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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,

Secondary Rhinoplasty (3): Tip
Keun Cheol Lee
The nasal tip is one of the most prominent com-
ponents in facial beauty, and is located centrally
in the midface, insignificant deformities of nasal
tip can be conspicuous, and it is stressful for the
patients. Inadequate projection, rotation, and
asymmetry of the nasal tip are the most common
problems after primary and secondary rhino-
plasty. The success of secondary nasal tip sur-
gery is in achieving proper projection, rotation,
favorable definition, and symmetry of the nasal
tip (Fig. 1).
The Features of Secondary Nasal
Tip Surgery
Incorrect judgment in primary operation and
results from the improper procedure can appear
in various deformities (Fig.  2). Therefore, to
get a successful result in secondary rhinoplasty
without failure, it is necessary to carefully check
the condition before and after the primary opera-
tion and accurately analyze the prior procedure.
And the biggest problem with nasal tip in sec-
ondary rhinoplasty is that the alar cartilage can
be deformed or lost by the previous procedure.
And limitation of donor site is common due to
previous surgery. According to the changed state
of the structures constituting the nasal tip, vari-
ous deformities can occur. Especially, over time
after operation, if fibrosis or retraction of spe-
cific nasal structures after destruction of the tip
supporting system has occurred, it may result in
undesirable results including supra-tip fullness,
under-projected tip, pinched tip, alar retraction,
and tip asymmetry.
The Goals of Secondary Nasal
Tip Surgery
After setting the surgical goal, understand the
various procedures required to achieve the surgi-
cal goal and then make an accurate surgical plan.
The first step is to check the detailed chronologi-
cal history of all previous nasal operations and
then identify the patient’s apparent cosmetic
problem and functional impairment, the anatomi-
cal structure and physical characteristics of the
alar cartilage and whether or not to use autolo-
gous tissues or artificial materials.
If possible, it is necessary to obtain the
patient’s preoperative photographs and compare
them with the present appearance, and then iden-
tify the type of technique performed on the alar
cartilage during the previous operation.
In other words, in order to make a plan for
a successful operation, it is important to under-
stand at least the following parts and make an
operative decision.
K. C. Lee (*)
Department of Plastic and Reconstructive Surgery,
Inje University Haeundae Paik Hospital, Busan,
South Korea

348
Tip projection
Tip rotation
Tip position
Ni
Short
Long
AC
AC
AC
downward rotation
upward rotation
Ti - ideal
105°= female
X - over projection
X1- under projection
Total projection
100°= male
X1
X
Ti
Fig. 1  Basic concept of tip projection, rotation, and position
Fig. 2  Various deformities in secondary nasal tip surgery
K. C. Lee

349
The degree of anatomical variation in soft
tissue and cartilage structure associated with
the shape of the nasal tip, elements playing an
important role in supporting the nasal tip and
their interrelationship and the effectiveness of
individual procedures or multiple combined pro-
cedures on the outcome.
Finally, the surgical plan should be personalized
for each patient. This is because even with similar
nasal tip deformities, the proper procedure should
be applied differently depending on the relation-
ship between the nasal tip and other parts of the
nose, and between the nasal tip and the face.
General Surgical Preparation
for Secondary Nasal Tip Surgery
Standardized preoperative photographs must be
checked in all views (Fig. 3). Imaging can help
surgeons better understand a patient’s aesthetic
desires. To prevent the occurrence of dissatisfied
patients, the operator and the patient’s aesthetic
goals must be matched.
Next, special attention to the quality and
thickness of the skin overlying the nasal tip is
needed, it can be damaged by previous surgery.
In thin-skinned patients, changes in the structure
Fig. 3  Standard series of photography in a rhinoplasty patient
Secondary Rhinoplasty (3): Tip

350
of the underlying nasal tip are well visible, but in
thick-skinned patients, it is well masked (Fig. 4).
Especially, in thick-skinned patients, due
to lack of flexibility and coaptation of the skin
envelope to the underlying tip framework, size
discrepancy between the nasal skin and the tip
structure can cause the formation of dead space
and poor nasal tip definition (Fig. 5). To prevent
this discrepancy, increasing the size of the skeletal
framework can be needed to adapt the nasal skin
envelope or reduction of the nasal skin envelope
is needed to refine the tip contour and definition.
And check if there is an existing asymmetry of
the alar insertion height, notching, or retraction
of alar rim. If in case of repositioning of alar car-
tilage, the possibility of asymmetry after opera-
tion must be noticed to the patients.
Endonasal examination must be carried out
using nasal endoscope to check the state of the
nasal septum, especially if there is a high septal
deviation, the state of the turbinate, and the nasal
valves (Fig. 6). If there is a high septal deviation,
care should be taken as there is a high possibil-
ity that the columella will deviate after the septal
extension graft is performed. And the septum may
be gently palpated to evaluate if the remaining sep-
tal cartilage can be used. If available septal cartilage
is none, the stiffness can be increased at the nasal
tip when structural grafting is done with costal car-
tilage after operation should also be informed.
Precautions for Secondary Nasal
Tip Surgery
In principle, the transverse mid-columella inci-
sion line of the columella should follow the inci-
sion line of the previous operation. If there are
two or more transverse incision lines, an accurate
surgical history investigation is required for the
incision line. If there is no special plan for the
incision, it is safe to choose the most recently
incised one of the two transverse incisions. If
the old incision line is chosen without complete
recovery of blood flow, tissue necrosis may occur
between the two incision lines.
Care should be taken when making incisions
in the soft triangle in patients with secondary
nasal tip surgery. In the previous surgery, there
is a high possibility that the alar cartilage was
changed by surgical techniques such as suture
technique, trimming, transposition, and grafting.
After making a shallow incision with a sufficient
distance of about 3 mm, check the shape of the
alar cartilage, especially the caudal margins of
the middle crura and the lateral crura, and then
make a complete incision (Fig. 7).
Fig. 4  The skin thickness should be checked by palpated
thickness of the skin between two fingers, because thin
skin may emerge any surgical pitfalls over time and thick
skin may mask the surgical results
Fig.3  continued
K. C. Lee

