhinoplasty patient. Facial Plast
Surg. 2018;34(1):3–8.
S. W. Park
115
Cochran CS, Afrooz PN. A simplified approach to nasal
tip shaping: the five-suture technique. Plast Reconstr
Surg. 2020;145(4):938–42.
Constantian MB. The boxy nasal tip, the ball tip, and alar
cartilage malposition: variations on a theme – a study
in 200 consecutive primary and secondary rhinoplasty
patients. Plast Reconstr Surg. 2005;116:268–81.
Davis RE, Hrisomalos EN. Surgical management
of the thick-skinned nose. Facial Plast Surg.
2018;34(1):22–8.
Dhir K, Ghavami A. Reshaping of the broad and bulbous
nasal tip. Clin Plast Surg. 2016;43(1):115–26.
Dosanjh AS, Hsu C, Gruber RP. The hemitransdomal
suture for narrowing the nasal tip. Ann Plast Surg.
2010;64(6):708–12.
Ghavami A, Janis JE, Acikel C, Rohrich RJ. Tip shaping
in primary rhinoplasty: an algorithmic approach. Plast
Reconstr Surg. 2008;122(4):1229–41.
Gruber RP, Friedman GD. Suture algorithm for the
broad or bulbous nasal tip. Plast Reconstr Surg.
2002;110(7):1752–64.
Gruber RP, Weintraub J, Pomerantz J. Suture techniques
for the nasal tip. Aesthet Surg J. 2008;28(1):92–100.
Gunter JP, Rohrich RJ. Correction of the pinched nasal
tip with alar spreader grafts. Plast Reconstr Surg.
1992;90(5):821–9.
Guyuron B, Behmand RA. Nasal tip sutures. Part II: The
interplays. Plast Reconstr Surg. 2003;112(4):1130–45.
Guyuron B, Lee M. An effective algorithm for manage-
ment of noses with thick skin. Aesthetic Plast Surg.
2017;41(2):381–7.
Han SK, Lee DG, Kim JB, Kim WK. An anatomic study
of nasal tip supporting structures. Ann Plast Surg.
2004;52(2):134–9.
Han SK, Ko HW, Lee DY, Kim WK. The effect of releas-
ing tip-supporting structures in short-nose correction.
Ann Plast Surg. 2005;54:375–8.
Jeong JY, Kim TK. Rebuilding nose: rhinoplasty for
Asians. Uijeongbu: Medic Medicine; 2018.
Kim JH, Park SW, Oh WS, Lee JH. New classification
for correction of alar retraction using the alar spreader
graft. Aesthetic Plast Surg. 2012;36(4):832–41.
Kim DA, Jeong JY, Oh SH. Bulbous tip correction focus-
ing on skin soft tissue envelope in Asian rhinoplasty.
Arch Aesthetic Plast Surg. 2014a;20(3):140–7.
Kim JH, Song JW, Park SW, Oh WS, Lee JH. Tip exten-
sion suture: a new tool tailored for Asian rhinoplasty.
Plast Reconstr Surg. 2014b;134(5):907–16.
Kim JH, Song JW, Park SW, Oh WS, Lee JH. Effective
septal extension graft for Asian rhinoplasty. Arch Plast
Surg. 2014c;41(1):3–11.
McKinney P. Management of the bulbous nose. Plast
Reconstr
Surg.
2000;106(4):906–17.
discussion
918-21
Nagarkar P, Stark RY, Pezeshk RA, Amirlak B, Rohrich
RJ. Role of the cephalic trim in modern rhinoplasty.
Plast Reconstr Surg. 2016a;137(1):89–96.
Nagarkar P, Stark RY, Pezeshk RA, Amirlak B, Rohrich
RJ. Role of the cephalic trim in modern rhinoplasty.
Plast Reconstr Surg. 2016b;137(1):89–96.
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):12–8.
Perkins S, Patel A. Endonasal suture techniques in
tip rhinoplasty. Facial Plast Surg Clin North Am.
2009;17(1):41–54.
Rohrich RJ, Adams WP Jr. The boxy nasal tip: clas-
sification and management based on alar carti-
lage suturing techniques. Plast Reconstr Surg.
2001;107(7):1849–63.
Rohrich RJ, Afrooz PN. Primary open rhinoplasty. Plast
Reconstr Surg. 2019;144(1):102e–17e.
Rohrich RJ, Hoxworth RE, Thornton JF, Pessa
JE. The pyriform ligament. Plast Reconstr Surg.
2008;121:277–81.
