Nâng Mũi Thẩm Mỹ Nâng Cao: Nghệ Thuật, Khoa Học Và Các Kỹ Thuật Lâm Sàng Mới

816
K. Conrad and A.J. Conrad
postoperative oral antibiotic administration is a
recommended prophylactic routine.
56.5
Complications
Complications of GORE-TEX implants in rhino-
plasty fall under two categories: (1) an undesir-
able contour due to inaccurate placement of the
implant, migration due to oversized undermin-
ing, inadequate or excessive augmentation, or
kinking – all related to the surgical technique –
and (2) migration due to excessive swelling,
microhematoma, or possible scar retraction,
infection, or extrusion – all caused by biological
phenomena.
Surgical technique-related complications are
corrected by removing with or without replac-
ing of the implant not earlier than 2–3 months
postoperatively when the acute swelling is
expected to completely subside. In the treat-
ment of biological complications, relying on
antibiotics is futile. Urgent removal of the
implant to prevent permanent tissue damage is
essential. Preoperative routine bacteriological
studies must be obtained. The patient should
receive a systemic antibiotic to be adjusted if
necessary according to the culture and sensitiv-
ity results. Such management as documented in
published reports [ 5 ] has fully prevented per-
manent deformity. In healthy patients, the rein-
sertion of the new GORE-TEX implant after
6 months or later will most likely result in a
favorable outcome. The overall incidence of
complications reported based on a number of
large series of cases varies from 0% to 3.5%. In
the longest 17-year follow-up, of the largest
reported series [ 5 ] (76.2% of patients with revi-
sion surgeries), the complications classi fi ed as
biological were cited at 1.9% and the surgical at
2.9% . The high percentage of revision rhino-
plasties stated in that publication may have
directly in fl uenced (increased) the overall
reported rate of complications. In the same
series of cases, all the complications became
apparent in the fi rst postoperative year.
56.6
Discussion
The use of alloplasts in rhinoplasty justi fi ably
remains controversial. It is easily explained by
their past poor performance, mainly related to
their physical properties suitable for successful
use in other parts of the body, yet failing when
applied in the “high-risk” area of the nose.
The excellent tissue compliance of GORE-
TEX attributed to its pliability and microporos-
ity can explain its remarkable performance as a
rhinoplasty implant whenever rigidity of the
material or structural support is not required.
Advantages of GORE-TEX implants in nasal
surgery have been con fi rmed and documented
in more than 20 years of its use. They outweigh
a
b
Fig. 56.10 ( a ) Introducer – Keith needle ready to be
guided through an intercartilaginous incision into the sub-
cutaneous pocket. ( b ) The pocket is corresponding to the
surface marking on the dorsum. Special care is taken for
the implant to slide into the port of entry without touching
the surrounding tissues. Note – the implant is prevented
from touching the drapes