351
In secondary nasal tip surgery, the elasticity
of the soft tissues is poor and the cartilage that
supports the soft tissues is often weakened. If
the skin and cartilage inside the nostril are lost
or the scar tissue is increased due to the incor-
rect incision in the soft triangle, alar retraction, or
pinched tip deformity may occur (Fig. 8).
In primary rhinoplasty, the middle part of the
lateral crura is most easily dissected due to rela-
tively firmly adhered to the upper lateral cartilage
with the scroll area and less mobility and because
the direction of lateral part of the lateral crus is
toward cephalic, the lateral part is far from the
incision line of the vestibule, but the middle part
of the lateral crus is close to the incision line. In
addition, the middle part of the lateral crus of the
alar cartilage is not tightly adhered to the peri-
chondrium with a somewhat flexible tissue on the
lateral of the nasal tip different from the dense
subcutaneous tissue of the nasal tip, therefore this
area is convenient to dissect.
However, it should be aware that in secondary
nasal tip surgery, the location of the lower lateral
cartilage and the flexibility of the soft tissue may
be different from that of the primary rhinoplasty.
So, to dissect the alar cartilage from the incision
line of the vestibule, if this is not acceptable, it
must dissect moving to the nasal tip. In primary
rhinoplasty, the type and frequency of proce-
dures applied to the alar cartilage are more in the
medial crus or the middle crus than in the lateral
crus, but because the degree of destruction and
weakness is more severe in the lateral crus.
In secondary rhinoplasty, since there are many
cases of implantation or injection of allografts,
xenografts, and artificial substances into the nasal
tip, it is better not to have the idea of detaching
the alar cartilage in the anatomical shape of the
alar cartilage when dissecting the alar cartilage
in secondary nasal tip surgery (Fig.  9). Since
allografts or xenografts remaining after removing
all artificial materials are already fibrotic change
like scar tissue in the nasal soft tissue, they are
left on the nasal cartilage at an appropriate thick-
ness, so expect the local activity to maintain the
shape of the nostril. It is good to use it to improve
the shape of the nose.
The most important surgical step in second-
ary nasal tip surgery is completely dissecting the
alar cartilage and making it free. First of all, to
Fig. 5  The patient with no significant changes of nasal tip before and after operation due to thick skin of nasal tip
Fig. 6  The endoscopic findings of septal deviation
Secondary Rhinoplasty (3): Tip

352
perform the operation conveniently, the entire lat-
eral crura of the alar cartilage must be completely
exposed, and then extend the incision line of the
vestibule toward the cephalic direction as much
as possible to expose the entire alar cartilage.
When division of the alar cartilage, it is
important to keep the possibilities in mind that a
suture technique has been performed during the
prior operation. Particularly, the medial intercru-
ral suture or interdomal suture must be accurately
found out, if you try to separate each of the alar
cartilage by cutting randomly between the alar
cartilage without the release of suture, if you are
not careful, you can lose the middle crus from
one of the alar cartilages (Fig. 10).
In addition, it may be necessary to dissect
from the cartilaginous middle vault. The carti-
laginous middle vault is a round roof formed by
connecting the upper lateral cartilage on both
sides with the nasal septum. That is, consisting
of a pair of upper lateral cartilage and the ante-
rior portion of the septal cartilage is connected
to the alar cartilage by a pyriform ligament. The
pyriform ligament fixes the alar cartilage to the
maxilla and cartilaginous middle vault while
having mobility. This structure can affect the alar
cartilage by abnormalities of the maxilla and car-
tilaginous middle vault, so that it suggests that
the middle 1/3 structure of the nose affects the
inferior 1/3 structure.
In other words, the mechanism by which the
alar cartilage is fixed while having mobility to the
cartilaginous middle vault is that the two struc-
tures are attached to the pyriform ligament in a
vertical direction along the pyriform rim, it is
connected by the soft tissue of the anterior surface
of the maxilla, it is connected to the ­periosteum
of the posterior surface of the pyriform aperture
and horizontally attached along the rim of the
pyriform aperture, therefore, when rotating the
alar cartilage separated from the cartilaginous
middle vault, the pyriform ligament must be cut
(Fig. 11).
If the cartilage on either side of the middle
vault is weakened or lost in the previous surgery,
the middle third of nose will appear deviated. In
addition, if the L-strut of the septum is weak-
ened due to excessive resection of the septum in
the previous surgery, it may be the cause of the
Fig. 7  Illustration and intraoperative view of soft triangle
and incision line. After making a shallow incision with a
sufficient distance of about 3 mm, check the shape of the
alar cartilage, especially the caudal margins of the middle
crura and the lateral crura, and then make a complete
incision
Fig. 8  The soft triangle notching due to an incorrect inci-
sion and closure in the soft triangle area
K. C. Lee

353
middle third deviation. On this occasion, there
are many cases where some saddle deformity or
deviation is created in the supra-tip area (Fig. 12).
When septal extension graft is planned to
control projection or rotation of the nasal tip, if
it is necessary to correct the central unit of the
nose including the nasal septum, or when there
is a need to correct the shape of the columella,
both alar cartilages should be separated. To fully
rotate the alar cartilage, use a procedure such as
spreading of the scroll area between the alar car-
tilage and the upper lateral cartilage, dissecting
and leaving of the mucous membrane only and
then cut it between the two cartilage, dissection
Fig. 9  Intraoperative view of various foreign bodies removed from the tip of the nose
Fig. 10  Intraoperative view of carefully separate each of the alar cartilage. Particularly, the medial intercrural suture or
interdomal suture must be accurately found out and cut before the separation of both alar cartilage
Secondary Rhinoplasty (3): Tip

354
of the mucous membrane at the posterior side
of the upper lateral cartilage and separating the
muco-­perichondrium of septum from the peri-
chondrium of lower lateral cartilage and upper
lateral cartilage (Figs. 13 and 14).
But care must be taken not to tear the muco-
sal membrane during dissection. However, even
if the mucous membrane is torn within 5 mm, it
is not necessary to suture it. If the mucous mem-
brane is torn or damaged beyond that, a mucosal
graft or composite graft should be performed.
For supporting the tip projection, a fixed sup-
port is often required. To implement definition
and accurate position of nasal tip, alar cartilage
can be positioned in an accurate position with
proper projection and rotation and then a fixed
support should be applied to maintain the posi-
tion of the alar cartilage.
In rhinoplasty, a septal extension graft is used
as a versatile graft. It acts as a fixed graft to the
Inter-alar
ligament
Pyriform
ligament
Fig. 11  The illustration of the anatomy of pyriform
ligament
Fig. 12  The patient with tip deviation and asymmetry due to the middle third of nose deviation
K. C. Lee