Rohrich RJ, Adams WP, Ahmad J, et al. Dallas rhino-
plasty: nasal surgery by the masters. Boca Raton: CRC
Press; 2014.
Rohrich RJ, Dauwe PB, Pulikkottil BJ, Pezeshk RA. The
importance of the anterior septal angle in the open
dorsal approach to rhinoplasty. Plast Reconstr Surg.
2017;139(3):604–12.
Sieber DA, Rohrich RJ. Finesse in nasal tip refinement.
Plast Reconstr Surg. 2017;140(2):277e–86e.
Suh MK. Tip-reduction surgery: bulbous tip correction
and long-nose correction. In: Atlas of Asian rhino-
plasty. Singapore: Springer; 2018. p. 491–559.
Tardy ME Jr, Patt BS, Walter MA. Transdomal suture
refinement of the nasal tip: long-term outcomes. Facial
Plast Surg. 1993;9:275–84.
Tebbetts JB. Shaping and positioning the nasal tip with-
out structural disruption: a new, systematic approach.
Plast Reconstr Surg. 1994;94(1):61–77.
Tebbetts JB. Secondary tip modification: shaping and
positioning the nasal tip using nondestructive tech-
niques. In: Tebbetts JB, editor. Primary rhinoplasty:
a new approach to the logic and the techniques. St.
Louis: Mosby; 1998. p. 261–440.
Toriumi DM. New concepts in nasal tip contouring. Arch
Facial Plast Surg. 2006;8:156–85.
Toriumi DM, Asher SA. Lateral crural repositioning for
treatment of cephalic malposition. Facial Plast Surg
Clin North Am. 2015;23(1):55–71.
Toriumi DM, Checcone MA. New concepts in nasal
tip contouring. Facial Plast Surg Clin North Am.
2009;17(1):55–90.
Nasal Tip Techniques (2): Bulbous Tip Correction
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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 Technique (3): Tip
Shortening
Seong Geun Park
The major esthetic problems for long nose in
Asian faces are aged appearance as well as
unpleasant facial expressions due to crooked
nasal tips when smiling.
In fact, whether the nose appears long or not,
a number of anatomical abnormalities and dis-
proportions can be observed in long nose.
Therefore, in order to correct the long nose, it is
necessary to understand the ideal and normal
anatomical position and structure of the radix,
dorsum, and mobile lower third of the nose, as
well as an extensive understanding of various
surgical methods to correct each part. Here, we
will focus on how to improve the esthetic of the
mobile tip.
Preoperative Analysis and Surgical
Planning
Byrd and Hober provided an excellent guide for
ideal nasal length, nasal tip, and radix using a
facial parameter. The ideal length (R-T) of the
nose is two-thirds of the distance from the gla-
bella (G) and alar base plane (ABP) and the same
as the distance from the stomion to the mentum
(S-Me). The length from corneal plan to radix, in
other words, radix projection is RT × 0.28. The
ideal tip projection is RT × 0.67 from the alar-
cheek junction (Fig. 1).
Nasofrontal angle and columellar-labial angle
greatly affect the appearance of a longer nose.
The nasofrontal angle varies depending on the
location of the radix. When the location of the
radix is high, the bony portion of the nose con-
nects the frontal line, which gives the nose an
appearance like the Greek sculpture, long, and
stiff. Also, when the columellar-labial angle is
acute, the mobile tip portion looks long. It is
uncommon for Asians to have a high radix, but it
is common to have an acute columellar-labial
angle.
To correct such problems, radix reduction
should be performed depending on the location
of radix, and augmentation of the anterior nasal
spine should be performed to correct the
columellar-labial angle for long nose correction.
However, the nasal length is subjective in rela-
tion to the patient’s unique anatomical character-
istics, such as the width of the face and the
correlation with the lips and the chin. Therefore,
the patient’s preference should be the primary
concern than the guideline length when correct-
ing the length of the nose.
S. G. Park (*)
Joseph Aesthetic Plastic Surgery Clinic,
Daegu, Republic of Korea
118
Classification and General Concept
In general, the most common reason for Asians to
have a long nose appearance depends on the
mobile tip rather than radix and mid vault. The
long nose can be divided into the following four
types based on the shape and position of the tip
alongside its moving features.
