Kỹ Thuật Phẫu Thuật Nâng Mũi Đỉnh Cao (Mastering Rhinoplasty)

94
Chapter 3  
Radix and Dorsum
Analysis
A 27-year old presented with an asymmetric deviated nose and a vague history of nasal
trauma which was not treated (Fig. 3.28). Functionally, she was obstructed at her left external
valve. Aesthetically, the patient was bothered by the deviated nose, the prominent dorsum,
and the overall size. The technical challenge was to straighten both the very asymmetric
bony dorsum and the entire nose while creating a smaller more refined look. Relocation
of the caudal septum was an absolute necessity for straightening the nose and opening the
external valve. Different osteotomies on the two sides improved the inherent asymmetry of
the bones. The spreader grafts were longer than usual (25 mm) and placed higher into the
bony vault to insure stability. A fascia graft over the dorsum was done to insure smoothness.
Operative Technique Highlights
  1) Harvest of deep temporal fascia
  2) Exposure of dorsum and septum
  3) Creation of 6 mm rim strips and extra mucosal tunnels
  4) Incremental dorsal reduction: bone 0.5 mm, cartilage 3 mm
  5) Caudal septal resection: 3 mm
  6) Septal harvest followed by caudal septal relocation L to R
  7) Asymmetric osteotomies: R double level, L low-to-low
  8) Columellar strut and tip sutures: CS, DC, ID, DE
  9) Insertion of dorsal fascia graft and tip fascia graft
10) Nostril sill excisions: R 1.7 mm, L 2.0 mm
11) Alar rim support grafts sutured into marginal incisions
Case Study:
Asymmetric
Bony Vault
Fig. 3.28 (a–j)

Case Study: Asymmetric Dorsum
95
Fig. 3.28 (continued)

96
Chapter 3  
Radix and Dorsum
Radix. Radix reduction is not as easy or effective as one might wish (Fig. 3.29). Thus, one
should be careful in thinking that a major reduction is possible – never design an “all or
none” operative plan based on a major radix reduction. Do not over-reduce the dorsum to
fit a new nasion which would be produced by a large radix reduction. In operative planning
and execution it is important to separate the radix area from the dorsum. I will usually do an
incremental dorsal reduction first using a rasp for the bony vault and scissors for the cartilage
vault. This initial dorsal reduction is conservative. Then the double-guarded osteotome is
inserted against the cephalic edge of the bony vault. The handle is levered upward towards
45° and then tapped with the hammer. After several taps, one should palpate the amount of
bone being removed. If satisfied, the tapping is continued until the osteotome strikes the skull
which is indicated by a dull thud. Rotating the osteotome causes the radix bone to disarticu-
late from the nasofrontal suture line. If the bone is not easily removed, a 2 mm osteotome can
be driven transversely across the radix via a stab incision beneath the eyebrow.
Dorsum. As previously stated, dorsal augmentation has changed dramatically (Fig. 3.30).
I no longer use solid grafts of septum or layered conchal grafts, but rather diced cartilage
grafts in fascia (DC−F). Since the vast majority of dorsal augmentations have been done in
Asian, secondary, or reconstructive cases, this technique will be discussed in-depth in those
sections. As regards primary Caucasian noses, the need for augmentation is usually in the
1–3 mm range and can be achieved progressively with either a double layer of fascia (F) or a
very small tapered DC-F graft with the thickest portion in the supratip area. In these ­patients,
I make the dorsal graft construct on the back table. The fascia is pinned to a silicone block.
The diced cartilage is placed on the fascia in the desired amount, the fascia folded over, and
the edges sutured with 4–0 plain catgut. The graft is molded with the fingertips until the
desired shape is achieved. These grafts are kept on the conservative side and can always be
augmented with small amounts of diced cartilage placed underneath, usually in the supra-
tip area. Most overresected secondaries will require maximum fullness over the bony vault,
whereas most Asian noses require a graft of uniform thickness.
P R I N C I P L E S

 Be conservative in planning a radix reduction, but be relatively aggressive in how much
bone you remove.

 A double-guarded osteotome is safer than a drill.

 DC-F grafts have replaced dorsal grafts of septum or concha.

 DC-F grafts can be customized to fit the dorsal defect, ranging from half-length to full-
length, as well as thickness (2–8 mm).

 DC-F grafts are never made larger than required, there is no absorption.
Decision Making
Level 3

Decision Making Level 3
97
Fig. 3.30 (a–c) Dorsal augmentation using diced cartilage in fascia (DC-F)
Fig. 3.29 (a, b) Bony excision of the radix
45°−60°
a
b

98
Chapter 3  
Radix and Dorsum
Analysis
A 19-year-old girl of Persian descent felt that her nose was too big, too wide, and too
­unattractive (Fig. 3.31). Compounding the problem of a heavy skin sleeve was the radix full-
ness which gave the impression that the nose started at the eyebrows. Palpation indicated that
the radix fullness was soft tissue rather than bone. Muscle resection followed by elevation of
the medial brow resulted in a more specific nasion point and also lowered the start of the nose
from the medial brow to the lash line. The width of the bony vault was narrowed markedly,
but required a total of eight osteotomies plus stabilization with long spreader grafts.
Operative Technique
  1) Maximum soft tissue defatting over the tip and dorsum
  2) Maximum muscle resection in the radix area
  3) Incremental dorsal reduction: bone 2 mm, cartilage 4 mm
  4) Caudal septal resection 5 mm and ANS resection
  5) Septal harvest
  6) Maximum narrowing of the bony vault: medial oblique, double-level and transverse
­osteotomies
  7) Spreader grafts placed high into the bony vault
  8) Insertion of columellar strut and tip sutures; CS, DC, and LCC
  9) Open structure tip graft sutured to domes and columellar
10) Alar wedge resections and alar rim grafts
11) Central endoscopic forehead lift with no temporal sutures
Case Study:
Radix
­Reduction
Fig. 3.31 (a–l)

Case Study: Radix ­Reduction
99
Fig. 3.31 (continued)

100
Chapter 3  
Radix and Dorsum
Aiach G, Gomulinski L. Resection controlée de la bussé nasal osseuse au niveau de l’angle
naso-frontal. Ann Chir Plast 27: 226, 1982
Byrd S, Hobar PC. Rhinoplasty: A practical guide for surgical planning. Plast Reconstr Surg
91: 642, 1993
Daniel RK. The radix. In: Daniel RK (ed) Aesthetic Plastic Surgery: Rhinoplasty. Boston:
Little, Brown, 1993
Daniel RK, Lessard ML. Rhinoplasty: A graded aesthetic anatomical approach. Ann Plast
Surg 13: 436, 1984
Daniel RK, Farkas LG. Rhinoplasty: Image and reality. Clin Plast Surg 15: 1, 1988
Daniel RK, Letourneau A. The superficial musculoaponeurotic system of the nose. Plast
­Reconstr Surg 82: 48, 1988a
Daniel RK, Letoumeau A. Rhinoplasty: Nasal anatomy. Ann Plast Surg 20: 5, 1988b
Gruber R, Chang TN, Kahn D et al Broad nasal bone reduction: An algorithm for osteotomies.
Plast Reconstr Surg 119: 1044, 2007
Guerrosantos J. Nose and paranasal augmentation: Autogenous, fascia, and cartilage. Clin
Plast Surg 18: 65, 1991
Guyuron B. Precision rhinoplasty. Part I: The role of life-size photographs and soft-tissue
cephalometric analysis. Plast Reconstr Surg 81: 489, 1988
Guyuron B. Guarded burr for deepening of nasofrontal junction. Plast Reconstr Surg 84:
513–516, 1989. Updated, Plast Reconstr Surg 106: 1417, 2000
Lessard ML, Daniel RK. Surgical anatomy of the nose. Arch Otolaryngol Head Neck Surg
111:25,1985
Miller TA. Temporalis fascia graft for facial and nasal contour augmentation. Plast Reconstr
Surg 81: 524–533, 1988
Nievert H. Reduction of nasofrontal angle in rhinoplasty. Arch Otolaryngol 53: 196, 1951
Parkes ML, Kamer, F, Morgan, WR. Double lateral osteotomy in rhinoplasty. Arch Otolaryngol
103: 344, 1977
Rohrich Rj, Hollier, LH. Versatility of spreader grafts in rhinoplasty. Clin Plast Surg 2: 225,
1996
Rorhrich RJ, Gunter JP, Deuber MA et al The deviated nose: Optimizing results using a
simplified classification and algorithmic approach. Plast Reconstr Surg. 110: 1509, 2002
Rorhrich RJ, Muzaffar, AR, Janis, JE. Component dorsal hump reduction: The importance
of maintaining dorsal aesthetic lines in rhinoplasty. Plast Reconstr Surg 114: 1298, 2004
Shah AR, Constantinides M. Aligning the bony nasal vault in rhinoplasty. Facial Plast Surg
22: 3, 2006
Sheen, JH. Aesthetic Rhinoplasty. St. Louis: Mosby, 1978
Sheen JH. The radix as a reference in rhinoplasty. Perspect Plast Surg 1: 33, 1987
Sheen JH. Rhinoplasty: Personal evolution and milestones. Plast Reconstr Surg 105: 1820,
2000
Skoog T. A method of hump reduction in rhinoplasty. Arch Otolaryngol Head Neck Surg
101: 207, 1975
Tardy MA Jr, Denneny, JC. Micro-osteotomies in rhinoplasty. Facial Plast Surg 1: 137, 1984
Reading List