355
nasal septum and help with position the nasal tip
and hold it into position. And it can be used in
cases where the nose has deviated, as well as in
cases where adjustment of length, projection, and
sizing are required (Fig. 15).
When using a septal extension graft as autog-
enous cartilage, the septal cartilage can be used
primarily, and when the septal cartilage cannot be
used, the costal cartilage is used. Usually, in many
secondary nasal tip operations, there is insufficient
septal cartilage, costal cartilage can be used for
structural grafts are necessary to restore natural tip
contours and appropriate alar margin support.
Derotation graft using conchal cartilage can
be applied if the cephalic force acting on the
rearranged alar cartilage is not great and the soft
tissue is not severely contracted and can be suf-
ficiently released after closure of the incision site.
But the derotation graft is responsible for only
the rotation of the alar cartilage, therefore an
intercrural strut and a shield graft can be required
additionally to implement projection and defini-
tion of the nasal tip (Fig. 16).
If the alar cartilage is secured to the septal
extension graft, it must be fixed with the appear-
ance of the nasal tip in mind after redraping the
covering skin envelope. In particular, the fixation
point is determined by carefully considering the
lateral relationship of the alar rim and columella,
lobule columellar angle, nasolabial angle, length
of philtrum, and length of the nose. In secondary
nasal tip surgery, alar cartilage is often damaged
or lost, and other cartilages or foreign bodies are
often grafted, so care should be taken. If both
alar cartilages are not fixed symmetrically, it will
cause alar retraction after surgery and making it
difficult to obtain symmetry between alar and
nostrils.
When the septal extension graft is used, the
alar cartilage is fixed in three points. For the pur-
pose of making the nasal tip, both alar cartilage
and septal extension grafts are fixed to the lobular
segment of the middle crura of the alar cartilage.
In this case, the proper position should be deter-
mined by taking full consideration of the rela-
tionship between the projection and rotation of
the tip, and the relationship between the alar rim
and the columella. And for the purpose of adjust-
ing the lobule columella angle, nasolabial angle,
the length of philtrum, both alar cartilage and
septal extension graft are fixed at the lower part
of columellar segment of medial crura of alar car-
tilage. And finally, in order to adjust the defini-
tion of the nasal tip by spreading the lateral crus
of the alar cartilage, fix each of the alar cartilage
and septal extension graft in the transverse direc-
Scroll
area
Septocolumeller
fibrous attachments
Interdomal
ligament
Fig. 13  The illustration and intraoperative view of the scroll area between the upper and lower lateral cartilage
Secondary Rhinoplasty (3): Tip

356
Fig. 14  Complete dissection of lower lateral cartilage from middle vault must be needed for the alar cartilage
manipulation
K. C. Lee

357
tion in the lateral genu of the lateral and middle
crus (Fig. 17).
During the closure, first, carefully suture both
soft triangles and then temporarily suture the
center of the columella and check the appearance
and symmetry of the nasal tip and alar, and then
suture the rest.
In secondary nasal tip surgery, the difference
between favorable and unsatisfactory results
can be determined even in the smallest details.
Therefore, keep in mind, next steps are very
important.
Identify all nasal surgery history, accurate
anatomic examination, understand patient’s
problems and goals, precise nasal analysis,
meticulous planning, careful operative execution,
and painstaking postoperative care.
Under-Projected Tip
Evaluation of nasal tip projection is a very criti-
cal factor because it helps to plan preoperatively
and evaluate postoperatively results in primary or
Fig. 15  Intraoperative view of septal extension graft. It can be used in various types
Derotation
graft
Derotation graft
Columellar strut
Fig. 16  Illustration and intraoperative view of the derotation graft with columella strut. First, derotation graft is applied
and then columella strut is needed for projection and definition of nasal tip
Secondary Rhinoplasty (3): Tip

358
secondary nasal tip surgery. But degree of nasal
tip projection is very difficult because there is no
well-defined reference.
Therefore, the relationship between nasal tip
projection and facial beauty can be influenced by
other facial proportions and features including
alar and lobule ratio, nasofrontal angle, nasola-
bial angle, and overall facial balance to achieve
lateral aesthetics.
But generally, the nasal tip projection can be
thought to the distance from the alar crease to
the nasal tip on the side, and the ideal distance
is nearly 55% to 65% of the tip lies anterior to a
vertical line adjacent to the most projecting part
of the upper lip. If this distance is less than 50%
it is thought that the nasal tip is under projected
(Fig. 18). And another reference of the ideal tip
projection is considered that the ratio of nasal
length (radix to tip) to the tip projection (alar
base to tip) is 0.67.
Before the operation, the first important step
is tip support test for under-projected tip defor-
mity, check the resistance when the nasal tip is
depressed and tip recoiling should be assessed to
check the stability and integrity of tip supporting
structure (Fig. 19).
The most common problem in secondary
nasal tip surgery is over-resected of the tip car-
c
a
b
Fig. 17  Illustration of the fixation point of alar cartilage
to the septal extension graft. a. For the purpose of making
the nasal tip fixed to the lobular segment of the middle
crura of the alar cartilage. b. For the purpose of adjusting
the lobule columella angle, nasolabial angle, the length of
philtrum, both alar cartilage and septal extension graft are
fixed at the lower part of columellar segment of medial
crura of alar cartilage. c. To adjust the definition of the
nasal tip by spreading the lateral crus of the alar cartilage,
fix each the alar cartilage and septal extension graft in the
transverse direction in the lateral genu of the lateral and
middle crura
A
B
A =50-60%
1.0
0.67
Ideal tip projection
Ideal tip projection
Under projected tip
Under-projected tip
Over-projected tip
Fig. 18  Illustration of the ideal tip projection is consid-
ered that the ratio of nasal length (radix to tip) to the tip
projection (alar base to tip) is 0.67 and the distance from
the alar crease to the nasal tip on the side, and the ideal
distance is nearly 55% to 65% of the tip lies anterior to a
vertical line adjacent to the most projecting part of the
upper lip
K. C. Lee