817
56 GORE-TEX Implants in Rhinoplasty
the acceptable rate of complications that have
been treated successfully and which are being
reduced by applying stricter requirements in
the choice of patients and the surgical tech-
nique. Avoiding the placement of Gore-Tex
when osteotomies are performed may further
reduce its rate of complications. In sharp con-
trast with other alloplasts where the risk of
complications persists for many years [ 2 ] , the
documented 17-year patient follow-up study
revealed no incidence of GORE-TEX compli-
cations past the fi rst postoperative year [ 5 ] . This
is a very signi fi cant fi nding in itself. The long-
term excellent esthetic effects, only limited sur-
gical intervention with relatively short operating
time required, place this material in a unique
category, different to all the previous implants
that have been tried and in many cases even
preferable to the use of autografts.
References
1. Sajjadian A, Naghshineh N, Rubinstein R (2010)
Current status of grafts and implants in rhinoplasty:
part II. Homologous grafts and allogenic implants.
Plast Reconstr Surg 125(3):99e–109e
2. Pak MW, Chan ES, van Hasselt CA (1998) Late com-
plications of nasal augmentation using silicone
implants. J Laryngol Otol 112(1):1074–1077
3. Mackay IS, Bull TR (1983) The fate of silastic in the
management of saddle deformity in the nose! J
Laryngol Otol 97(1):43–47
4. Lovice DB, Mingrone MD, Toriumi DM (1999)
Grafts and implants in rhinoplasty and nasal recon-
struction. Otolaryngol Clin North Am 32(1):
113–141
5. Conrad K, Torgerson C, Gillman GS (2008)
Applications of Gore-Tex implants in rhinoplasty
reexamined after 17 years. Arch Facial Plast Surg
10(4):224–231
6. Godin MS, Waldman SR, Johnson CM Jr (1999)
Nasal augmentation using Gore-Tex a 10-year experi-
ence. Arch Facial Plast Surg 1(2):118–122
7. Conrad K, Gillman G (1998) A 6-year experience
with the use of expanded polytetra fl uoroethylene in
rhinoplasty.
Plast
Reconstr
Surg
101(6):
1675–1684
8. Godin MS, Waldman SR, Johnson CM Jr (1995) The
use of expanded polytetra fl uoroethylene (Gore-Tex)
in rhinoplasty: a six-year experience. Arch Otolaryngol
Head Neck Surg 121(10):1131–1136
9. Gosain AK, Persing JA (1999) Biomaterials in the face:
bene fi ts and risks. J Craniofac Surg 10(5):404–414
10. Garner WL (1997) Gore-Tex facial implants. Plast
Reconstr Surg 100(7):1899–1900
11. Torgerson C, Conrad K (2009) 20-Year experience
with the Conrad modi fi cation of the Freer elevator as
a pull-in suture introducer. Arch Facial Plast Surg
11(4):267–269

819
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_57, © Springer-Verlag Berlin Heidelberg 2013
57
57.1 Introduction
The complex nasolabial region, which corre-
sponds to the area covering the maxilla below, is
composed primarily of two dominant aesthetic
structures: the nose and the upper lip. The Le Fort
I osteotomy is usually performed in order to repo-
sition the maxilla and to correct any maxillary
dentoskeletal deformity. This osteotomy is usu-
ally carried out through the transection of the
perioral and perinasal musculature and through a
wide periosteal degloving.
What is really essential is a wide understand-
ing of the anatomy of the interconnections
between the hard framework and the soft tissues,
and in particular of the muscular web, to manage,
properly, the changes that a maxillary exposure
and repositioning produce on the nose and on the
upper lip. Secondary changes on the nasolabial
unit that have occurred following this orthog-
nathic procedure include the following: the wid-
ening of the alar bases; the upturning of the nasal
tip with a subsequent increasing of the supratip
depression; the alterations of the nasolabial angle;
the increasing of the prominence of the alar
groove; the fl attening, the drooping, and the thin-
ning of the upper lip; the reduction of the vermil-
ion’s exposure; and, fi nally, the downturning of
the commissures of the mouth.
Many authors proposed their techniques to
handle these effects with variable and unpredict-
able or unstable results [ 1– 13 ] . Applying appro-
priate surgical techniques, many undesirable
secondary changes can be prevented, maintaining
the nose unchanged and achieving the aesthetic
enhancement of the lip. This procedure permits
the simultaneous performance of rhinoplasty and
maxillomandibular osteotomies.
57.2
The Nasolabial Unit Concept
The nasolabial unit is an aesthetic component of
the facial volumes and contours in which the soft
tissues re fl ect intrinsic conditions related to their
distribution and to their thickness, But above all,
they reveal the disposition and the morphology of
the skeletal structures below. Since the contour is
a much easier aspect to analyze, due to its being
made up of a line and not of volumes which, on
the contrary, are characterized by light areas fad-
ing into shadow ones, the author has always pre-
ferred evaluations that analyzed the morphology
of the upper lip in its subunits in pro fi le: subnasal
or angle, line of the lip, and vermilion. It is there-
fore necessary to understand that the form of the
upper lip cannot be distinguished from the lower
part of the nose and from the point of in fl ection of
Simultaneous Rhinoplasty
and Orthognathic Double
Jaw Procedures: How to Get
the Nasolabial Unit Harmony
Mirco Raffaini
M. Raffaini , M.D., D.D.S., Ph.D.
Professor of Maxillo-Facial Surgery ,
University of Florence , Via Rocco Bormioli, 5/A ,
43122 Parma , Italy
University of Florence ,
Florence , Italy
e-mail: mircoraffaini@facesurgery.it