1. Type I: Long nose with drooping tip
2. Type II: Long nose with normal height tip
3. Type III: Long nose with overprojected tip
4. Type IV: Long nose with bulbous tip
To understand what causes a long nose and
how to correct it, the concept of the quadripod
should be understood. Anderson’s tripod concept
is an important long-lasting concept that describes
the nasal tip as a tripod junction supported by
three limbs. The central limb consists of two
medial crura, and the lateral limbs are the lateral
crura of the lower lateral cartilage. The surgeon
can adjust the tip position by manipulating the
length of central and lateral limbs (Fig. 2). In cor-
recting long nose, the position of the caudal sep-
tum is considered additionally. If the caudal
septum is long, the nose can be lengthened even
if the lower lateral cartilage is normal. Thus, this
is where quadripod concept comes in, which is
Anderson’s tripod concept in addition to the posi-
tion of the caudal septum (Fig. 3).
It is evident that correcting the long nose is a
complicated procedure, as it requires several
techniques for tip modification which is not a
mandatory consideration in other nasal surgeries.
Thus, the surgeon must carefully design and lay-
out the patient’s problem before performing any
surgical procedures when it comes to long nose
correction.
Long Nose with Drooping Tip
(Type I)
This type of long nose is called smile tip since the
tip of the nose droops downward when the patient
is laughing or moving the oral commissure later-
ally. It is the most common cause of making the
nose seem longer. Generally, the long noses with
drooping tips have the following characteristics
(Fig. 4):
1. Caudal displacement of the nasal tip which
gets worse when smiling
2. Convex nasal dorsum with the dorsal hump
3. Acute columellar-labial angle, which gets
worse when smiling
Anatomic Causes of Long Nose
with Drooping Tip
In order to fix this problem, the underlying ana-
tomical causes of a long nose with a drooping tip
must be understood. The causes of the drooping
tip of a long nose are classified into two different
Fig. 1 The ideal length (R-T) of the nose is two-thirds of
the distance from the glabella (G) and alar base plane
(ABP) and the same as the distance from the stomion to
the mentum (S-Me)
S. G. Park
119
mechanisms: static and dynamic causes. Static
causes result from malposition and incorrect
innate shape of the nasal structure. As the name
suggests, static anatomic structures are as fol-
lows: nasal septum, upper and lower lateral carti-
lages, and ligaments in between each is the main
cause. Dynamic causes result from facial expres-
sion muscles such as the depressor septi nasi
muscle and the levator labii superioris alaeque
nasi muscle. However, in most the cases, both the
dynamic and static causes work simultaneously
to result in drooping tip. An additional consider-
ation is required if the skin of the tip is thick and
bulbous, as it also makes the nose look longer.
Abnormal Position and Shape of Alar
Cartilage and Septal Cartilage
1. Excessively long and vertically oriented lat-
eral
crura
with/without
underdeveloped
medial crura (Fig. 5)
2. Long caudal septum with/without highly
positioned anterior septal angle (Fig. 6)
3. Weak or absent distal septal supporting sys-
tem by trauma or surgical maneuver (Fig. 7)
Dynamic Pulling Forces on the Nasal
Tip by Underlying Muscles
Dynamic forces that affect drooping tips are
caused by two muscles. (1) Depressor septi nasi
muscle: a small muscle connecting the tip to the
bilateral sides of the anterior nasal spine and
orbicularis oris muscle, which acts to pull down
the tip downwards while smiling. (2) Levator
labii superioris alaque nasi muscle originates
from the superior frontal process of the maxilla
and runs obliquely downward lateral to the nasal
bone and alar base from top to bottom. This mus-
cle divides into strips and attaches to the skin of
the nasolabial fold, ala base, and upper lip mus-
cle. These two muscles pull the alar base to the
cephalic direction on the nasal wing and droops
the tip in the caudal direction, which often causes
relapse of the drooping tip after operation
(Fig. 8).
Fig. 2 Anderson’s tripod concept is useful to understand the tip position modification. Tip position can be adjusted by
manipulating the length of central and lateral limbs of alar cartilage and augmentation of columellar base
Nasal Tip Technique (3): Tip Shortening
120
Correction of Long Nose
with Drooping Tip
To build and maintain adequate tip projection, the
operator should simultaneously approach the
multiple factors that cause the drooping tip. The
following four steps are an important guidelines
that will give a strategic insight to correcting
drooping tip nose.
First, the alar cartilage or nasal septal cartilage
problem should be settled. Second, to make the
corrected alar cartilage stable, which is to make
the tip projection and columella shape secure, a
firm columella strut or batten graft should be per-
formed. Third, dynamic factors such as depressor
septi nasi muscle and levator labii superioris
alaque nasi muscle should be cut or weakened to
prevent recurrence. Fourth, in cases with a thick
and bulbous tip, the soft tissue should be reduced,
and the redundant skin after framework should be
modified.