359
tilaginous framework such as the alar cartilages,
the nasal septum, or both. Over-resection of the
alar cartilage can be occurred to make a more
small, more defined contour and more rotation
of tip with only cartilage resection. But, If the
cartilages were over-resected, it is prone to result
in adverse effect, such as poor definition, frame-
work instability, and cartilage collapse. In most
patients, cartilage collapse can cause the under-­
projected nasal tip and further worsen unsuccess-
ful esthetic results (Fig. 20).
Anatomic Cause
of Under-Projected Tip
The length and strength of the medial crura of
alar cartilage play an important role in tip pro-
jection and definition. The short, weak medial
crura may lose its supra-tip definition because
of the reduced difference between dorsal height
and domal peak. Additionally, under-projected
tip can be a loss of tip support systems includ-
ing integrity of the medial and lateral crus,
attachment of the medial crus to septum, and
attachment of upper lateral to lower lateral
cartilages.
1. Underdeveloped medial crura generally lack
tip projection and lack tip definition (Fig. 21).
2. Under-projected tip may be related to aging
face due to weakening of tip support mecha-
nism (Fig. 22).
3. Inadequate tip support from nasal trauma or
prior surgery that destabilizes the tip support
is a common cause (Figs. 23 and 24).
4. Under-projected tip may be related to locally
loss of alar cartilage at the anterior septal
angle cartilage, owing to injury or prior exces-
sive resection (Fig. 25).
5. Under-projected tip may be related to over-­
resection of septum with regard to inadequate
trimming of upper lateral cartilages and alar
cartilage, lack of tip support, or inexperienced
trimming and suturing of the upper and alar
cartilages to the septum (Fig. 26).
Fig. 19  Tip support test, check the resistance when the nasal tip is depressed and then tip recoiling should be assessed
to check the stability and integrity of tip supporting structure
Secondary Rhinoplasty (3): Tip

360
Fig. 20  Over-resection of caudal septum and lower lat-
eral cartilage. It may occur during for tip rotation proce-
dure due to over-resected caudal septum and cephalic
trim. Correction with columella strut and structural graft
for strengthening tip support structure. Always not exces-
sive cephalic trim is good
Excised
Caudal resection
8mm
Conservative trim
Aggressive trim
4.0mm
6.0mm
8.0mm
Cephailc trim
K. C. Lee

361
Correction of Under-Projected Tip
For most patients, it is also helpful to consider
the tip rotation as well, as it is beside the ideal
nasolabial angle (95 to105 degrees is appropriate
for women and 90 to 100 degrees is appropriate
for men) (Fig. 27).
Correction
principle
of
under-projected
tip must be based on the tripod model that are
reinforcing or elongation of the medial crura,
cephalic trimming of the lateral crus, shortening
caudal septum and reestablish support mecha-
nism. In secondary patients, anatomical restora-
tion of the weakened or destroyed lower lateral
cartilages and reconstruction of a favorable, well-
defined nasal tip framework should be operated
for satisfactory surgical results (Fig. 28).
1. Structural graft of alar cartilages reinforces
the tip structure and the destroyed support
structures and changes the position of the
nasal tip to overcome the scar contraction
forces of the long-term healing stages.
Especially columellar strut is a valuable skill
Fig. 20  (continued)
Secondary Rhinoplasty (3): Tip

362
for stabilizing the nasal base and correction
of medial crus deformity by strengthening
and elongation of medial crus. When addti-
tonal more tip projection is required, a
slightly long and strong columellar strut may
be useful, and medial crus are advanced
secure to the strut. In addition, columellar
struts can support the nasal tip (Figs. 29 and
30). The main drawback of columellar strut
is that the graft is floating and does not attach
to the septum. This means that, unlike a sep-
tal ­extension graft, nasal tip position is less
predictable.
2. In secondary patients with excessive resection
of nasal tip structure, projection of tip is gen-
erally declined and maybe reconstructed with
Fig. 21  The patient with underdeveloped medial crura
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363
intercrural graft, septal extension graft, and
onlay tip graft (Fig. 31).
3. Medial crural and interdomal suture can mod-
ify the tip and increase tip projection by
strengthening the medial crura.
4. Transdomal suture can narrow and move the
domes, so the dome can be refined to rein-
force the projection.
5. Cephalic trim can improve the definition by
rotation of the tip to the cephalic position. The
nasal tip can be rotated cephalic direction by
making a gap between the upper lateral carti-
lage and alar cartilage (Fig. 32).
6. Onlay tip graft can increase the height and
contour of the nasal tip and may emphasize
well tip defining points and highlights and
may make a more favorable shape to the
insufficient tips after surgery. It can be used in
various shapes including triangular, trapezoi-
dal, or shield-like (Fig. 33).
7. Correction of the aging under-projected tip is
tip rotation and the tip support complex resta-
bilizing is necessary (Fig. 34).
Autologous cartilages are the optimal source
for structural graft of the nasal tip. When pos-
sible, septal cartilage is a suitable graft material
because it is rigid, straight. However, septal car-
tilage is often used in the primary operation and
is often not sufficient in a secondary operation.
Fig. 22  Illustration and photography of the secondary
under-projected tip deformity due to skeletal aging. Tip
support weakens, descent of nasal tip, nasal elongation,
and nasolabial angle changes. The pyriform aperture has
been remodeled upward to pull out the alar base. So, it
induces derotation of the nasal tip and acute nasolabial
angle
Secondary Rhinoplasty (3): Tip

364
Auricular cartilage may be used for onlay tip
grafts and shield type grafts, but flaccidity and
convolutions of auricular cartilage may limit its
use in structural grafts. Autologous rib cartilage
can be used If significant support is required.
Sometimes, tip asymmetry can also be caused
by uneven placement of structural grafts. In
placement of the grafts symmetrically is very
important. When placing the columellar strut
directly on the premaxilla, may displace it from
the midline after operation. When the columel-
lar strut overlaps the caudal septum, it may shift
from the midline. When there is no soft tissue
pad between the columellar strut and the anterior
nasal spine, the patient may feel a clicking sensa-
tion while smiling.
If a septal extension graft is fixed in the sep-
tum with an overlapping type, this may cause
nasal tip deviation. To prevent this, sometimes it
is necessary to be fixed with end to end type.
If structural grafts for alar cartilage are too
thick, the thickness of the grafts can become
bulky around the tip and narrow the airway. Be
careful, if you use rib cartilage. Especially, the
lateral crural strut graft made with rib cartilage
should be very thin to prevent this situation.
Supra-Tip Deformity
Supra-tip deformity is a congenitally or after a
poorly executed rhinoplasty, which means that
the area just above the nasal tip is convex, which
is not good for beauty. Looking at the nose from
the lateral side, the nose is more aesthetically
pleasing if the supra-tip area is slightly lower
than the tip of the nose, rather than a straight line
from the root of the nose to the nasal tip.
Fig. 24  Nasal tip under projection due to loss of tip support by previous operation. Correction with columella strut and
shield graft
5
3
7
4
1
9
2
8
6
Fig. 23  Tip Support system. 1. Size, shape, strength, and
resiliency of the alar cartilage. 2. Attachment of the medial
crura to the septum. 3. Attachment of upper lateral carti-
lage to alar cartilage. 4. Interdomal soft tissue. 5.
Cartilaginous dorsum. 6. Soft tissue attaching lateral crura
to piriform wall. 7. Alar cartilage attachment to skin and
soft tissue. 8. Nasal spine. 9. Membranous septum and
nasal spine
K. C. Lee