Tip surgery remains the most discussed and least understood aspect of the rhinoplasty
operation. The foundation of tip surgery is the interrelated “3 As” of anatomy, aesthetics,
and analysis. The six tip characteristics of volume, width, definition, projection, rotation,
and shape will be related to the underlying anatomy and overlying surface aesthetics. The
surgeon will learn to distinguish the intrinsic tip from the lobule, as well as the influence
of intrinsic and extrinsic factors on the tip itself. Then, in perhaps the most controversial
aspect of this book, I will present only two tip operations, albeit with numerous variations.
The operations are open tip suture and open tip graft. With these two operations, the surgeon
can correct 95% of primary tip deformities. Each step in the procedure will be presented
in great detail and must be mastered by the reader. Rather than try every tip operation
available, the novice surgeon has the luxury of mastering only two interrelated procedures,
thus achieving a greater understanding of surgical cause and effect. This chapter will serve
as the foundation for all tip surgeries. Additional applications to a wide range of specific
tip deformities are discussed throughout the book, especially in Chapter 8 and Chapter 9.
Introduction
Tip
Techniques4

102
Chapter 4   Tip Techniques
Tip surgery can appear extraordinarily complex due to the wide variation in tip anatomy,
patient desires, and surgical options. To overcome this complexity, I favor the following pro-
gressive tip operation, which a surgeon can master and then expand to cases of increasing
levels of difficulty (Fig. 4.1)
Level 1. A Five-Step Tip Suture Technique. The combination of an open approach and
tip suturing has revolutionized tip surgery allowing the surgeon to control the individual
tip characteristics of width, projection, definition, and supratip break. Suturing provides
a graded controlled method of tip shaping. The five components are as follows: (1) create
symmetrical rim strips, (2) insert and fix a columellar strut, (3) domal creation sutures for
definition, (4) an interdomal suture for tip width control, and (5) a tip-positioning suture to
create a supratip break (Fig. 4.2). This relatively simple approach using standard absorbable
sutures will work for at least 60% of all primary tips. As long as the surgeon is conservative
in suturing tension, all sutured tips will be more symmetrical and refined than when first
exposed. Careful records must be kept as the surgeon must teach themself surgical cause
and effect at each postoperative visit. Obviously, judgment comes from experience which can
only be gained in the operating room.
Level 2. Advanced Suturing and Add-On Tip Grafts. Once the surgeon has a moderate
experience with tip sutures, additional sutures can be employed in dealing with more chal-
lenging tips as regards asymmetry and excessive width. The domal equalization suture brings
the domes into alignment while the lateral crural convexity suture reduces convexity of the
lateral crura. Yet, it is the application of add-on Tip Refinement Grafts to the sutured tip
that can give the requisite shape and definition which elevates and refines the final result.
Level 3. Structure Tip Grafts. In contrast to add-on grafts, which accentuate the sutured tip,
a structure tip graft replaces the tip anatomy. The tip definition as seen through the skin is
created by the tip graft and not the alar cartilages. The majority of structure tip grafts are
simply golf-tee shaped shield grafts inserted within the alar architecture or positioned above
the alar domes to achieve greater definition. These grafts reach their ultimate expression as
isolated entities in secondary cases where the entire alar cartilages have been previously
excised.
Simplifying Tip Surgery. It is only in the last 5 years that I have become convinced that 95%
of all primary tips are Level 1 and 2 cases. This fact means that the surgeon can get good
results mastering one operation – open tip suture techniques with optional add-on grafts. The
ability to master all the nuances of one progressive operation that can be individualized to
each specific case is revolutionary. There is no need to struggle with ten different tip opera-
tions unless you want to do the remaining 5% of cases which are Level 3. Equally, I do not
recommend a closed delivery approach for tip suturing as my experience indicates that it
rarely achieves the symmetry or precision of an open approach.
Overview

Overview
103
Fig. 4.2 (a–d) Intraop changes created by tip sutures
Fig. 4.1 Tip analysis. (a) Level 1, (b) Level 2, (c) Level 3, see case studies at end of chapter

104
Chapter 4   Tip Techniques
Analysis
A 20-year-old girl presented with the complaint that she felt her bridge was too convex and
her tip too droopy (Fig. 4.3). She wanted a smaller, cuter nose. There were no functional issues.
This patient demonstrates that a simple tip suture technique can dramatically change a tip.
There were no destabilizing excisions or incisions of the lateral crura. Also, there is no need
for either an open structure or multilayer tip graft underneath this thin skin. On anterior
view, the tip change is quite dramatic. Tip suture techniques have revolutionized rhinoplasty
surgery because they allow the surgeon to make significant yet controlled changes in the tip
with minimal morbidity.
Operative Technique
1) Open approach with confirmation of pre-op tip analysis and op plan.
2) Creation of symmetrical rim strips – 12 mm wide reduced to 6 mm.
3) Incremental dorsal reduction: bone (1 mm), cartilage (3 mm).
4) Shortening of caudal septum (2.5 mm), the anterior nasal spine (ANS) was resected.
5) Septal harvest.
6) Low-to-less and transverse osteotomies.
7) Bilateral spreader grafts.
8) Insertion of columellar strut and tip sutures: CS, DC, ID, TP.
9) Nostril sill excisions (R:2, L:2)
Case Study:
Tip Suture
Fig. 4.3 (a–j)

Case Study: Tip Suture
105
Fig. 4.3 (continued)

106
Chapter 4   Tip Techniques
Based on extensive fresh cadaver dissections and intraoperative observations during open
rhinoplasty (Daniel 1992), I have divided the alar cartilages into three crura (medial, middle,
and lateral), each composed of two segments with distinct junction points of aesthetic
importance (Fig. 4.4).
Medial Crus. The medial crus is the primary component of the columella and can be sub-
divided into two portions: lower footplate segment and superior columellar segment. The
footplates vary in size, shape, and angulation. The superior columella segment represents the
narrow waist of the columellar and its overall length correlates with nostril length.
Columella-Lobular Junction. A distinct junction occurs between the paired vertically ori-
ented medial crura and the divergent angular middle crura. It marks the transition from
nasal base to the tip lobule and usually corresponds with the nostril apex ±1–2 mm. It is the
breakpoint in the columella’s “double break.”
Middle Crus. As originally defined by Sheen (1987), the middle crus begins at the columellar-
lobular junction and ends at the lateral crura. It can be subdivided into a lobular segment and
a domal segment. The shape of the lobular segment varies in width and length, which can have
a profound effect on tip shape, e.g., short segments produce snubbed tips. The lobular seg-
ments abut in the midline cephalically but diverge caudally similar to an open book standing
on end. The domal segment extends from the medial genu, which marks its transition with
the infralobular segment, to the lateral genu, which marks its junction with the lateral crura.
and bracket the domal notch, which in turn determines the soft triangles or soft tissue facets
of the lobule. The shape of the domal segment varies from concave to smooth to convex.
Domal Junction. The domal junction is the critical landmark of the refined tip and marks
the transition from middle crura to lateral crura. The tip-defining points fall consistently on
the domal junction line. Anatomically, the most aesthetic configuration is a convex domal
segment adjacent to a concave lateral crura. It is this configuration that one is trying to
produce with domal sutures.
Lateral Crura. The lateral crura may be subdivided into the lateral crus and the accessory
cartilage ring. The lateral crus is the main component of the nasal lobule and influences its
shape, size, and position. Each of its borders has surgical significance. Cephalically, a “scroll
formation” exists between lateral crus and upper lateral cartilage with interspersed sesamoid
cartilages. Laterally, the crus passes posterior away from the nostril rim and tapers in size.
Three additional factors are critical: configuration, axis of orientation, and axis of curvature.
The configuration has been subdivided into six shapes based upon relative concavity and
convexities. For example, the severely concave lateral crura produces a pinched tip but is
easily corrected by flipping rather than excising the excess cephalic lateral crura.
Tip Anatomy