820
M. Raffaini
the line called subnasal. The nasolabial pro fi le is
directly related to the position and to the shape of
the hardware below.
The nasolabial unit’s hard support consists of
two different parts: the lower or dentoalveolar
maxillary part and the upper or nasal one. The
lower part of that supporting skeleton is made up
of the frontal teeth with their tipping and their
position in the maxillary alveolar structures and
of the position of the basal maxillary skeleton.
The upper part is substantially the lower nasal
framework, composed of two skeletal elements, a
tripod (Fig. 57.1 ) resting on a median strong ped-
estal (Fig. 57.2 ) formed by the anterior nasal
spine, and the caudal third of the septum. The
paired lower lateral cartilages form the fl exible
tripod. The anterior septal angle is beneath the
apex of the tripod – the paired tip domes. The pos-
terior septal angle and the nasal spine support the
feet of the medial crura. Overlying this tripod-
pedestal skeleton, and supported by it, is a skin-
soft tissue envelope or covering, with its thickness,
intrinsic dimensions, and textures (Fig. 57.3 ).
Together, the tripod-pedestal skeleton and the
skin-soft tissue envelope provide the shape of the
nasal lower third de fi ning the subnasale position
and conditioning all the lip (tethering and curling).
So to read clearly the contour of the pro fi le of the
nasolabial unit and to understand the supporting
framework, we have to consider, besides the den-
tomaxillary structure, the tripod shape and strength
as well as the size and shape of the pedestal. Then,
we determine the interplay between the upper and
lower skeletal parts to address the treatment alter-
natively on the dentomaxillary structure, on the
nasal structure, or on both of them.
In particular, the pedestal features are very
important to in fl uence directly the morphology of
the upper lip and indirectly the tripod which is
affected accordingly. The tripod rests on a pedes-
tal which is essentially the caudal septum and the
nasal spine. The feet of the medial crura articu-
late with the posterior septal angle and the nasal
spine, and the domes are supported by the under-
lying anterior septal angle. The pedestal may be
excessive in any of the following dimensions: its
dorsal length caudally, its anterior projection at
the anterior septal angle, and its caudal extension
of the posterior septal angle involving or not the
dimension of the nasal spine.
Fig. 57.1 The tripod: the
central limb is composed by
the conjoined medial crura,
whereas the lateral crura form
the two lateral limbs

821
57 Simultaneous Rhinoplasty and Orthognathic Double Jaw Procedures
A gross enlargement of the pedestal in the
anterior septal angle anteriorly, frequently cou-
pled with an overprojected nasal spine, may lift a
normal-sized tripod to an overprojected position
and tether the lip upward producing an appear-
ance of lip with de fi cient support. This nasal mor-
phology is named “tension nose” because the
pedestal in excess stretches all the nasolabial unit
and the dentoalveolar structure appears de fi cient
as a consequence of this tethering. The key to
deprojecting such a tip lies not in advancing the
teeth or the maxilla neither in reducing the size of
the tripod, but rather in trimming the excessive
pedestal component (Fig. 57.4 ).
In another case, the excess of the caudal septum
may force the tripod and the nasal tip downward
into an underrotated or plunging tip position.
Again, the pedestal excess must be addressed to
affect rotation in the septal caudal portion. Both the
lower nose and the nasal angle improve, without
any modi fi cation of the teeth position (Fig. 57.5 ).
Thus, a nasal tip may be overprojected and
downrotated because of the excessive length of the
lateral limbs of the tripod, whereas the pedestal is
almost normal or slightly de fi cient. The treatment
in this case is a reduction of the tripod with or
without a mild pedestal increase (Fig. 57.6 ).
The opposite condition is related to a de fi ciency
of the pedestal due to a short nasal spine or to an
underprojected septum in its anterior septal angle.
The nasal tip results unsupported and the subna-
sale point retruded with an acute nasolabial angle
and an evident accentuation of the labial curl.
Fig. 57.2 The pedestal: the
upper caudal septum supports
the nasal tip; the lower caudal
septum and the anterior nasal
spine de fi ne the support of the
subnasale and the upper lip
Fig. 57.3 The soft tissue envelope is a complex structure
composed of skin, subcutaneous layer, muscular and
peripheral connective tissue layer, submucosa with minor
salivary glands, and mucosa