365
One of the most common complications
of primary rhinoplasty, which is identified by
fullness or convexity just above the nasal tip
(Fig. 35).
Anatomic Cause
Supra-tip deformity is characterized by an over-­
projected supra-tip, an under-projected tip, and a
cephalic-oriented lower lateral cartilage. A very
common cause of supra-tip deformity occurs
when nasal humpectomy was done, if the opera-
tors leave excess height of the septum, which
leads to increased fullness in the supra-tip area
(Fig. 36).
It is necessary to determine whether the cause
of the convex area above the tip of the nose. It is
necessary to judge whether the cause of the con-
vex appearance of the supra-tip is due to exces-
sive resection of the caudal dorsum, or the fact
that it does not properly elevate the caudal area
of the septal cartilage. If the contour of the nose
is improved when lowered as much as the bony
vault by pressing the area just above the convex
tip of the nose with a finger, it can be seen that it
is due to over-resected caudal dorsum (Fig. 37).
1. If the supra-tip deformity is due to insufficient
resection of the caudal dorsum, it can be diag-
nosed by palpating the caudal nasal portion of
the remaining septal cartilage (Fig. 38).
Fig. 24  (continued)
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2. Other causes are supra-tip tissue excess, inad-
equate tip projection, or a combination of
these factors (Fig. 39).
3. A significant amount of fibrosis was observed
in the area above the tip in patients with sec-
ondary rhinoplasty compared to patients with
primary rhinoplasty. The excessive fibrosis or
scar tissue is due to failure to reduce dead
space during previous rhinoplasty (Fig. 40).
Correction of Supra-Tip Deformity
Accurate reduction of the caudal dorsum, elimi-
nation of dead space and the reestablish adequate
nasal tip projection are important to avoid the
occurrence of a supra-tip deformity.
Supra-tip deformities must be corrected
depending on their etiology and the appearance
of the deformity. Therefore, in case of correction
of the supra-tip deformity, a combination of wide
and safe dissection of the nasal skin, resection of
the excessive scar, soft tissue, nasal dorsum, aug-
mentation of the nasal tip and dorsum and sep-
tal extension graft are required. Sometimes, the
supra-tip advancing suture may be useful.
And especially, it is critical to remind that
individual patient’s soft tissue can be responded
differently to operation. Supra-tip deformity cor-
responded to an increased skin thickness and
Fig. 25  Under-projected tip due to local loss of alar cartilage and buckling formation. Correction with septal extension
graft, cap graft, and shield graft
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Fig. 25  (continued)
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Fig. 26  Nasal tip projection loss due to septal weakening
by over-resection of septum with regard to inadequate
trimming of upper lateral cartilages and alar cartilage,
lack of tip support, or inexperienced trimming and sutur-
ing of the upper and alar cartilages to the septum.
Correction with septal extension graft and tip-plasty
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Increase
Decrease
Rotation
Nasotrontal angle
n
prn
sn
Is
sto
Nasal tip angle
Nasolabial angle
Fig. 27  Illustration of the nasal tip rotation and nasolabial angle
Fig. 28  Illustration of under-projected nasal tip and its subsequent correction
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Fig. 29  Various structural grafts
Fig. 30  Columella strut made using auricular and septal
cartilage. This is a method of making a strut at the nasal
tip to make it straight and fixing this strut to the nasal sep-
tum. It is relatively simple and effective. Depending on
the position of the graft, it may control the nasal support
and projection
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Fig. 30  (continued)
Fig. 31  Septal extension graft for improving tip projection and strengthening tip support structure due to excessive
resection of nasal tip structure
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sebaceous glands, which is likely to increase
postoperative swelling, scarring, and fibrosis,
therefore, it can be difficult to predict the out-
come after surgery (Fig. 41).
1. If the etiology is excessive resection or weak-
ened of the septal cartilage in the prior sur-
gery, a septal extension graft combined with a
spreader graft stabilize septal structure and
allows tip projection and position to be
adjusted by securing the medial crus to the
septal extension graft (Fig. 42).
2. If the cause is insufficient resection of the
caudal dorsum and under-projected tip, tip
projection and additional resection of the
caudal dorsum may be applied. But some-
times, it is better to elevate the nasal dorsum
rather than resecting the caudal portion of
the septal cartilage. When estimating the
height of the area just above the nasal tip
after changing the shape of the cartilage
structure in order to improve supra-tip
deformity, it is necessary to take into account
that the thickness of the skin at this area is
Fig. 31  (continued)
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Fig. 32  The nasal tip can be rotated in cephalic direction by making a gap between the upper lateral cartilage and alar
cartilage using appropriate cephalic trimming. Correction by cephalic trimming and intercrural graft
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Fig. 32  (continued)
Fig. 33  Correction with columella strut, onlay and shield graft for tip projection
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Fig. 33  (continued)
Fig. 34  Correction of the under-projected tip is using septal extension graft for tip rotation and tip support structure
restabilizing
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Fig. 34  (continued)
Normal
Supralip
Break point
Polly Break
Deformity
Ideal
supratip
break
Fig. 35  Illustration and photography of supra-tip deformity patients
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thick. Direct contact between the nasal skin
flap and the alar cartilage is very critical in
correcting a supra-tip deformity. Sometimes,
advancement suture of the nasal soft tissue
is an effective procedure. Scar tissue arising
as a result of the supra-tip operation may
reduce dead space, and this technique may
be used to reposition the nasal tip. But If the
edema or swelling on the supra-­tip area was
developed after rhinoplasty, ­compressive
taping can be used to reduce dead space and
hematoma (Fig. 43). →.
3. Resection of the excess subdermal tissue just
above the tip of the nose and supra-tip carti-
lage graft to reduce dead space, and supra-tip
advance suture may be applied. But, resection
of the soft tissue is easy to mistake that the
fullness will simply be lowered, but there is a
limitation. It should be kept in mind that if
you resect it too much, you will be left with
only the deformity forever, rather than making
it look good (Fig. 44).
4. If the cause is not projecting the nasal tip prop-
erly, it will be improved by projecting the
Fig. 36  Inadequate humpectomy can produce supra-tip deformity
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378
nasal tip. Structural grafts for tip projection
can be used including columellar strut graft,
septal extension graft, and tip grafts. Especially
columellar strut grafts reinforce tip supports,
strengthen stability, and improve tip projection
as the medial crura advances (Fig. 45).
Pinched Nasal Tip
The pinched nasal tip is identified with the defi-
nite boundary between the nasal tip and the alar
lobule, separation of the nasal tip from the sur-
rounding nasal subunits, therefore, it interferes
with the overall harmony and balance of the nose.
When viewed from the front, pinched nasal tip
may be bound by vertical shadows isolating the
nasal tip from the alar lobule and from the basal
view, pinched nasal tip is seen as medial collapse
and notching of the alar margin and a loss of natu-
ral appearance of the triangular shape of the nasal
base, therefore pinched nasal tip is a permanent
sinking of the vestibular wall, obstruction of the
nostril and making an unaesthetic alar groove on
one or both sides. The concavity degree and the
stability of the lateral crus are significant causes
of esthetic and functional problems (Fig. 46).
As well as esthetic deformity, weakly sup-
ported alar margin can collapse due to negative
airway pressure during inspiration, which may
be the cause of decreased nasal breathing with
instability external nasal valve.
Anatomic Cause
1. The pinched nasal tip deformity may be inher-
ited, if the lower lateral cartilage is too thin or
narrow to support the sides of nasal the tip,
therefore, the nose falls slightly inward
(Fig. 47).
2. But more often iatrogenic consequences of an
incorrectly executed operation including tip
suturing, division, and resection of the cephalic
edge of the alar cartilage in order to narrow the
tip, which results in the lateral crural defor-
mity and weakens the support of the alar mar-
gin, it causes medial collapse of the alar lobule
and pinching of the nasal tip (Fig. 48).
3. Occasionally, concomitant vestibular scar
retraction and over-protrusive shield grafts
can also make the image of a pinched nasal
tip.
Fig. 37  Supra-tip deformity and depression of the nasal
dorsum due to excessive resection of caudal dorsum in a
rhinoplasty
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Fig. 38  Supra-tip deformity due to insufficient resection of the caudal dorsum. Correction by remnant humpectomy
and septal extension graft with tip-plasty
Fig. 39  Supra-tip tissue excess, inadequate tip projection, or a combination of these factors
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Correction of Pinched Nasal Tip
The goal of the pinched nasal tip correction is
to restore nasal tip contours and to support alar
margin. Therefore, need to understand that lateral
compartment support close to the alar margin is
important. Conventional tip-suture techniques
tried to narrow the tip reduces the dome angle,
medialize, and make an adverse connection
between the cephalic and caudal margins of
the lateral crus. Too tightly cinching suture the
domes results in pinched nasal tip and disloca-
tion of alar support, medially weakening of the
alar margin support results in medial dislocation,
notching, and retraction of the alar.
Methods designed to recontour pleasing nasal
tip architecture and reestablish strength to the
tip and the alar margin using cartilage graft and
suture techniques.
1. If severe concavities are present, lateral crural
strut graft is used to strengthen the crura, to
support the alar and to protect from retraction
and fading out the demarcation of tip and alar
lobules (Fig.  49). Lateral crural strut grafts
and alar contour grafts can help with correc-
tion of both functional and esthetic deformity,
be able to provide the support of the alar mar-
gin and correct external valve collapse, there-
fore, achieve a favorable nasal tip contour.
The lateral crural strut graft must be inserted
after completely freeing the lateral crura and if
want to control domal projection, the dome repo-
sitioning can be moved to laterally for increasing
projection or medially for decreasing projection.
One of the disadvantages of this graft is that it
gets thicker in the nostril, especially the inside
of the nose.
After fixation, interdomal suture is then placed
for appropriate approximation of the domes and
secure the dome to the septal extension graft.
Additionally, tip or infra-tip onlay graft will be
needed, according to differ from width, thick-
ness, and position, control of tip projection, tip
width, and definition and can change the degree
of supra-tip and infra-tip break. However, the
nasal base width may increase, the nostrils widen,
and the stiffness of the nose may increase and lat-
eral crural strut grafts also may move the medial
of the vestibular skin and disturb the airway if the
graft is placed in non-precise position.
Fig. 39  (continued)
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2. To recontour a natural transition from tip to
alar lobule is difficult applied only the lateral
crural strut graft and dome defining tech-
niques, so alar contour graft will be needed to
make the pleasing tip contour. This graft can
be inserted by making a narrow pocket using
two vertical incisions. Alar contour grafts are
useful in correction of the pinched nasal tip
for the purpose of improving alar margin posi-
tion, creating a more satisfactory triangular
shape on basal view and providing a natural
transition between the nasal tip and alar lob-
ule (Figs. 50 and 51). But it can often mobi-
lize postoperatively and make a depression or
create a retraction site from the nasal tip to the
alar rims. Thus, to prevent migration, secure
fixation is necessary.
3. Although, alar extension graft is designed to
correct for alar retraction, it can provide struc-
tural strength to alar cartilage that is congeni-
tal weakly or damaged by prior surgery, so it
can be applied to reconstruction of the tip of
the nose. It can be used to reconstruct the lat-
eral crura of the lower lateral cartilage, and
the lower lateral cartilage structurally rein-
forced by a graft has the advantage of
­improving the shape of the nasal tip and alar
rim (Figs. 52 and 53).
Big Tip Nose
One of the most common difficulties of second-
ary nasal tip surgery is the big tip such as broad,
bulbous, or round tip. According to the tip pathol-
ogy, careful elevation of the skin flap and make
a smaller, more refined nose with a slight dorsal
curve with an acceptable, natural appearance,
Excessive soft
tissue or sacr tissue
Fig. 40  Supra-tip deformity due to the excessive fibrotic tissue or scarring
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382
and a more defined tip are the goals of operation
(Fig. 54).
For better esthetic outcomes, it is essential for
the surgeon to know the components of the nasal
tip and how they contribute to nasal tip projection.
Therefore, the skin, subcutaneous tissue, superfi-
cial musculoaponeurotic system, ligaments, and
the lower lateral cartilage must be considered in
combination.
Generally, a big tip in secondary rhinoplasty
can have alar cartilage malposition, especially
the lateral crura of alar cartilage is cephalic rota-
tion along an axis toward the medial canthus of
the eye.
The patients with big nasal tip can be mani-
fested as bulbous with hypertrophy of both the
nasal skin and cartilaginous structure and may
be easy to provide excessive or poorly supported
nasal tip narrowing due to the breakdown of the
balance between the tip and alar rim after opera-
tion (Fig. 55). If surgical approaches should be
considered the appropriate extent of nasal tip
­surgery balanced between alar rim support and
soft tissue reduction. But sometimes reductive
techniques are prone to make unnatural results
over time.
Creating a pleasing and harmonious nasal
tip structure is the most difficult procedure of
Fig. 41  Patient with thick nasal skin and abundant sebaceous glands
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primary and secondary rhinoplasty. A pleasing
nasal tip is formed when a balanced relation-
ship is created between the soft tissue cover and
underlying nasal tip structure. Open rhinoplasty
with a combination of tip defatting, resection of
soft tissue, strengthening of lower lateral carti-
lage, and cartilage tip graft placement is recom-
mended due to the complexity of the surgical
techniques.
Anatomic Cause
1. Generally, big tip in secondary rhinoplasty
has alar cartilage malposition. When long axis
of the alar cartilage extends toward canthus of
the eye, usually, the direction of the long axis
points the lateral canthus, but boxy or big tip
is often toward medial canthus. In other
words, the lateral crura of alar cartilage are
cephalic rotated and the position of the lateral
end of the lateral crura is not lowered, but
located at a high position, therefore, the dome
can be bulbous (Fig. 56).
2. If the skin of nasal tip is too thick, the nasal tip
tends to be a rounded appearance. If the skin
is not the problem, the shape of the cartilage
in the nasal tip may be the cause. Wide or con-
vex shape of alar cartilage creates a bulbous
nasal tip (Fig. 57).
Fig. 42  Septal extension graft combined with spreader grafts can stabilize septal structure
Secondary Rhinoplasty (3): Tip