Tip Anatomy
107
Fig. 4.4 (a–f)Tip anatomy

108
Chapter 4   Tip Techniques
Although tip analysis can be subjective, decisions must be made and an operative plan for-
mulated. The goal of analysis is to determine what the tip characteristics are and how far they
deviate from ideal. Over the years, I have evolved a set of six criteria which facilitate decision-
making. These characteristics consist of three intrinsic tip factors (volume, ­definition, and
width) and three additional factors (projection, rotation, and position) that can be intrinsic,
extrinsic, or both (Fig. 4.5). Each criterion can be graded as normal or abnormal with pro-
gression from minor, moderate, to major. Although initially confusing, this system is rapidly
applied and serves as a decision-making ladder for formulating the operative plan.
Volume. Tip volume refers to the size of the lateral crura. Essentially, one evaluates the size,
shape, and axis of the lateral crura. In 90% of female rhinoplasties, some degree of cephalic
lateral crura resection is done which reduces volume, minimizes overlap at the scroll forma-
tion, and reduces intrinsic convex curvature of the lateral crura. This excision produces three
aesthetic improvements: (1) it makes the tip smaller, (2) it sets off the tip thereby improving
definition, and (3) it rotates the tip slightly upward. It also makes tip suturing easier.
Definition. Definition is a true aesthetic concept which implies the degree of detail, refine-
ment, and angularity of the tip. It is determined anatomically by the adjacent relationship
between the convexity of the domal segment and the concavity of the lateral crura with its
surface expression revealed or obscured by the overlying skin. The anatomical configuration
which correlates with the best tip definition is a convex domal segment with an adjacent
concave lateral crura. The critical importance of the skin envelope should never be forgot-
ten (Fig. 4.6).
Width. Width refers to the interdomal distance and is easily measured on the skin surface
between the two tip-defining points. The ideal interdomal width correlates often with the
width of the philtral columns and the dorsal lines.
Shape. Virtually every clinician recognizes certain tip shapes including the 3 Bs (broad, ball,
and boxy), the 3 Ps (Pinocchio, pinched, and parenthesis) plus a myriad of other shapes. Each
of these shapes denotes a certain combination of anatomical deformities and, more impor-
tant, a certain set of potential postoperative problems. For example, the boxy tip consists
often of thick alar cartilages, but weak alar sidewalls which can easily collapse postoperatively
unless supported with rim grafts.
Aesthetics:
Intrinsic factors

Tip Aesthetics: Intrinsic Factors
109
Fig. 4.6 (a–c) Intraopertive aesthetics
a
b
Smooth
Convex
Concave
Domal notch
Downward
rotation
Upward
rotation
Projection
Rotation
Width
Definition
Fig. 4.5 (a, b) Aesthetics – intrinsic factors

110
Chapter 4   Tip Techniques
The intrinsic characteristics are dictated by the configuration of the alar cartilages. In con-
trast, the extrinsic factors are often determined by the abutting supporting structures (Fig.
4.7). A classic example is the high-arched tension nose. Total tip projection may be excessive,
but once the large dorsal hump and long caudal septum are excised, the tip may even be
intrinsically deficient due to small alar cartilages. Thus, one must learn to analyze the tip,
both for its intrinsic and extrinsic factors (Fig. 4.8). Ultimately, one has to consider the total
characteristic comprised of both intrinsic and extrinsic contributions.
Projection. Tip projection can be defined as the distance from a vertical facial plane passing
through the alar crease to the nasal tip. According to Byrd (1993), ideal tip projection is con-
sidered to be two thirds the ideal dorsal length which in turn is two thirds the ideal midface
height. It is determined by the intrinsic tip cartilage configuration, the extrinsic structural
abutments, or both. One can measure intrinsic projection by a vertical from the columellar
breakpoint to the tip projection line. For example, the true Pinocchio tip is due to extremely
long alar cartilages, whereas the more common over-projecting tip is most frequently due to
a large cartilaginous vault that pushes the tip outward. Surgically, the extrinsic factors are
eliminated first and then the intrinsic tip modification is done if necessary.
Rotation. Tip rotation is most easily defined as the tip angle, which is measured from the
vertical plane at the alar crease to the tip. This angle is set at 105° for females and 100° for
males. Anatomically, it is determined by the intrinsic tip cartilage configuration, the extrin-
sic structural abutments, or both. For example, the tip can be pushed down by large lateral
crura (intrinsic), a prominent caudal septum (extrinsic) or both. It is critical to determine
the etiology in order to design the ideal operation. Essentially, the diagnosis can be made by
evaluating each of the three crura and then by palpating the caudal septum/ANS.
Position. Tip position refers to the location of the tip along the dorsal line (N-T) and is of
great concern in shortening the long nose. Essentially, one will often excise cephalic lateral
crura (intrinsic) and caudal septum (extrinsic) to shorten the nose. Certainly, septocolu-
mellar grafts demonstrate the concept of extending dorsal length without altering rotation.
Another, critical relationship is to remember that the dorsal line (N-T) can be dramatically
effected by changes at the nasion (N) which creates an illusion that tip position has been
altered. For example, augmenting the radix will make the dorsum longer and create the il-
lusion that the tip is more dependent.
Aesthetics:
Extrinsic factors

Tip Aesthetics: Extrinsic Factors
111
a
b
c
x - overprojection
x' - overprojection
AC - Ti = 2/3Ni - Ti
Total projection
AC
C'
C'
NTi = 2/3MFH
Long
Ti
Ni
AC
Short
Ti
Ti
x
x'
Ni
AC
AC
105° - female
100° - male
AC
AC
x°
y°
x = y
Ti
Ti
T
upward rotation
Ti - ideal
downward rotation
Intrinsic projection
Fig. 4.7 (a–c) Aesthetics – extrinsic factors
Fig. 4.8 (a, b) Patient analysis – intrinsic versus extrinsic factors