Correction of the Alar Cartilage
Modified Transdormal Suture for Medial
Crus Lengthening
In the case of a nose with long lateral crus in the
longitudinal axis and short, underdeveloped
medial crus, horizontal mattress suture aids the
proximal portion of lateral crus by lengthening
the medial crus. Depending on the suture site and
angle, the shape of the nasal tip is changed.
Vestibular skin at the dome needs hydro-
dissection or undermining before transdormal
suture. The transdormal suture rotates the nasal
tip upward, pulls the medial crus upward and nar-
rows the angle between the medial and lateral
crus of the alar cartilage. To prevent relapse, tiny
scoring incisions on the perichondrium of the
newly created domes are carried out. Newly
located domes are fixed to the columellar strut by
horizontal mattress suture to maintain a new tip
shape (Fig. 9).
Making Cartilage Rein Flap or Partial
Resection of the Cephalic Portion
of Lateral Crura
This technique is especially effective in relation to
large and wide lateral crus. The cephalic portion
of lateral crura is divided into a cartilage flap with
the pedicle base located on the dormal portion of
the alar cartilage. The procedure in addition to
make the fibrous attachment in between the upper
lateral cartilage and lower lateral cartilage
released, resulting in the alar cartilage more mov-
able to cephalic direction. The cartilage rein flap
is attached to the anterior septal angle to make the
nasal tip secure its upward rotation. Moreover,
lateral crural spanning suture helps to narrow the
Fig. 3 Quadripod concept is Anderson’s tripod concept
in addition to the position of caudal septum
S. G. Park
121
alar flaring and to maintain tip structure. More
volume can be added to supra-tip area by rein flap
(Fig. 10). Boccieri et al. tried to use this flap as a
spreader graft on the septal angle area.
Lateral Crura Shortening with Resection or
Overlay Suture
In case with an excessive length of lateral crura,
the 3–5 mm width between mid and distal third
portion of lateral crura could be simply resected or
overlayed by overlapping suture after freeing ves-
tibular skin from the undersurface of lateral crus.
This procedure reduces the length of the lateral
crus and to make the tip upwardly rotated.
Transected distal and proximal segments should
be superimposed and secured with horizontal mat-
tress sutures using 5-0 Prolene or PDS (Fig. 11).
Columellar Septal Suture and Excision
of Caudal Septal Cartilage
Columella septal suture helps in cases of hanging
columella. The medial crura of the alar cartilage
should be sutured upward to the caudal septum to
make the tip height controlled as well as making
the hanging columella corrected (Fig. 12).
a
b
Fig. 4 (a) Caudal displacement of the nasal tip, convex nasal dorsum with the dorsal hump, acute columellar-labial
angle are characteristics of type I long nose. (b) These are get worse when smiling
Nasal Tip Technique (3): Tip Shortening
122
a
b
Fig. 5 (a) Long and vertically oriented lateral crus causing the long nasal tip. (b) Long and convoluted lateral crus with
short medial crus causing the long and drooping tip
a
b
Fig. 6 (a) Long caudal septum and high positioned anterior septal angle (arrow) push the nasal tip downward. (b)
Design of excision line to reduce caudal septum
S. G. Park
123
Fig. 7 Caudal portion of the dorsal septum is weak and
crooked to the side, which causes nasal tip drooping when
smiling. The reason for this phenomenon is inappropriate
septal surgery performed when the patient was young.
(a–c) Pre-operation view of a 24-year-old man. Ever since
his septal surgery, his nasal tip drooped and deviated even
more so during smiling, and this became more prominent
as time passed. (d, e) Unroofing and exposed dorsal sep-
tum; Long lateral crura and short medial crura with septal
deviation caused by weak dorsal and distal septum. (f, g)
Spreader graft with a thick septum to straighten the dorsal
septum and mid septum. (h) Columella strut graft with
layered symba of auricular cartilage. (i) Secured cartilage
rein flap on the new anterior septal angle. (j) Lateral view
before shield graft. (k–m) 5 Months postoperation view
d
a
b
c
Nasal Tip Technique (3): Tip Shortening
124
e
f
g
h
Fig. 7 (continued)
S. G. Park
125
i
j
k
l
Fig. 7 (continued)
Nasal Tip Technique (3): Tip Shortening
126
Tebbetts employs two suture types, which are
projection control and tip rotation suture. The pro-
jection control suture holds the medial crura and
the septum (2). In contrast, the tip rotation suture
(1) secures the cephalic border of the medial crura
more anteriorly as well as holding the dorsal sep-
tum near the anterior septal angle (Fig. 13).