384
Generally, the anatomic characteristics of
the big or bulbous nasal tip are a wide inter-
domal distance, a thick skin with abundant
sebaceous gland, an interdomal fibrofatty tis-
sue, soft tissue scarring, abnormalities of lower
lateral cartilages, and a poor tip support of the
caudal septal attachments and intracrural liga-
ments. An important anatomic feature is the
interdromal fat pad or fibrotic scar tissue affect-
ing the nasal tip projection. This is more com-
monly present in patients with thick-skinned
noses, and a prominent feature of bulbous nose
(Fig. 58).
Correction of Big Tip
Dome resection, resection of the lateral crural
tail to rotate the alar cartilage arch, lateral cru-
ral reduction, removal of interdomal soft tissue
Fig. 42  (continued)
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385
and scar tissue, lateral crural relocation, alar rim
splinting with autogenous grafts, and a variety of
suture techniques are being used.
1. Reduction of skin and soft tissue or fibrotic
scar tissue
Evaluating the skin envelope of the tip struc-
ture is critical to properly draping the skin for a
balanced tip. The appropriate skin thickness in the
nasal tip area is successfully noticed tip definition
but thick skin certainly masks tip definition and can
be represented to trapdoor-like effect with long-
lasting swelling or edema and a deficient tip defi-
nition. Therefore, safely and effectively debulking
procedures are important and additional tip graft
can make a more definition of the tip structure.
Fibrofatty tissue can be seen in the alar lobule
area but less in the nasal tip area. But the fibrotic
scar tissue could be the opposite situation.
Anyway, to avoid soft tissue and skin necrosis
during debulking procedure of the soft tissue in
nasal tip, not dissect superficially and preserva-
tion of the subdermal plexus and the appropriate
subcutaneous tissue are safe. But in other cases,
if patients have too much thin skin, sharp angles
and step-off appearance of the tip may have
occurred, therefore, in this situation, to make a
Fig. 43  Illustration and intraoperative view of supra-tip advance suture and septal extension graft for correction of
supra-tip deformity
Excessive soft
tissue or
scar tissue
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Fig. 43  (continued)
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387
Fig. 44  Resection of the excess subdermal tissue and fat just above the tip of the nose
Fig. 45  Improve nasal tip projection using septal extension graft, tip graft
L.C.
concavity
Pinched tip
Fig. 46  The shape of lower lateral cartilage easy to pinched nasal tip deformity
Secondary Rhinoplasty (3): Tip