112
Chapter 4   Tip Techniques
Incisions. Immediately prior to the incisions, I redraw the transcolumellar incision. I still
prefer Goodman’s original inverted V with wings (Fig. 4.9). A small 3 mm equilateral inverted
V is drawn whose apex is at the narrowest point of the columella beneath the columella
breakpoint. The transcolumellar incision is now made. Holding the columella with the non-
dominant hand, a #11 blade is used to make the inverted-V incision and then a #15 blade
is used to make the transverse wings being careful to scratch through the skin overlying
the cartilage. The standard infracartilaginous incision consists of three parts: lateral crura,
dome, and columella. Using a 10 mm double hook, the surgeon retracts the alar rim and then
provides counterpressure with the ring finger. An incision is made along the caudal border
of the alar cartilage. The columellar portion of the infracartilaginous incision is placed
2–3 mm behind the lateral margin of the columellar as it simplifies subsequent suturing of
the columellar strut.
Exposure. Exposure consists of two steps: visualizing the alar cartilages and the dorsum.
With the incisions completed, a columella to tip dissection technique is used with three-point
traction (Fig. 4.10). The assistant retracts the alar rim upward with a small double hook and
retracts the dome downward with a single hook. The surgeon then elevates the columellar
skin with a small double hook and dissects upward using the angled Converse scissors. It is
often necessary to switch back and forth between the two sides, and to use extreme caution
as one approaches the domes. As soon as the skin is retracted upward, the domes are pulled
downward with a 10 mm double hook and the skin elevated off the alar cartilages. Then the
dorsal space is entered in the midline. The area overlying the septal angle is entered with the
blunt tip scissors and dissection continues in the avascular space over the dorsum.
Although the “columella to tip” exposure method is the classic one, the bidirectional
exposure technique is easy to learn and extremely useful in scarred secondary tips (Fig. 4.11).
Essentially, one makes the standard infracartilaginous incision and then dissects over the
lateral crura using blunt tip tenotomy scissors. The dissection is continued toward the domes.
The columellar skin is elevated off the cartilage via the columellar component of the infra-
cartilaginous incision. Then, the short skin segment is elevated from the transcolumellar inci-
sion up to the prior dissection.
Tip Analysis. Once the exposure is completed, it is important to take a tip time out and
reassess the operative plan. Ask the following questions: (1) Will the alar anatomy allow me
to do the procedure I had planned? (2) Will sutures work, and if so which combination? (3)
Will add-on grafts be necessary to get the requisite definition? (4) Are the alars so massive,
deformed, or over-projected that a domal excision plus structured tip graft is necessary?
Open Approach

Open Approach
113
a
b
Fig. 4.10 (a, b) Exposure: columellar to tip 
b
a
Fig. 4.11 (a, b) Exposure: bidirectional 
Fig. 4.9 (a–c) Incisions 
a
b
c

114
Chapter 4   Tip Techniques
Without question, tip surgery is the most complex, frustrating portion of a rhinoplasty
due to the patient’s expectations and anatomical variations. In my first Atlas, I fell into the
trap of being encyclopedic and presenting a large number of tip techniques. Today, I find that
I use tip sutures plus simple add-on grafts of excised alar cartilage in 85% of my primary
cases (Tables 4.1 and 4.2). The other 15% consists of either a closed rhinoplasty with minimal
tip change (10%) or an open structure tip graft for maximum change (5%).
I published my first paper on open tip sutures in 1987 and over the subsequent 20
years, I have reached certain conclusions (Daniel 1987, 1999). First, tip sutures are effective at
achieving significant permanent tip refinement. Second, the technique need not be complex,
but rather can be sequentially additive until the desired tip change is achieved. Third, each
tip characteristic can be achieved using a specific suture; i.e., tip definition with domal cre-
ation ­sutures. Fourth, the suture material is always absorbable (polydioxanone suture [PDS]),
which eliminates long-term extrusion or infection, is colored (violet) to improve visibility, is
usually small (5–0 PDS), and is on a short-cord sharp needle (PS3). Five, asymmetry is mini-
mized through out the tip suturing process with the final results always less asymmetrical than
the original alar configuration. Six, one should use only as many sutures as needed to achieve
the desired tip, there is no need to put eight sutures in every nose. Seven, I never hesitate to
take out a suture that is not right – a pointy dome will show through the skin and too vertical
a columellar will result in a long infralobule. Eight, sutures should be tied to the ideal ten-
sion point, neither too tight nor too loose. Avoid excess tension, if one must err always use
less tension rather than too much. Nine, there is no need to undermine the mucosa prior to
placing the suture; one simply penetrates the cartilage without going through the underlying
mucosa. If necessary, the underlying mucosa can be injected with local anesthesia prior to su-
ture placement to avoid penetrating it. Ten, one must learn surgical cause and effect, so keep a
detail diagram of the sutures and refer to it at each postoperative visit. Better yet, take intraop
photos from four different views and print them out – look at them at every post-op visit.
Recently, it became obvious to me that surgeons are teaching tip suture techniques the
wrong way. Traditionally, the emphasis was placed on the direct and indirect consequences of
each individual suture. In contrast, I now teach tip suture techniques from exactly the oppo-
site view point – what tip characteristic do I want to achieve and which suture will produce it.
Fortunately, the operation is sequential and a true “sew as you go” method. One simply stops
when the desired refinement is obtained.
Be fore warned that numerous authors use different names for the same suture. I have
always tried to respect the original name of the suture as its author intended. This same cour-
tesy has not been extended by others and thus there is total confusion between various texts.
Fortunately, the suture is more important and longer lasting than its name.
Open Tip Suture
­Technique: An
Overview

Open Tip Suture ­Technique: An Overview
115
Table 4.1 Tip factors and tip sutures
Volume
Excision lateral crura
Projection
Columellar strut
Definition
Domal creation suture
Tip width
Interdomal suture
Tip position
Tip position suture
Asymmetry
Domal equalization suture
Crural convexity
Lateral crural convexity sutures
Extra definition projection
Add-on grafts (TRG)
Table 4.2 Open Tip Suture Technique: Step-by-Step 
Step
Surgical technique
Effect
Frequency
Step #1
Symmetrical rim strips
Decreases volume
99%
Cephalic lateral crura excision
More suturable
Leave 6 mm
Step #2
Columellar strut with strut suture
Increases projection
99%
Prevents drooping
Step #3
Domal creation suture R & L
Increases definition
95%
Step #4
Interdomal suture
Decreases tip width
90%
Creates tip diamond
Step #5
Domal equalization suture
Increase symmetry
75%
Step #6
Lateral crural convexity suture
Decreases convexity
of lateral crura
20%
Crua straight
Step #7
Tip position suture
Increase projection
75%
Increases rotation
No excess
Step #8
Add-on grafts (TRG)
Increases definition
40%
Increases projection
Step #9
Alar rim grafts
Supports alar rims
10–15%

116
Chapter 4   Tip Techniques
Purpose
The cephalic portion of the lateral crura is excised in virtually all cases to reduce the volume
of the nasal tip and to increase the malleability of the cartilages for suturing. The excision
also produces a significant change in the convexity of the cartilages. The lateral crura is not
excised when major concavities of the lateral crura exist that can be treated by folding or
flipping the crura.
Technique
The skin is elevated over the nasal tip using the open approach. The alar cartilages are ana-
lyzed as to configuration, size, and symmetry. The operative plan is reevaluated to see if any
changes are warranted based on anatomical findings. An example of changing the operative
plan would be if a significant concavity was found in the alar cartilage which one decides
to treat with a lateral crural “fold” rather than excision. The line of planned excision is
marked on the alar cartilage using a caliper and a marking pen. The excision line is marked
6 mm from the caudal edge (Fig. 4.12). Preservation of a 6 mm rim strip allows insertion of
any requisite shaping sutures as well as retaining sufficient support for the nostril rim and
preventing any alar retraction. However, three points are important in drawing the excision
line: (1) the initial 6 mm width is drawn at the widest point of the lateral crura, (2) the line
is then tapered to preserve the natural width of the domal notch, and (3) the line follows
the caudal border of the lateral crura laterally preserving a 6 mm width (Fig. 4.13). Once
the line is drawn, the underlying mucosal surface of the alar cartilage is injected with local
anesthesia to facilitate dissection. The cartilage is then held with forceps and a #15 blade
is used in incise the lateral crura along the marked excision line. The actual excision of the
cartilage begins at the domal notch and then progresses laterally. The excision follows the
scroll junction with the upper lateral cartilages cephalically. Every effort is made to remove
the cartilage intact as it is often used for add-on tip refinement grafts (TRG).
P R I N C I P L E S

 Volume reduction of the tip is achieved by excising the lateral crura.

 Removing the lateral crura creates symmetrical rim strips which will be sutured.

 Keep a 6 mm wide rim strip for support and suturing.

 Follow the caudal border of the lateral crura, tapering your excision at either end.