822
M. Raffaini
a
b
c
Fig. 57.4 ( a ) Preoperative: typical “tension nose” with overprojected pedestal. ( b ) Rhinoplasty. ( c ) Postoperative: the
rhinoplasty was not able to change the inadequate pro fi le of the upper lip

823
57 Simultaneous Rhinoplasty and Orthognathic Double Jaw Procedures
a
b
Fig. 57.5 Nasal pedestal reduction case. ( a ) Preoperative. ( b ) Postoperative

824
M. Raffaini
a
b
Fig. 57.6 Nasal pedestal de fi ciency with tripod excess. ( a ) Preoperative. ( b ) Postoperative

825
57 Simultaneous Rhinoplasty and Orthognathic Double Jaw Procedures
The harmonization between the lower nose and
the lip is obtained by increasing the pedestal with
grafts (Fig. 57.7 ).
Each alteration of the nasolabial unit has to
be studied considering the lower part or den-
tomaxillary framework and the upper part or
nasal cartilaginous skeleton: when the nasal part
is altered, the nose is approached according to
the tripod-pedestal concept. Through this con-
cept, the nose can be manipulated to control its
tip rotation (underrotated, normally rotated,
overrotated), its projection (underprojected or
overprojected), and its shape (tripod excess,
defect, or distortion). The nasal structure altera-
tion directly in fl uences the upper lip morphol-
ogy. So the nasal surgical procedures up to a
complete rhinoplasty are an integrated part of
the orthodontic-surgical treatment to obtain
more harmonious outcomes.
57.3
The Nose and Maxilla
Moreover, the nose, due to its location in the
central face, plays a fundamental role in the
harmonious perception of the face. Therefore,
the correction of many dentomaxillary defor-
mities demands not only a combination of
orthodontics and orthognathic surgery but also
a nasal morphological correction. Usually, the
rhinoplasty was performed at a later time (6
months or more) after maxillary and mandibu-
lar osteotomies to reduce the risk of unfavorable
postoperative recovery. These were related to
intermaxillary fi xation, to the dif fi culty in per-
forming the nasal-changing procedures due to
the midface deformation after a maxillary sur-
gery, to the increased postoperative edema, and
to the discomfort and the longer operating time.
Performing maxillary osteotomies and rhino-
plasty in a single surgical procedure has become
possible for the last 10 years, with the routine
application of internal rigid fi xation with plates
and screws to the jaws, eliminating the need for
intermaxillary fi xation.
Advantages include the need for only one sur-
gical procedure, an improved access and visibil-
ity to some structures like the septum or nasal
spine of the nose during maxillary surgery, and
the possibility to obtain a more harmonious cor-
rection of the nasolabial unit, focusing on the
solution of the problems in a well-addressed
manner.
The main disadvantages are related to the fact
that it may be dif fi cult to assess the extent of the
nasal modi fi cations needed after the maxillary
osteotomies have been performed. The changes
of the nasal morphology following the maxillary
osteotomy are well known: this is due to the dis-
ruption of the nasal support system produced by
the maxillary sectioning and repositioning fol-
lowed by soft tissues swelling in the lip, cheeks,
and paranasal area. Any surgically induced alter-
ation may adversely affect the surgeon’s capabil-
ity to evaluate the needs for modi fi cations of the
nose intraoperatively.
57.4
Unfavorable Modi fi cations
of the Nasolabial
Unit Consequent
to Le Fort I Osteotomy
Several studies have been published on the rela-
tionship between maxillary osteotomies and the
modi fi cations of nasal aesthetics and upper lip
morphology. The classic osteotomy following
the lines of the Le Fort I fracture (Dr. Le Fort
has never performed any osteotomy, according
to Paul Tessier’s funny clari fi cation) is probably
the most commonly performed orthognathic
surgical procedure for correction of facial skel-
eton dysplasia. It is traditionally carried out
through an incision in the vestibular groove, on
the alveolar side, largely skeletalizing the max-
illa, detaching the nose’s lateral cartilages
fi brous ligaments (the pyriform ligament) [ 14 ]
from the pyriform opening, and splitting the
cartilaginous septum from the nasal spine
(Fig. 57.8 ).