388
balanced change from the dorsum to the tip, aug-
mentation of soft tissue is necessary (Figs.  59,
60, and 61).
To avoid soft tissue and skin necrosis during
debulking procedure of the soft tissue in nasal tip,
not dissect superficially and preservation of the
subdermal plexus and the appropriate subcutane-
ous tissue.
2. Cephalic trimming of alar cartilage
Reduction of cephalic lower lateral crus
may be effective in reducing fullness as well as
modifying residual convexities of the lower lat-
eral cartilage and is often required for effective
correction of bulbous tip with tip suture and
grafts procedures, but not always necessary.
Check the size, strength, and position of the
lower lateral crus is necessary. Symmetric and
conservative trimming are important (Figs. 62
and 63).
3. Tip suturing and Tip grafts
Size, strength, and position of lower lateral
crus are evaluated and then decide which of
cephalic trim, tip suture, and graft techniques or
reshape and reposition of the tip support struc-
ture is better. In other words, after considering
everything and then strengthening the alar carti-
lage for tip projection and tip graft is used for a
more defined tip.
Accurate placement and proper tension con-
trol of the suture techniques are required for
a well-supported and defined tip structure.
However, tip sutures alone are not always enough
to provide a balanced tip projection and appear-
ance. Columellar strut is a useful surgical method
to maintain or strengthen tip support and increase
tip projection.
The most common tip grafts may be the onlay
grafts and infra-tip grafts. The combination of
these two grafts can further define the nasal tip
structure by natural transition from the nasal tip to
the columella. The onlay tip grafts provided for a
natural transition from the supra-tip breakpoint to
the tip area with the tip projection (Fig. 64). But
the fixation is unstable, displacement, rotation, or
buckling during healing stage can occur. When
infra-tip volume and projection are lack or the
breakpoints are inadequate, infra-­tip grafts can be
needed. It is helpful to score the superior edge of
the cartilage so that it bends effectively at predict-
able breakpoints.
Shield grafts are helpful in patients with loss
of projection in the nasal tip lobule.
Cap graft placed on the nasal tip to increase
tip definition and give more projection (increased
nasal length). This is usually made from septal
cartilage.
Fig. 47  Inherited deformity of lower lateral cartilage
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389
Onlay grafts are placed on top of a site and
can be placed anyplace in the nose. In most cases,
these grafts serve to augment areas that can cause
depression due to lack of cartilage.
When placing an onlay graft it is important to
check sharp edges of the graft. It is often better
to crush the edges of the cartilage graft slightly to
prevent it is visible from the outside.
Onlay grafts are visible grafts but, placed
underneath the nasal structure are invisible
grafts. Invisible grafts are less risky for vis-
Fig. 48  Iatrogenic medial shift of lower lateral cartilage due to over-resection of cephalic trimming of lower lateral
cartilage. Correction with lateral crural strut graft
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Fig. 49  Lateral crural concavity and pinched tip and lateral crural strut graft for correction of pinched nasal tip
deformity
K. C. Lee