 It is rarely necessary to narrow the domal notch area.
Step #1
Symmetrical
Rim Strips
(Tip Volume
Reduction)

Step #1 Symmetrical Rim Strips (Tip Volume Reduction)
117
Symmetrical Rim Strips
Fig. 4.13 (a–d)
Fig. 4.12 (a, b) Symmetrical rim strips 
a
b
6
6

118
Chapter 4   Tip Techniques
Purpose
The columellar strut and suture serve three purposes: tip stability, tip projection, and colu-
mellar shape (Fig. 4.14). The strut fosters verticality and projection while eliminating plung-
ing of the tip on smiling postoperatively. Suturing the alars to the strut creates a unified tip
complex and improves symmetry. Equally important, the strut provides a rigid intrinsic
shape for the columellar thus rendering it somewhat independent of caudal septal deviations.
Technique
The three steps are shaping, insertion, and suture fixation. Although the shape can vary, the
columellar strut is usually cut 20 mm long, 2.5 mm wide, and 1.5 mm thick. The ideal graft
material is from the vomerine septal cartilage because of its rigidity and thickness (Fig. 4.15).
The graft is easily shaped to the desired dimensions using a #15 blade. The midpoint is
marked with a pen. The recipient site between the alar cartilages is easily made by vertical
spreading of the dissection scissors downward toward the ANS. The strut is inserted down
to its midpoint. Then, the alars are elevated upward, rotated toward the midline, and fixed
individually to the strut with a #25 needle. The needle is inserted high on the middle crura just
below the domes. This fixation placed above the columellar breakpoint tends to verticalize
the tip. Symmetry is important as regards domal location and caudal relationships. The #25
needle can be adjusted as necessary to achieve symmetry. The columellar suture consists of
a vertical suture of 5–0 PDS. The needle enters at the columellar breakpoint, passes through
the alars and strut, and then crosses again high in the infralobule – thus the suture is totally
within the middle crura.
Although some surgeons widely separate the alar cartilages for either septal exposure
or total mobilization, this maneuver necessitates a total rebuilding of the crural relationship.
I prefer to create a true pocket between the alars as it preserves significant intercrural fibrous
connections and simplifies strut insertion.
P R I N C I P L E S

 Do not overly separate the medial and middle crura.

 One of the biggest advantages of the columellar strut is that it insures that the columellar
is straight and renders it somewhat independent of the caudal septum.

 Struts can be shortened through the transfixion incision and is often done to drop projec-
tion or avoid fullness in the subnasale region.
Step #2
­Columellar Strut
and Suture
(Tip Projection)

Step #2 ­Columellar Strut and Suture (Tip Projection)
119
Fig. 4.15 (a–d)
Columellar Strut Insertion
Fig. 4.14 Columellar strut insertion 
c′
c′
up
90°
twist

120
Chapter 4   Tip Techniques
Purpose
The domal creation suture produces tip definition by creating the ideal aesthetic tip anatomy
even from flat or concave cartilages (Fig. 4.16). Essentially, one inserts a horizontal mattress
suture at the domal notch and cinches it down to create a convex domal segment next to
a concave lateral crura. This anatomical configuration produces a very attractive tip when
the skin is redraped. Rather than being an abnormal shape, this configuration is a normal
anatomical finding in attractive tips when viewed during an open rhinoplasty. Our desire is
to replicate the most attractive normal domal configuration.
Technique
Although conceptually simple, the surgeon must become facile with insertion of the domal
configuration suture. I prefer to use a short-cord needle (P3) with highly visible violet-
colored absorbable suture material (Fig. 4.17). The domal notch is located. The domal seg-
ment is gently squeezed using an Addson-Brown forceps to determine the exact location for
the suture and the amount of convexity. The desired dome-defining point is marked. Then
a horizontal mattress suture is placed from medial to lateral with the knot tied medially.
The tension is gradually tightened until the desired domal convexity is achieved. The goal
is the juxtaposition of gradually increasing domal convexity next to gradually increasing
lateral crura concavity. One should concentrate on these two areas and not worry about any
persistent convexity of the lateral crura which can be controlled with another suture. The
following five suture errors are to be avoided: (1) too tight can result in a sharp point under
thin skin, (2) too loose fails to achieve the desired definition, (3) too medial a placement
snubs off the tip, (4) too lateral a placement lengths the infralobule, and (5) do not try to
modify the entire lateral crura, just the portion immediately adjacent to the dome. Unlike
incision and excision techniques which weaken the rim strip and often lead to bossa, the
domal suture is initially reversible and can be replaced several times depending upon the
rigidity of the cartilage. In contrast to grafts, tip sutures achieve definition without visibility,
cartilage atrophy, or thinning of the skin.
P R I N C I P L E S

 Learn to recognize the domal notch – it is the key reference point for locating the domal
creation suture.

 Gently squeeze the domal notch with an Adson-Brown forceps and determine the desired
convexity and ideal location of the dome-defining point.

 Place the suture from medial to lateral with the knot tied medially.

 As you tighten, the domal segment will become convex. Try to avoid too concave an adja-
cent lateral crura or alar rim grafts will be necessary.

 Do not tighten excessively. Consider adding a second domal creation suture.

 Stand at the head of the table to assess symmetry.
Step #3 Domal
Creation Suture
(Tip Definition)

Step #3 Domal Creation Suture (Tip Definition)
121
Fig. 4.17 (a–d)
Domal Creation Suture
Fig. 4.16 (a, b) Domal creation suture 
a
b

122
Chapter 4   Tip Techniques
Purpose
The interdomal suture controls tip width both at the domes and in the infralobule. It is a
simple vertical suture that begins on one crura adjacent to the domal creation suture, exits
above the columellar suture, crosses over to the opposite crura at the same level, and then
exits adjacent to the domal creation suture. The knot is gradually tightened until the ideal
width is achieved. One must avoid producing either a single pointy tip or close the infralobule
too much. One must maintain a normal angle of domal divergence. It is wise to remember
the usual anatomical variations of the middle crura (Fig. 4.18).
Technique
The simplicity of inserting this stitch is due to its occurrence in the tip suturing sequence
(Figs. 4.19 and 4.20). Since the columellar strut suture and domal creation sutures are already
in place, the location of the interdomal suture is virtually predetermined. The suture enters
just below the domal creation knot on the left and exits just above the strut suture on the
middle crura. Then, the needle enters the right crura directly across on the middle crura
and exits just below the domal creation knot. The only decisions are how far back from the
caudal border to insert the suture and how tight to tie the knot. In general, the suture is
placed 2–3 mm back from the caudal border of the crura. If placed too close to the edge then
excessive narrowing of the columellar occurs. Too far back a placement is almost impossible
because of the columellar strut. The suture is gradually tightened to reduce the interdomal
width, not to create a single pointy tip. Remember the “tip diamond” concept. Also, the colu-
mellar flares at its base, narrows at its mid point, and gradually widens in the infralobule.
Thus, one must avoid narrowing the infralobular columellar excessively.
P R I N C I P L E S

 Too tight a knot produces a pointy tip while too loose causes a wide tip.

 The normal angle of domal divergence is approximately 30°.

 Very rarely a tip will present as too narrow. Interdomal width can be increased using a
wider columellar strut and no interdomal suture.

 As with all sutures, if the tip shape is good to begin with then there is no obligation to
insert this suture.
Step #4
­Interdomal
Suture
(Tip Width)
Fig. 4.18
Middle crura variations
Normal
Reciprocal
Wide

Step #4 ­Interdomal Suture (Tip Width)
123
Interdomal Suture
Fig. 4.20 (a–d)
Fig. 4.19 (a, b) Interdomal suture 
a
b

124
Chapter 4   Tip Techniques
Purpose
The domal equalization suture helps to insure symmetry of the tip. It is inserted through the
cephalic border of the domal segments and tightened until the cartilages touch (Fig. 4.21).
Conceptually, the suture insures tip symmetry, creates the cephalic point of the tip diamond,
and lowers the cephalic portion of the rim strip below the tip-defining points. Although the
domal equalization suture is a primary insurer of tip symmetry, every step in the tip sutur-
ing process improves symmetry; i.e., fixation of crura on the columellar strut and domal
creation sutures.
Technique
Of all the tip sutures, the domal equalization stitch is probably the easiest to insert and the
most difficult to do wrong. The needle enters the right dome beneath its cephalic edge, exits
1.5–2.5 mm on to the domal segment, then enters at a comparable point on the left domal
segment, and exits beneath the cephalic edge of the left (Fig. 4.22). The knot is then tied until
the cartilages touch. The suture brings the cephalic edge of the two convex domal segments
together, thus creating the apex of the tip diamond. The knot is cut short and it becomes
buried beneath the cephalic edge of the rim strips. Equally, it depresses the cephalic border
of the rim below that of the caudal border, thus moving the tip-defining point toward the
caudal border of the domal segment.
P R I N C I P L E S

 This suture is used frequently, but it is not always required.