826
M. Raffaini
a
b
Fig. 57.7 Nasal pedestal de fi ciency. ( a ) Preoperative. ( b ) Postoperative

827
57 Simultaneous Rhinoplasty and Orthognathic Double Jaw Procedures
Summarizing the procedure mainly consists of
creating a wide disruption of the muscular liga-
mental insertions of the whole nasolabial unity.
Adverse changes can occur to a variable
degree following the classic outline of Le Fort I
osteotomy in the lip and nasal region, including
widening of the alar nasal bases, upturning of the
nasal tip creating a saddle effect, upper or lower
dislocation of the columella and fl attening, and
thinning and lengthening of the upper lip with
loss of the ideal curl. The reduction of soft tis-
sues’ fullness in this region can result in changes
similar to those seen with aging, including deep-
ening and increasing of nasolabial groove,
reduced vermilion, and lateral retraction of the
upper lip with downturning of the commissures
of the mouth. These modi fi cations are mainly
associated with maxillary movement’s direction
and entity, extension of subperiosteal dissection
and muscular transection or disruption, and han-
dling of musculature and mucosa during the clo-
sure of the surgical access.
Various methods of soft tissue repositioning and
closure of the vestibular incision (alar base cinch
suture, mucosal V-Y suture, W incision and suture,
etc.) in order to control nasal and labial changes
have been described in the literature [ 4, 7– 10 ] ;
however, predictability is not expected and stable
success has not been consistent among reports.
To prevent these unfavorable effects, many
authors [ 6, 11 ] have proposed a new outline cutting
under the nasal spine to respect the integrity of
the nasolabial muscle. The author suggests the
use of this technique combined with a very small
mucosal incision (3 cm large) limiting the
periosteal dissection to the surface of the osteot-
omy, working in two lateral tunnels, and osteoto-
mizing at a lower level in respect of the teeth apex
(Fig. 57.9 ). The aim of this procedure is a more
Fig. 57.8 Upper jaw: in red is the classic outline of Le
Fort I osteotomy.
a
b
Fig. 57.9 ( a ) Outline in red of the modi fi ed technique.
( b ) The conservative technique of Le Fort I osteotomy

828
M. Raffaini
a
b
Fig. 57.10 ( a ) Preoperative male with CII biretruded with small mandible and severe deformation of the nose. ( b ) Six
years postoperative following bimaxillary advancement, chin vertical increase, and rhinoplasty