391
ibility but may not be implemented in certain
cases.
Asymmetry Nasal Tip
Asymmetric nasal tip is a more common prob-
lem of primary and revisional rhinoplasty. This
is manifested by anatomic deformities of tip,
alar, nostrils, and columella and that is one of the
most difficult problems encountered in revisional
rhinoplasty.
Caudal nose is composed of septum, lower
lateral cartilage, and anterior nasal spine. If
these caudal components are deviated, the nasal
tip and columella become deviated and the nos-
trils can be asymmetric. For optimal results with
patients’ satisfaction, surgeons should be aware
of structural abnormalities attributable to caudal
asymmetry of the external nose and correspond-
ing surgical procedures. Therefore, accurate pre-
operative evaluation is important to check the
anatomical cause of the asymmetry and under-
standing the anatomical structures that affect the
shape of the nasal tip and how intrinsic asymme-
try of its framework and integrity can change its
Fig. 50  Illustration and intraoperative view of alar rim
grafts. It improves the strength and stability of the alar
lobule
Fig. 51  Alar rim graft for pinching deformity. Sometimes it is corrected in a relatively simple way, but more often it is not
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Fig. 52  Dr. HS Kim devised a technique suitable for cor-
recting alar retraction that occurs in the nose of Asians
with weak cartilage structure. It is an alar extension graft
that overlaps and reinforces with triangular shape of carti-
lage to the structurally weak alar cartilage
Fig. 53  The shape of the dome has been improved and recovered pinching of the alar wall
Fig. 54  The patients with a big and thick skin of nasal tip
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shape, and then you must make an optimal surgi-
cal plan to correct it.
Anatomic Cause
1. Asymmetry lower lateral cartilage
Tip asymmetry can be largely divided into
vertical asymmetry and horizontal asymmetry of
both lower lateral cartilages. Vertical asymmetry
is a case where the height of both sides is dif-
ferent from the cephalic and caudal directions.
Sometimes it comes from an abnormality of the
alar cartilage, but it is mainly caused by external
factors other than the alar cartilage, such as nasal
bone, septum, upper lateral cartilage, and maxilla
act as external factors of asymmetry (Fig. 65).
Horizontal asymmetry refers to intrinsic
asymmetry of bilateral lower lateral cartilage and
Intrinsic asymmetry is described by Dr. Rohrich
that when there is an anatomical asymmetry of
Fig. 55  The type of bulbous nose. Skin tissue is thick or cartilage are overdeveloped, large, and spread out
Fig. 56  Illustration of cephalic rotation of the lateral crura of alar cartilage in bulbous nasal tip. Normal type and
cephalic rotation of lower lateral cartilage
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Fig. 57  Illustration of type of normal and thick subcutaneous tissue of nasal tip
Inter domal distance
Angle of Divergence
Fig. 58  Big tip with a wide interdomal distance, a thick
skin with abundant sebaceous gland, an interdomal fibro-
fatty tissue, soft tissue scarring, abnormalities of lower
lateral cartilages, and a poor tip support of the caudal sep-
tal attachments and intracrural ligaments
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395
the lower lateral cartilage, the projection of both
domes differs regardless of the anatomical char-
acteristics, and that both domes are not posi-
tioned at the same distance from the midline, so
they appear deviated.
The degree of asymmetry of nasal tip may
vary depending on the shape of tip defining point
and the dome part of the tip where the lateral
and middle crura of the lower lateral cartilage
meet. It is possible to classify into various types
according to the degree of unbalance of the dome
protrusion on both sides by the structures consti-
tuting them and the deformity of the dome posi-
tion in the middle line (Fig. 66).
However, it is not enough to analyze the exter-
nal deformity that appears in the lower third of
the nose as only the change in the size and loca-
tion of the alar cartilage, and the deformity and
loss of the alar cartilage.
This is because the caudal margin of the sep-
tum greatly affects the deformity of the lower
third of the nose. In fact, most of the nasal tip
asymmetries are related with a septal deviation,
whether the cause is inherited or acquired. If,
before the completion of nasal development, con-
genital septal deviation or septal injury occurred,
asymmetric force can affect the lower lateral
cartilage and then asymmetric growth of the alar
cartilage can lead to deformity of lower lateral
cartilage and caudal nasal deviation. These prob-
lems can increase the problems of correction of
the nasal tip asymmetry. Therefore, in secondary
nasal tip surgery, it is often needed to separate the
bilateral alar cartilages from the nasal septum.
Fig. 59  Skin necrosis due to excessive reduction of soft tissue
Fig. 60  Intraoperative view of resection of scar tissue on the tip using dual plane dissection
Secondary Rhinoplasty (3): Tip