 Small differences in placement point are done on either alar to fine tune symmetry.

 This suture is surprisingly effective with minimal risk.
Step #5 Domal
Equalization
Suture
(Tip Symmetry)

Step #5 Domal Equalization Suture (Tip Symmetry)
125
Domal Equalization Suture
Fig. 4.22 (a, b)
Fig. 4.21 Domal equalization suture

126
Chapter 4   Tip Techniques
Purpose
The lateral crural mattress suture (LCMS) pioneered by Gruber (2005) has revolutionized our
treatment of the wide tip as well as broad, boxy, and ball tips. It is a simple transverse mat-
tress suture that is placed at the point of maximum convexity on the lateral crura (Fig. 4.23).
The point of convexity is marked with a pen and then a mattress suture straddles it perpen-
dicular to the rim strip beginning from the caudal border. The needle enters about 1 mm from
the caudal edge and exits 1 mm from the cephalic edge, then a similar bite is taken 6–8 mm
laterally, coming from the cephalic to the caudal border. The suture is gradually tightened
until the convexity is flattened.
Technique
The lateral crural mattress suture solves one of the greatest challenges in tip rhinoplasty
– how to eliminate convexity and width in the alar rim strip without incising or excising
the alar cartilage. For years, the only solution was some variation of interdigitating cuts or
segmental excisions that ultimately led to bossa formation or lateral crura collapse. Thus,
this suture must be mastered. Fortunately, it is rather straightforward. Since the rim strip has
been cut at 6 mm, there is sufficient cartilage to work with. When first using this suture, mark
the convexity and then measure 3 mm on either side (Fig. 4.24). The needle is inserted about
1 mm from the caudal edge and exits 1 mm from the cephalic edge. One then moves laterally
an equal distance from the marked point of maximum convexity. The needle enters 1 mm
from the cephalic edge and exits 1 mm from the caudal edge. The knot is gradually tightened
until the convexity disappears. The lateral crura should be straight or slightly concave. One
wants to avoid too much tightening as it can cause marked concavity. If insufficient change
has occurred which is often the case with rigid cartilages, an additional suture can be added,
usually lateral to the original. Why insert the suture from the caudal border? Gruber prefers
this method as it makes the knot less visible. In contrast, I feel that the cephalic location
somehow depresses and can bunch up the cephalic border, both problems are avoided with
a caudal placement.
P R I N C I P L E S

 Creation of 6 mm wide symmetrical alar rim strip facilitates future insertion of the lateral
crural mattress suture.

 With experience, one can insert the suture in 3–4 mm wide rim strips that are often en-
countered in secondary cases.

 One wants to avoid penetrating the mucosa and exposing the suture, One can add local
anesthesia beneath the convexity prior to suturing.
Step #6 Lateral
Crural ­Mattress
Suture (Crural
Convexities)

Step #6 Lateral Crural ­Mattress Suture (Crural Convexities)
127
Lateral Crural Mattress Suture
Fig. 4.24 (a–d)
Fig. 4.23 (a–d) Lateral Crural Mattress Suture 
a
6m
b

128
Chapter 4   Tip Techniques
Purpose
The tip position suture achieves both tip rotation and increased projection which in turn
creates the supratip break that most patients want (Fig. 4.25). It is a simple transverse suture
between the infralobular mucosa and the anterior dorsal septum. It is placed from the top
through an open approach using 4–0 PDS on a medium-size needle (FS2). As the knot is
tightened, the tip rotates upward and projects above the dorsal line creating a supratip set-
off. Early on, one should do a single throw, redrape the skin, and assess its effect – be careful,
over rotation is a disaster.
Technique
Despite the disasters it can produce if over-tightened, the tip position suture achieves two
very much desired tip characteristics – tip rotation and sufficient tip projection to produce a
supratip break. It is not inserted until the ideal intrinsic tip has been created. Once satisfied
with tip width and definition, then the final position becomes critical. A 4–0 PDS suture on
an FS2 needle is used. The surgeon stands at the top of the table. The suture is transverse
beginning with a pass through the mucosa of the infralobule with optional inclusion of the
columellar strut (Fig. 4.26). The next pass is through the dorsal septum about 3–4 mm back
from the anterior septal angle usually avoiding the spreader grafts. In general, I will do a
double throw, redrape the skin, and asses the changes before adding additional sutures. It is
never tied tightly. Rather, the suture serves as a loop bringing the tip above the anterior septal
angle. The goal is to rotate the tip slightly while giving additional support to the tip which
in turn creates the desired super tip break. I find this method of suturing more effective and
with less risk of columellar distortion than Gruber’s columellar-septal suture. Equally, I am
not a fan of the tongue-in-groove technique where the alar cartilages are rotated on either
side of the caudal septum and then fixed with sutures. The problem is that fine-graded adjust-
ments in rotation and projection cannot be made once the alars are sutured to the septum.
In contrast, the tip position suture is inserted after the ideal tip is created and tension can
be added incrementally.
P R I N C I P L E S

 The tip position suture is the most powerful of all the tip sutures and must never be tied
too tight!

 The needle passes through the mucosa of the columellar just behind the upper middle
crura. There is no need to include the columellar strut.

 Judging the effect of the suture is best done by placing a single throw on the knot, redrap-
ing the skin, and evaluating. Too loose is much better than too tight.
Step #7 Tip Posi­
tion Suture
(Tip Rotation
and Projection)

Step #7 Tip Position Suture Tip
129
Tip Position Suture
Fig. 4.26 (a–d)
Fig. 4.25 (a, b) Tip position suture 
a
c
d
b

130
Chapter 4   Tip Techniques
Purpose
Once suturing is completed, small tip grafts of excised alar cartilage can be added to provide
additional refinement (Fig. 4-27). They are truly “Tip Refinement Grafts – TRG” which are
added to the final sutured tip as an “enhancement” rather than incorporated into the struc-
ture of the tip (Daniel 2009).
Technique
Whenever possible, excised alar cartilage is used as it is quite pliable, easily shaped, and can
be layered. These grafts have minimal risk of showing through the skin in contrast to rigid
grafts of septal or conchal cartilages. There are 5 types:
1) Domal TRG. These grafts accentuate the dome defining points and are relatively small
(8x4mm). They are sutured over the domes covering the domal creation sutures. Single
or double layers are employed depending upon the desired definition.
2) Shield TRG. These are shield shape with a distinct dorsal edge to produce dome defining
points. The shoulder of the graft is sutured to the domal notch. A second “booster” graft
can be placed behind the shield to force the tip more caudal.
3) Diamond TRG. These grafts are diamond in shape and cover the entire tip diamond to
set the tip off from the rest of the tip lobule. They are sutured at each domal notch, the
columellar breakpoint, and the midline junction of the cephalic lateral crura.
4) Folded TRG. These grafts have the same shape as a long diamond, but are folded at their
widest point with the shorter end folded behind. The graft is projected 1-2mm above the
domes. Essentially, one is pushing the dome defining points caudally while achieving both
increased definition and projection.
5) Combination TRG. Any combination of these 4 grafts can be used to achieve a specific
goal. One variation is to insert multiple shields and diamonds to increase volume. Another
grouping is to add a domal graft first, then bend a diamond over it which accentuates the
tip diamond under thicker skin.
Inherently, these grafts are also concealing any asymmetries. If the grafts are too visible, the
first choice is to remove them. If the grafts are absolutely essential as in an asymmetric tip
with thin skin, then one can consider over laying a fascia graft.
P R I N C I P L E S

 Whenever possible use excised alar cartilage for add-on TRGs.

 These grafts accentuate changes produced by suturing.

 If in doubt, remove the graft.