However, as time passes septocrural suture
eventually becomes loosely fitted; therefore over-
correction should be considered.
In cases of the excessively long nasal septum,
caudal septum tends to push medial crus of alar
cartilage caudally and it also prevents cephalic
rotation of the nasal tip. The caudal portion of the
septum should be removed using strip excision to
move the medial crus of alar cartilage in the
cephalic direction. Some patients have posterior
caudal septum and anterior nasal spine at the cau-
dal location, which causes short upper lip and
blunt nasolabial angle. To fix the long appearing
columella base, both the anterior nasal spine and
the posterior caudal septum should be shortened
(Fig. 14).
Consideration of the Nasal Tip
and Columella Support
Columella Strut Graft for Tip Support
The columella strut graft is particularly important
procedure to correct and prevent recurrence of
the drooping tip. The effect of columella strut
graft is tip projection and up-rotation as well as
widening of columellar–labial angle. It can be
divided into fixed and floating types. If the medial
crus is less developed and weak, the fixed type is
preferred. In a fixed columella strut graft, the dis-
tal end of the graft should be placed on the ante-
rior nasal spine (ANS), but it is practically
m
Fig. 7 (continued)
Fig. 8 Depressor septi nasi muscle and levator labii supe-
rioris alaque nasi muscle act as a functional unit to make
the drooping tip more prominent and cause the recurrence
of drooping tip postoperation
S. G. Park
127
a
b
c
d
Fig. 9 (a, b) In between the two blue lines of the lateral
crus is the position of the newly formed medial crus. The
lateral crus is folded upward to create medial crus. (c)
Horizontal mattress suture is done to make the new dome.
(d) Newly located domes are fixed to the columellar strut
by horizontal mattress suture to maintain a new tip shape
Nasal Tip Technique (3): Tip Shortening
128
impossible; thus it should be placed in front of
ANS. Therefore, the length of the graft should be
longer and durable against drooping force. If the
medial crus are well-developed, the floating type
is recommended because it appears more natural
when laughing as there is a soft tissue between
the end of the graft and the ANS. However, in the
case of underdeveloped ANS, the columellar-
labial angle is deep, and the drooping tip is hard
to adjust. The augmentation of ANS by autoge-
nous tissue or silicone implant will suffice this
problem (Fig. 15).
Septal cartilage, auricular cartilage can be
used for columellar strut graft depending on the
condition of alar cartilage and surgeon’s prefer-
ence. Personally, one prefers auricular cartilage
over septal cartilage due to auricular cartilage’s
soft, elastic, and flexible texture compared to the
septal cartilage. Also, auricular cartilage has
durable strength to create up to 3 cm length colu-
mellar graft (Fig. 16).
Shield Graft
Thick skin causes unsatisfactory correction of the
drooping tip even after proper correction of the
tip cartilage shape. More defined tips are achieved
by shield graft on the tip. Auricular cartilage with
perichondrium or septal cartilage is used to make
Fig. 10 Cartilage rein flap with the pedicle base located on the domal portion of the alar cartilage. Cartilage rein flap
is then attached to the anterior septal angle to make the nasal tip secure its upward rotation position
Fig. 11 Lateral crural overlay technique. Conservative
resection of lateral crus between mid one-third and lateral
one-third of lateral crus and vestibular skin is dissected
from alar cartilage. Transected distal and proximal seg-
ments should be superimposed and secured with mattress
suture
S. G. Park
129
shield graft, and it is supported posteriorly by an
additional trapezoid-shaped cartilage graft fixa-
tion with remaining cartilages.
Depending on the location of the shield graft,
the tip can be up-rotated or de-rotated.
For up-rotation of the tip, it is helpful when
the lower part of the shield graft is not placed
inferior to the interdormal portion (Fig. 17).
Solving Problems with the Muscles:
The Dynamic Components
Depressor septi nasi muscle and levator labii
superioris alaque nasi muscle have been
researched numerously, and many articles have
been published, but the structure and shape about
them are still in controversy. Generally, depressor
septi nasi muscle pull the nasal tip downward,
and the levator labii superioris alaque nasi mus-
cle elevates the alar base. The two muscle is
excised partially to weaken skin traction force.
This is considered important when correcting
drooping nasal tip.