829
57 Simultaneous Rhinoplasty and Orthognathic Double Jaw Procedures
conservative approach on the soft tissue struc-
tures. After the mobilization and the reposition-
ing of the maxilla, the closure of the access is
carried out by suturing the transected muscles.
Using this technique, the Le Fort I osteoto-
my’s drawbacks on the nose or on the upper lip
have been almost eliminated. Besides, in case of
original alteration of the nose, a rhinoplasty can
be performed simultaneously. The usual sequence
carried out in that case sees the orthognathic
procedure as the fi rst one, under nasotracheal
intubation, with the jaws fi xed with plates and
screws to get solid skeletal structures. Then, as a
second step, the intubation is converted in an
orotracheal one in order to allow the rhinoplasty
procedure.
57.5
Indications for Rhinoplasty
Associated with Treatment
of Dentomaxillary
Deformities
Any dorsal humped nose, saddle nose, tension nose,
broad-based nose, nasal tip deformation (broad,
boxy, globous, downrotated, asymmetric tip)
demanding correction can be treated in association
with maxillary and mandibular osteotomies.
The procedure becomes very dif fi cult only in
case of severe nasoseptal deviation or extreme
septal alteration with major functional problems
requesting a complete cartilage rebuilding; in
these cases, the delayed procedure is advised.
The rhinoplasty could be performed according
to two access, open or closed, depending on the
area of deformation: the closed access is usually
preferred in case of limited dorsal deformity. In
case of tip needing correction, the open access is
mandatory. Any defect can be approached with
the preferred technique: reductions, repositions,
sutures, and grafts [ 15, 16 ] . Only in case of mild
to moderate septal deviation the correction
demands special care to stabilize the septum in
the midline with sutures. Wide use of columellar
struts fi xed or not to the maxilla is mandatory in
case of tip support de fi ciency.
The simultaneous correction of the nose and
of the maxillary alteration can result in a well-
balanced and harmonic face in only one proce-
dure, thus reducing the morbidity and increasing
the patients’ satisfaction.
57.6
Clinical Examples
The following clinical examples of double jaw
orthognathic surgery combined with rhinoplasty
are the more concrete representations of the
exposed concepts.
This young male had CII biretruded with small
mandible and severe deformation of the nose
(Fig. 57.10 ). Bimaxillary advancement, chin ver-
tical increase, and rhinoplasty were performed.
This female patient had asymmetric mild CIII
with unsupported and downrotated nasal tip
(Fig. 57.11 ). She had (double jaw orthognathic
surgery) maxillary advancement and frontal rota-
tion of the maxilla, rhinoplasty, and soft tissue
lipo fi lling.
This female patient had asymmetric CIII with
maxillary de fi ciency and unsupported nasal tip
(Fig. 57.12 ). She had maxillary advancement,
mandible and chin reduction and symmetrization,
and rhinoplasty.
This female had CII biretruded with postrotated
mandible and overprojected nose (Fig. 57.13 ). She
had maxillary impaction, mandibular advance-
ment, and rhinoplasty.

830
M. Raffaini
a
b
Fig. 57.11 ( a ) Preoperative asymmetric mild CIII with
unsupported and downrotated nasal tip. ( b ) Four years
postoperative after (double jaw orthognathic surgery)
maxillary advancement and frontal rotation of the max-
illa, rhinoplasty, and soft tissue lipo fi lling

831
57 Simultaneous Rhinoplasty and Orthognathic Double Jaw Procedures
a
b
Fig. 57.12 ( a ) Preoperative female with asymmetric
CIII with maxillary de fi ciency and unsupported nasal tip.
( b ) Three years postoperative after maxillary advance-
ment, mandible and chin reduction and symmetrization,
and rhinoplasty

832
M. Raffaini
a
b
Fig. 57.13 ( a ) Preoperative female showing CII biretruded with postrotated mandible and overprojected nose. ( b ) Four
years after maxillary impaction, mandibular advancement, and rhinoplasty