 Fascia grafts can cover concealer grafts under a thin skin envelope.
Final Photos
Always take 4 close-up (macro view) photographs of the tip before closing the skin. These
should be top-down, lateral, basilar oblique, and basilar. Print the 4 photos on one page and
place it next to the operative diagram in the patient’s chart. Review the operative diagram
and tip photos at every potop visit- it is how you teach yourself surgical cause and effect.
Step #8 Add-on
Grafts
(Tip Refinement)

Step #8 Add-on Grafts (Tip Refinement)
131
Fig. 4.28 Types of TRG. (a) domal, (b) shield, (c) diamond, (d) folded
Add-On Grafts
Fig. 4.27 Add-on tip refinement grafts (TRG)

132
Chapter 4   Tip Techniques
Purpose
Alar rim grafts were developed to correct alar rim retraction in secondary cases. However, their
use has increased dramatically as tip suture techniques have gained in popularity. Alar rim
grafts counteract the subtle effects of tip suturing on alar rim shape, both rim retraction and rim
depression. Small tapered pieces of rigid cartilage (8–10 mm long, 2–3 mm wide) are placed either
subcutaneously along the alar rim (alar rim graft – ARG) or are sutured into a true rim incision
(alar rim structure graft – ARS) depending upon the severity of the rim changes (Fig. 4.29).
Technique
The grafts are usually carved from septal or excised cartilaginous vault material. In general,
I find excised alar cartilage too weak. The dimensions are 8–12 mm long and 2–3 mm wide
with tapering cephalically both in width and thickness.
ARG. Insertion of an alar rim graft can be made either medially from the infracartilaginous
incision or laterally from a stab incision on the mucosal surface of the alar base (Fig. 4.30a, b).
Then a subcutaneous pocket is made 2–3 mm back and paralleling the alar rim. One should
never dissect into, or unfurl, the alar rim as it will cause irreparable rim distortion. The graft
is slipped into the pocket and one should see an immediate improvement in both alar rim
retraction and depression. The cephalic end of the graft toward the tip is always checked
to avoid future bossa formation or distortion of the soft tissue facet. The infracartilaginous
incision is closed in the standard fashion. One should expect that patients will inquire about
these grafts, especially those with inquisitive fingers. One can tell the patient that the grafts
will soften with time and reduce in volume by 50%. In reality, most patients adjust to the
grafts once they are reassured.
ARS. When the alar rim is extremely weak with preexisting external valve collapse, then the
graft is sutured into a true marginal rim incision irrespective of the original open incision
(Fig. 4.30c, d). The pocket is dissected away from the rim – never unfurl the alar rim. The
graft is placed in the pocket. The graft is incorporated into the closure using 4–0 chormic. On
occasion, the cephalic end can be too rigid and placed too far toward the tip resulting in either
a tip bossa or distortion of the soft tissue facet. Treatment is excision. Avoidance is achieved
by careful palpation and inspection followed by appropriate excision prior to closure. Too
long a graft laterally can cause a wide nostril base, again excision is the treatment.
P R I N C I P L E S

 When indicated, alar rim grafts are a necessity, not an option.

 Detail inspection from the head of the table will reveal alar rim retraction, whereas inspec-
tion from the foot of the bed shows alar rim depression (think boxy tip).

 Careful carving of the graft is as important as careful placement of the graft.

 Too small a graft is much preferred to too long a graft.

 Nostril changes are very three-dimensional, so inspect the nostrils carefully.
Step #9 Alar Rim
Grafts
(Nostril Rim
Shape)

Step #9 Alar Rim Grafts (Nostril Rim Shape)
133
ARG and ARS Grafts
Fig. 4.30 (a,b) Alar rim grafts (ARG), (c,d) alar rim structure grafts (ARS)
Fig. 4.29 (a,b) Alar rim grafts (ARG) and (c,d) alar rim structure grafts (ARS) 
a
b
c
d

134
Chapter 4   Tip Techniques
At its simplest, an open structure tip procedure consists of a columellar strut and a shield
shape tip graft sutured to the middle crura via an open approach. It originated with Johnson
(1990) as a stunning solution for the “problem noses” of the endonasal era. During the past
decade, I have modified the operation as follows: (1) domal sutures rather than domal exci-
sion to modify the anatomical domes whenever possible, (2) altering the shape and size of
the crural strut as necessary, (3) columellar-septal sutures to effect adjustments in projection
and rotation rather than relying solely on the tip graft, and (4) recognition of the limitations
for the procedure.
Indications. I divide the indications into three groups: (1) severe deformities where excision
of a domal segment is necessary followed by a concealing tip graft, (2) major deformities
where domal sutures would be inadequate thus necessitating a tip graft, and (3) moderate
deformities where tip sutures were tried, but the addition of a tip graft was an intraopera-
tive decision. This “reverse” approach from severe to moderate parallels my preference to
use a destructive (domal/excision), reconstructive (tip graft), tip technique only for the
most difficult of cases. I do an open structure tip for the following cases: (1) asymmetric
and abnormal shapes, (2) major deformities of width or definition, (3) major inadequacies
of projection or rotation, and (4) most ethnic and cleft lip noses.
Technique. Although one’s initial impression is that it is a fixed rigid procedure, the reality
is that the open structure tip graft can be varied widely to accommodate a diversity of tips.
Step #1 Cephalic Rim Strips. Following exposure of the alar cartilages, I reassess my preop-
erative analysis and operative plan. I tend to excise cephalic lateral crura early to improve
dorsal exposure and septal access (Fig. 4.31a, b). The goal is to establish symmetrical rim
strips rather than symmetrical excisions.
Step #2 Columellar Strut. Shape, insertion, and fixation of the columella strut are all critical.
In most cases, I favor the standard straight 20 × 3 mm crural strut made from septal cartilage
(Fig. 4.31c, d). I prefer a longer wider columellar strut when the columella is retracted or the
columella labial angle is acute. The insertion pocket is created by passing the Stevens scis-
sors vertically between the crura down toward, but at least 2 mm short of, the anterior nasal
spine thereby avoiding clicking of the strut. The graft is temporarily held in place with a #25
needle. A single mattress suture of 5–0 PDS is inserted across the columella at the columellar
breakpoint. Next, the domes are modified either with sutures or excision.
Step #3A Domal Modification (Sutures). I have found that domal creation sutures are an
excellent nondestructive method of achieving the desired changes in domal angle prior to
insertion of the tip graft (Fig. 4.31e, f). I use domal sutures for the majority of cases and re-
serve domal excision for severe deformities. These are the same domal creation sutures used
in open suture tips (4.31c, d). Domal equalization and interdomal sutures are contraindicated
as interdomal width will be controlled by the width of the tip graft.
Open Structure
Tip Graft

Open Structure Tip Graft
135
Open Structure Tip Graft
e
f
Fig. 4.31 Open Structure Tip Graft (OST) 
(a, b) Symmetrical rim strips (c, d) columellar strut 

(e, f) domal suture

136
Chapter 4   Tip Techniques
Step #3B Domal Modification (Excision). Excision of a domal segment is done as a tapered
full-width domal segment excision (Fig. 4.32a, b). I excise a domal segment to make major
tip changes. Once the crural strut is sutured in place, I measure up from the columella
breakpoint 6–8 mm and mark a transverse cut in the lobular segment of the middle crura
(a point that often corresponds with the medial genu of the domal notch). Then the cut is
made without going through the underlying mucosa, a move simplified by injecting it first
with local anesthesia. The domal segment and lateral crura are then elevated off the mucosa,
overlapped at the transverse cut, and then the redundancy is excised, ranging from 4-8mm.
The cut edges are then repaired with interrupted 5–0 PDS.
Step #4 Graft Shaping. A three-stage sequence is used for shaping the tip graft. The shape
has shifted from shield shape to a more tapered golf-tee shape graft integrated between the
divergent middle crura. The initial triangular “block” is cut with a superior edge 10 mm wide
and tapered sides to a 4 mm wide inferior edge with a total length of 15–18 mm (Shaping
#1). Then, the dorsal edge is beveled and shoulders cut on either side. The sides are bev-
eled creating a narrow waist (Shaping #2). The final shaping occurs in situ once the graft is
sutured in place (Shaping #3).
Step #5 Graft Placement. I now conceive of graft placement as being either integrated or
projected (Fig. 4.32c, d). Usually, I integrate the graft into the divergent middle crura allow-
ing the tip of the graft to rise slightly above the domes. The goal is to create ideal tip defini-
tion and width by accentuating the preexisting tip, but without any visibility of the graft.
When the skin is thick or major changes are required, then the tip graft is placed to project
above the domes and create a new tip. As one begins to project the graft 2–3 mm above the
domes, it becomes necessary to add a cap graft behind the tip graft to give support and fill
the dead space.
Step #6 Graft Suturing. In most cases, I use four stitches of 5–0 PDS to hold the graft in place:
two at the level of the middle crura and two just above the columella incision (Fig. 4.33).
I do not hesitate to add sutures at the level of the domes to integrate the graft into the domal
architecture. If the graft is angulated or asymmetrical, then I will insert small “door stop”-
shaped booster or leveling grafts behind the main tip graft.