Fig. 12 The site of columella septal suture changes tip height and columella position
Fig. 13 (1) Tip rotation suture and (2) Projection control
suture
Nasal Tip Technique (3): Tip Shortening
130
Excision of the Depressor Septi Nasi
Muscle and Columella Base Augmentation
Depressor septi nasi muscle originates from both
sides of the anterior nasal spine and interdigitated
orbicularis oris muscle. This muscle ascends
along the columellar base and attaches to the
footplate of the medial crura and membranous
septum. According to Hwang et al., the depressor
septi nasi muscle is contiguous with the dermato-
cartilagenous ligament which ligamentous struc-
ture goes up to the supra nasal tip (Fig. 18).
Activation of this muscle will pull the nasal tip
downward, elevate the upper lip, and decrease the
labiocolumellar angle.
Two types of approaches are used to excise
and weaken this muscle. The first method begins
with open rhinoplasty technique and dissection
between perichondrium of medial crus, upwardly
toward the dome, inferiorly toward the footplate
of medial crus and the anterior nasal spine and
posteriorly toward the septal cartilage. The
depressor septi nasi muscle and dermocartilage-
nous ligament in between the crura or complex
tissue should be excised or dissected and rolled to
a
b
c
Fig. 15 (a) Floating strut graft. (b) Fixed strut graft. (c) ANS augmentation with floating strut graft
Fig. 14 Caudal portion of the septum should be removed
using strip excision to move the medial crus of alar carti-
lage in the cephalic direction. To fix the long appearing
columella base, both the anterior nasal spine and the pos-
terior caudal septum should be shortened (yellow arrow)
S. G. Park
131
be inserted in front of the anterior nasal spine to
augment columellar-labial angle (Fig. 18).
The second method is through intraoral ves-
tibular incision just beside the frenulum. After
exposing the origin of DSN muscle in both sides
and cutting them, the two edges are sutured
together for security.
If the columellar-labial angle is overly acute,
using transverse frenulum incision, the origin of
the depressor septi. nasi muscle is excised. Then
anterior nasal spine should be exposed supraperios-
tally to place V-shaped silicone implant or autoge-
nous tissue for elevated columellar base (Fig. 19).
Weakening of Levator Labii Superioris
Alaque Nasi Muscle and Peri-alar
Augmentation
When the alar base is excessively pulled during
smiling, the nose appears overly long and arrow
shaped. With the depressed alar base, the nasola-
bial fold is prominent, causing aged appearance.
This is caused by the levator labii superioris alae-
que nasi muscles which attaches to the lateral
crura abutment of alar cartilage and the nasal
hinge. Intraoral vestibular incision just on top of
canine is performed to dissect the levator labii
superioris alaeque nasi muscle in the alar base.
Make a periosteal dissection under alar base to
insert a breakwater stone-shaped silicone implant
to elevate the alar base (Fig. 20). The muscular
function of the levator labii superioris muscle is
weakened by elevating the alar bases. By doing
so, the nasolabial fold is weakened, which ulti-
mately results in patient’s youthful appearance.
Debulking of Bulbous Tip
and Redundant Nasal Skin
Management
Despite well manufactured nasal tip cartilage
framework, many of them are accompanied with
soft tissue bulkiness and nasal tip skin redundancy.
Patients with soft tissue bulkiness on the nasal tip
are modified using the debulking technique
(Fig. 21). Gruber mentioned appropriated under-
mining makes skin excision unnecessary for long
nose correction.
Also, redundant skin of the dorsal portion is
reduced after cartilage framework surgery due to
skin shrinkage of scar contraction. However, if
there is remaining skin on the infra lobular por-
tion, trim the excess skin on the columellar inci-
sion site (Fig. 27).
Fig. 16 Auricular
columellar strut graft
elongated up to 3 cm
Nasal Tip Technique (3): Tip Shortening
132
Strategy of Collaborative Approach
for Long Nose with Drooping Tip
There are multiple causes and morphology of
long nose with drooping tips. Partial approach to
such problem is not enough to expect promising
results. To address all of the causes for long nose
with drooping tip, five basic procedures are con-
sidered: (1) horizontal mattress suture on the
proximal portion of lateral crus for medial crus
lengthening, (2) excision of cephalic portion of
lateral crura or making rein cartilage flap, (3)
floating or fixed type columellar strut graft
depending on the development of medial crura,
(4) shield graft for more defined tip shape, (5)
excision of the depressor septi nasi muscle.