833
57 Simultaneous Rhinoplasty and Orthognathic Double Jaw Procedures
References
1. Epker BN, LaBlanc JP (1990) Orthognathic surgery:
management of postoperative complications. Atlas
Oral Maxillofac Surg Clin North Am 2:901–933
2. Carlotti AE Jr, Aschaffenburg PH, Schendel SA
(1986) Facial changes associated with surgical
advancement of the lip and maxilla. J Oral Maxillofac
Surg 44(8):593–596
3. Rosen HM (1999) Aesthetic perspective in Jaw sur-
gery. Springer, New York
4. Guymon M, Crosby DR, Wolford LM (1988) The alar
base cinch suture to control nasal width in maxillary
osteotomies. Int J Adult Orthodon Orthognath Surg
3(2):89–95
5. O’Ryan F, Schendel S (1989) Nasal anatomy and max-
illary surgery. Part I. Aesthetic and anatomic principles.
Int J Adult Orthodon Orthognath Surg 4(3):27–37
6. Kawamoto H (1989) Simpli fi cation of the Le Fort I
osteotomy. Clin Plast Surg 16(4):777–784
7. Loh FC (1993) A new technique of alar base cinching
following maxillary osteotomy. Int J Adult Orthodon
Orthognath Surg 8(1):33–36
8. Rosenberg A, Muradin MS, van der Bilt A (2002)
Nasolabial esthetics after Le Fort I osteotomy and
V-Y closure: a statistical evaluation. Int J Adult
Orthodon Orthognath Surg 17(1):29–39
9. Peled M, Ardekian L, Krausz AA, Aizenbud D (2004)
Comparing the effects of V-Y advancement versus
simple closure on upper lip aesthetics after Le Fort I
advancement. J Oral Maxillofac Surg 62(3):315–319
10. Jacono AA, Quatela VC (2004) Quantitative analysis
of lip appearance after V-Y lip augmentation. Arch
Facial Plast Surg 6(3):172–177
11. Mommaerts M (1991) Precongress EACMFS: orthog-
nathic surgery course, Brugges, 1991
12. Altman JI, Oeltjen JC (2007) Nasal deformity associ-
ated with orthognathic surgery: analysis, prevention,
and correction. J Craniofac Surg 18(4):734–739
13. Cassidy M, Oeltjen J, Panthaki Z, Taller SR (2007)
Nasolabial aesthetics. J Craniofac Surg 18(4):
756–765
14. Rohrich RJ, Hoxworth RE, Thornton JF, Pessa JE
(2008) The pyriform ligament. Plast Reconstr Surg
121(1):277–281
15. Daniels RK (2004) Mastering rhinoplasty, 2nd edn.
Springer, New York, p 2010
16. Gunter JP, Rohrich RJ, Adams WP (2007) Dallas rhi-
noplasty: nasal surgery by the master, 2nd edn.
Missouri Quality Medical Publ., St. Louis

Part VI
Tip Procedures

837
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_58, © Springer-Verlag Berlin Heidelberg 2013
58
58.1 Introduction
Lifting of the nasal tip is usually performed sur-
gically after trimming or resecting portions of the
medial nasal cartilages via cutting the depressor
septi muscle and with the use of polytetra-
fl uoroethylene (Gore-Tex) threads or patches or
solid silicone implants, with the use of liquid sili-
cone or other fi llers, and non-surgically using
Botox for paralyzing the depressor septi muscle
[ 1– 3 ] . It has minimal or no complications, desired
lift can be achieved, and it can be repeated or
revised easily. The authors have devised a simple
technique of lifting the nasal tip using Prolene
3/0 suture under local anesthesia.
58.2
Procedure
Patients should be healthy, free from any physical
or mental disability or illnesses, should not be
taking any kind of allopathic or homeopathic
medications, should be highly motivated, and
should have realistic expectations. The ages of
patients can vary between 20 and 60 years, or
more. All female patients should be nonpregnant
and nonlactating. A consent form is signed by all
the patients. Preoperative photographs are taken
in all cases.
The original suture nasal tip lift technique
crossed horizontally at the inferior part of the gla-
bella (nasion) (Fig. 58.1 ). The new technique of
suture nasal tip lift crosses horizontally at the junc-
tion of the nasal bone and cartilage (Fig. 58.2 ).
Suture Nasal Tip Lift
Hassan Abbas Khawaja and Melvin A. Shiffman
Reprinted with permission from Khawaja HA, Shiffman MA: Suture nasal
lift. In Khawaja HA, Shiffman MA: Simpli fi ed Cosmetic Surgery: Art,
Science and Practice , Lahore, Pakistan, Hassan Abbas Khawaja
2010:417–427.
H. A. Khawaja , M.D. (*)
Department of Cosmetic Plastic Surgery & Dermatology ,
Cosmetic Surgery and Skin Center ,
53-A, Block B II, Gulberg III , 54660 Lahore , Pakistan
e-mail: drkhawajaha@live.com
M. A. Shiffman , M.D., J.D.
Section of Surgery , Newport Specialty Hospital ,
17501 Chatham Drive , Tustin , CA 92780-2302 , USA
e-mail: shiffmanmdjd@yahoo.com
Fig. 58.1 The original suture nasal tip lift