Open Structure Tip Graft
137
Open Structure Tip Graft
c
d
Fig. 4.32 (c) Tip graft integrated 
(d) tip graft projected 

Fig. 4.33 (a, b) Domal sutures with open structure tip graft
Fig. 4.32 (a, b) Open structure tip graft (domal excision)

138
Chapter 4   Tip Techniques
The Problem
In these cases, the tip is simply unattractive. The goal is to eliminate the negatives thereby
producing a much more refined tip. Open tip suture techniques are highly effective in cor-
recting these problems. The operative sequence is a variation of the following (Fig. 4.34).
Technique
Step #1. The overall volume of the tip is reduced by creating the symmetrical rim strips. The
excision of cephalic lateral crura parallels the caudal border and never encroaches on the
domal notch medially. A 6 mm wide strip is left.
Step #2. The columellar strut insures stability and projection of the tip. A pocket is made
between the middle crura down toward the ANS. The alar cartilages are elevated, rotated
medially, and then temporarily fixed with a #25 needle in the infralobule. A vertical suture
of 5–0 PDS fixes the crura to the strut.
Step #3. Definition is created at each tip point with a domal creation suture that crosses the
domal notch. This horizontal mattress suture of 5–0 PDS begins and ends on the medial
side of the domal notch. As the suture is tied, the dome becomes convex while the adjacent
lateral crura becomes slightly concave.
Step #4. Tip width is controlled with an interdomal suture. Suture placement is easily
­determined. Tension is increased until the domes approach each other cephalically, while
the caudal border is often separated by 4–6 mm. One has the option of adding a domal
equalization suture to improve symmetry if necessary.
Step #5. Frequently, a supratip break is desired with a “set-off” of the tip above the dorsal
line. A tip position suture is inserted between the mucosa of the infralobular columella and
the septal angle. Tension is increased to achieve rotation and finalize projection. Note: do
not tie this suture too tight – err on the side of conservatism.
Lessons Learned
After 20 years and a few thousand sutured tips, experience has taught me the following:
1) Always use a columellar strut. It promotes stability, symmetry, and projection, while
minimizing tip droop. It prevents a plunging tip – so much to gain for so little effort.
2) Use absorbable sutures to minimize infection. Dyed sutures are easier to see.
3) Most problems occur from too much tension, not too little.
4) The “domal notch” is the location for the domal creation suture – learn to recognize it.
5) The middle crura should be “open” – do not tie the interdomal suture too tight.
6) The domal equalization suture improves symmetry and lowers the cephalic rim.
7) The tip position suture creates supratip break, but be very careful – do not tie too tight.
8) Be prepared to do alar rim grafts – they are often necessary.
9) If the strut is too long and pushes down the columellar base, then shorten it.
10) Record your tip operation with intraop photos and drawings on the op diagram. Refer
to them at every post-op visit. Only you can teach yourself surgical cause and effect.
Decision
Making:
Level 1

Decision Making: Level 1
139
Fig. 4.34 Tip suture technique: (a) Step #1: volume ­reduction, (b) Step #2: tip projection, (c, d) Step #3: domal defini-
tion, (e, f) Step #4: interdomal width, (g, h) Step #5: supratip break

140
Chapter 4   Tip Techniques
Analysis
A 21-year-old patient of Middle Eastern descent presented with a wide unattractive tip
(Fig 4.35). She wanted a significant change in the nose, but especially a cuter tip. She agreed
to having a chin implant done at the same time. This is truly a Level 1 case as all the surgeon
has to do is rasp down the small bump, narrow the base bony width, and refine the tip. A bal-
anced approach was done to establish the profile including a fascia graft to the radix. The tip
change was achieved with just five steps: (1) volume was reduced by excising cephalic lateral
crura, (2) projection was increased with a columellar strut (CS), (3) definition was created
with domal creation suture (DC), (4) symmetry was improved with a domal equalization
suture (DE), and (5) supratip break was insured with a tip position suture (TP).
Operative Technique
1) Harvest of deep temporal fascia
2) Open approach and confirmation of tip analysis and operative plan
3) Incremental reduction – bony 0.5 mm, cartilage 3 mm
4) Caudal septal resection (3 mm)
5) Low-to-high osteotomies. Bilateral spreader graft placement
6) Columellar strut insertion followed by tip sutures: CS, DC, DE, TP
7) Radix graft of fascia
A large chin implant was inserted at the beginning of the case.
Case Study: An
­Unattractive Tip
Fig. 4.35 (a–j)

Case Study: An ­Unattractive Tip
141
Fig. 4.35 (continued)

142
Chapter 4   Tip Techniques
The Problem. Most Level 2 patients consider their tip to be the major reason for having a
rhinoplasty and they want a significant tip improvement. Technically, a fundamental change
in the underlying tip anatomy is required to achieve the desired aesthetic goal. It is at this
point that add-on and structure tip grafts have to be considered. These are intermediate cases
between the refinement of Level 1 and the total change of Level 3. The surgeon should feel
confident with their tip suturing skills before progressing to these more challenging cases.
Techniques. Several sutures can be added to the standard five-step technique with the most
common being the lateral crural mattress suture (LCC). The broad tip is characterized by
lateral crura convexity which is easily corrected with the LCC thereby avoiding destabilizing
incisions or excisions. Once suturing is completed and there is a need for more tip definition,
then add-on grafts are used. If one has totally misdiagnosed skin thickness or compliance
such that add-on grafts are ineffective, then a structured tip graft is the only solution.
Specialized Sutures. After creating an attractive tip, the most common challenge is excessive
convexity of the lateral crura which is often seen as a broad tip. The point of lateral convex-
ity is marked with a pen and then the lateral crura mattress suture straddles it (Fig. 4.36a).
The tension is increased until the convexity disappears and the crura is straight – one should
avoid producing a concave lateral crura. When the skin is closed it may be necessary to add
an alar rim graft, especially in a boxy tip.
Add-On Tip Grafts. The use of add-on Tip Refinement Grafts (TRG) made from excised alar
cartilage has revolutionized the finesse aspect of tip suturing. Grafts can be placed in the
infralobule to conceal asymmetries or to create fullness (Fig. 4.36b). Alternatively, a domal
graft can be placed over the domes to improve definition and in double layer to increase
projection by 1 mm. Both shield shape and domal shape grafts can be placed in combination
to increase refinement and produce additional volume. Due to their pliability and thinness,
visibility or absorption of the grafts is rarely a problem (Daniel 2009).
Structure Tip Grafts. Following completion of tip suturing, definition and projection may
be inadequate especially in thicker skin patients. The solution is a rigid shield shape graft
of septal cartilage (Fig. 4.36c). These grafts are highly tapered and designed to fit within the
crural framework. Therefore, it is critical to remove any interdomal or domal equalization
sutures before suturing the graft into place. In most cases, the top two fixation sutures pass
through the caudal border of the domal notch and are fixed to the shoulders of the tip graft.
This maneuver insures that the graft fits between the crural edges and provides greater tip
definition. In Level 3 cases, a structure tip graft is planned from the beginning, the domes
often require excision, and the tip graft is placed higher with a cap graft backing to maxi-
mize tip projection
Decision
Making:
Level 2