To go on in detail, there are five additional
methods for five prominent problems. First, for
a
b
c
d
Fig. 17 (a) Shield graft for tip up-rotation. (b) Shield graft for tip derotation. (c, d) Shield graft for tip up-rotation with
posteriorly positioned trepzoid-shaped cartilage
S. G. Park
133
a
b
Fig. 18 (a) Dermocartilagenous ligament (P), which
connects between DSN muscle (M) and supra-tip (This
picture of cadaver dissection is provided by Dr. Jae Yong
JEONG). (b) Democartiligenous ligament can be removed
or rolled, pinched in and fixed for ANS augmentation.
This eliminates dynamic tip drooping force and increases
columellar-labial angle
a
b
c
Fig. 19 (a) Preparing Silicone implant. (b) Through transfrenulum incision, the anterior nasal spine is exposed after
cutting DSN muscle. (c) V-shaped silicone implant is inserted into the supraperiosteal pocket of ANS
Nasal Tip Technique (3): Tip Shortening
134
excessively long nasal septum, excise distal sep-
tal cartilage and suture between the columella
and distal septum. Second, in the case of the
excessive length of lateral crura, resect lateral
crura and overlay it by overlapping suture. Third,
for bulbous drooping tip with a large amount of
soft tissue and redundant nasal skin, debulk the
subcutaneous fat tissue and nasal SMAS layer of
the mobile tip and trim the redundant columella
skin. Fourth, for nasal structure with acute
columellar-labial angle and small ANS, use
plumping graft or implantation for augmentation
of ANS. Last, in the case of depressed alar base
and prominent nasolabial fold, augment perialar
with autogenous tissue or silicone implant
(Fig. 22). All of the additional methods described
a
b
Fig. 20 (a) Design and insertion position of silicone
block. (b) Make a periosteal dissection under alar base to
insert a breakwater stone-shaped silicone implant to ele-
vate alar base. The muscular function of the levator labii
superioris muscle is weakened by elevating the alar bases
a
c
b
Fig. 21 (a) Unroofing with subcutaneous dissection. (b) Exfoliate the remaining fat and nasal SMAS tissue to the
supra-perichondrial level to remove bulky tissue. (c) Exfoliated tissue can be used for supra-tip augmentation
S. G. Park
135
above can greatly improve the nasal structure of
the long nose with drooping tip with promising
results (Fig. 23).
Long Nose with Normal Height Tip
(Type II)
In the case of long nose with normal height tip,
the lateral crus are abnormally long, or the distal
septal cartilage is caudally displaced. If the pro-
file of the nasal dorsum is appropriate, first use a
transfixion incision on the anterior portion of the
caudal septum margin. The distal septum is
excised as a strip and sutures the distal septal
margin and the proximal portion of the medial
crus with 5-0 PDS. Then excise the redundant
membranous septum and suture with 5-0 chromic
to correct the long tip with hanging columella. As
a result, the nasal tip will project more and the
medial crus upward (Fig. 24). If the lateral crus
are long and the dorsal profile is mildly flat, it is
possible to fully correct with various surgical
methods applied in type I (long nose with droop-
ing tip), but for the overall shape of the nose, the
tip can be projected a little more than the original,
and dorsum augmentation can be performed
using thin silicone or dermofat to make the over-
all esthetic composition (Fig. 25).
Long Nose with Overprojected Tip
(Type III)
Overprojected nasal tip with a long nose is
uncommon in Asia.
The cause of overprojected nasal tip is overde-
veloped septal cartilage or overdeveloped lateral
1) horizontal mattress suture on proximal portion of lateral crus for medial crus lengthening
2) Excision of cephalic portion of lateral cruraor making reincartilage flap
3) floating or fixed type columellar strut graft depending on the development of medial crura
4) shield graft for more defined tip shape
5) excision of the depressor septi nasi muscle.
Excessively long nasal septum,
- excise distal septal cartilage
Eexcessive length of lateral crura,
- resect lateral crura and overlay suture.
bolbous drooping tip with large amount of soft tissue
-
debulk the subcutaneous fat tissue and nasal SMAS layer
-
Trimming redundant columella skin
acute columellar-labial angle and small ANS
-
pluming graft or implantation for augmentation of ANS
depressed alar base and prominent nasolabial fold,
- augment perialar with autagenous tissue or silicone implant.
Fig. 22 Strategy of a collaborative approach for long nose with drooping tip
Nasal Tip Technique (3): Tip Shortening
136
Fig. 23 (a–c) Pre-operation view of 37-year-old woman,
(d) preop design for shortening lateral crus (black arrow),
transdormal suture line for medial crus lengthing (*) and
incision line for rein flap (yellow arrow). (e, f) Excision of
the distal septum and spreader graft using excisied distal
sepum for deviated dorsal septum (yellow arrow). (g, h)
Elevated rein flap and secured rein flap on the dorsal sep-
tum and lateral spanning suture to narrow lateral crus of
alar cartilage. (i) Fixed columella strut graft with auricular
cartilage. (j) Shield graft and crushed auricular cartilage
around shield graft. (k–m) Postoperative 6 months, tip
will derotate more as time passes
a
b
c
e
d
b
S. G. Park
137
f
g
h
i
Fig. 23 (continued)
Nasal Tip Technique (3): Tip Shortening
138
j
k
l
m
Fig. 23 (continued)
S. G. Park
139
a
b
c
d
e
f
Fig. 24 (a) Transfixion incision on the anterior portion of
the caudal septum margin. (b) Distal septum is excised as
a strip. (c) Suture the distal septal margin and the proxi-
mal portion of the medial crus with 5-0 PDS. (d) Excise
the redundant membranous septum and suture. (e, f)
Perop and postoperative 3 months view. The nasal tip pro-
jected more and the medial crus upward
Nasal Tip Technique (3): Tip Shortening
140
Fig. 25 (a–c) preoperative view of 35-year-old women. (d,
e) Long and curved lateral crus of alar cartilage and design
for excision. (f, g) After excision of cephalic portion of lat-
eral crus, lateral crura shortened. (h) Columellar strut graft
with septal cartilage. (i) Shield graft and silicon implanta-
tion for nasal dorsum. (j–l) 11 months postoperative view
b
c
d
e
a
S. G. Park
141
f
g
h
i
j
k
Fig. 25 (continued)
Nasal Tip Technique (3): Tip Shortening
142
and medial crura of the lower lateral cartilages or
a combination of both.
The common cause of overprojected tip is
overdeveloped septal cartilage, which can be
characterized by high anterior septal angle and
long caudal septum. The reduction of the dorsal
septum and caudal septum leads to the movement
of the lower lateral cartilages into a less projected
position. This results in de-projected and up-
rotated tip position.
If the lower lateral cartilages are overdevel-
oped, the long medial and lateral crura should be
shortened to lower the tip according to Anderson’s
tripod concept (Fig. 2). Long medial crura will
require a method of directly lowering the medial
crural height, which is performed by transecting
the crura and overlapping the midportion using
double-mattress sutures with 5-0 PDS. The
appropriate segment of the medial crus should be
separated from the underlying vestibular skin
prior to shortening the medial crura. The weak-
ened medial crura should be strengthened using
columellar strut graft. Long lateral crura can be
shortened by the lateral crural shortening proce-
dure. Medial and lateral crural shortening proce-
dures can change tip position into de-projection
and up-rotation position (Fig. 26).
The operative technique to shorten type I long
nose such as cartilage rein flap, shortening of the
septum, and medial crural-septal suture can be
applied to further correction of the tip. In addi-
tion, when the tip and columella skin is redraped,
the skin remains, and the redundant skin is
trimmed (Fig. 27).
Long Nose with Bulbous Nasal Tip
(Type IV)
This type is a common form of the nasal tip in
Asian. The upper half of the nose is flat, and the
lower half is boubous and chunky. With flattened
radix extending to the boubous tip, the overall
impression of the nose is depressed and long.
Furthermore, the mobile tip is in the chunky form
with thick skin, wide alar base and acute
columellar-labial angle. It is not actually a long
nose by measurement, but it makes the nose
appear wide and long (Fig. 28).
Most of the time, the lateral crus and medial
crus are in normal size, but it is considered small
compared to the size of the nasal tip. Also, the
septal cartilage is often underdeveloped and is
accompanied by retracted columella. In this case,
it is important to remove the soft tissue such as
subcutaneous fat and layer of nasal SMAS from
the tip. The method for alar cartilage framework
is similar to type I, such as transdormal suture
and tip up-rotation with rein flap and the colu-
mella fixed strut graft with shield graft for tip
definition. For depressed nasal dorsum, correct
dorsal profile with a silicone implant or dermofat
graft with dorsal augmentation. Underdeveloped
anterior nasal spine requires augmentation of
premaxilla with silicone or autogenous tissue.
There are two methods for debulking soft tis-
sue of the nasal tip depending on the operator
preference. First, open rhinoplasty incision tech-
nique, which unloops the mobile tip with subcu-
taneous dissection, is done and then peeling a
layer of supra-perichondrial plan of lateral crus
l
Fig. 25 (continued)
S. G. Park