838
H.A. Khawaja and M.A. Shiffman
58.3
Anesthesia
Two percent chilled Xylocaine is used for points
a, b, and c (Fig. 58.2 ). Point a is midway between
the base of the nose and the highest projection of
the nasal tip. Points b and c are either on the
medial nasal cartilages or on the lower perios-
teum of the nasal bones. All of the marked tracts
Fig. 58.2 ( a ) Simpli fi ed suture nasal tip lift technique of the authors. ( b ) Position of the buried knots, and incision for
cutting the depressor septi nasi muscle
a
Incision for
cutting the
depressor septi
muscle
Position
of the
buried knots
b
Incision for
cutting the
depressor
septi muscle
Position of
the buried
knots
Depressor
septi nasi
muscle
bellies

839
58 Suture Nasal Tip Lift
from point a to b, from b to c, and from c to a are
anesthetized. The depressor septi muscle and the
overlying skin are also in fi ltrated.
58.4
Surgical Technique
(Figs. 58.3 and 58.4 )
A straight needle with attached Prolene 3/0 is
introduced at point a. It is passed subcutaneously
toward point b, and needle exits at point b. The
needle is passed from point b to c deep through
the nasal cartilage or through the lower perios-
teum of nasal bone. The needle is passed subcu-
taneously from point c to point a, the starting
point. The assistant holds the two ends of the
Prolene thread in one hand. Now incision is
made vertically at the junction of skin and carti-
lage with a number 11 scalpel blade. Now, with a
fi ne scissors, dissection is done and all of the
depressor septi muscle is cut below the two ends
of the Prolene thread. Traction is now applied on
the two ends of the Prolene thread to achieve the
desired lift, and 4–5 knots are tied. The ends of
a
b
c
d
Fig. 58.3 ( a ) Preoperative male patient. ( b ) Needle
entering the nasal tip and exiting at level of junction
of nasal bone and cartilage. ( c ) Needle traversing the
periosteum of nasal bones. ( d ) Postoperative with fi nal
position of the nasal tip after burying the knots, and
cutting the depressor septi muscle

840
H.A. Khawaja and M.A. Shiffman
the Prolene thread are cut short. The knots are
automatically buried when the skin is pinched up
with the thumb and index fi nger. If dif fi culty is
experienced in burying the knots, a tiny incision
is made just below the knots that helps to bury the
knots. Postoperatively, antiseptic ointment is
applied over the entry/exit points and the incision
site. Sterile tape is applied at the upper part
(points b–c area) and at the lower part (point a
and adjoining area including incision). Cold com-
pression is done postoperatively for 2 h intermit-
tently and is advised for the next 48 h. Cefadroxil
monohydrate (antibiotic), which is started 1 day
before surgery, is continued for 7 days postopera-
tively. In addition, analgesics, anti-in fl ammatory
enzymes in tablet form, mild antiseptic cleaning,
and antibiotic ointment for 2–3 days at the entry/
exit points and incision site are suggested to the
patients.
Long-term follow-up after 2–5 years shows
persistence of results (Figs. 58.5 , 58.6 ). No com-
plications like slipping or loosening of knots
have been noted by us in any of the patients.
Minor bruising and postoperative edema is con-
sidered a normal happening. Bruising is minimal
in an occasional patient, and edema is temporary
and mild and subsides rapidly with anti-
in fl ammatory enzymes and postoperative cold
compression.
58.5
Discussion
Threads for augmentation of facial rhytids, for
lifting the malar fat pad, for brow suspension,
and for facial and neck lifting have been
described in the literature [ 4– 7 ] . Surgical eleva-
tion of the nasal tip has been traditionally per-
formed after resecting the medial nasal cartilages
or via sectioning the depressor septi muscle, a
technique practiced by Fournier. Lifting of the
nasal tip has also been performed using Gore-
Tex (polytetra fl uoroethylene) patches or solid
silicone implants. The senior author (HAK) has
used Gore-Tex threads, and recently, in the last
few years, silk threads via KH needle (Khawaja-
Hernandez) or a conveniently sized Keith needle
for elevating the nasal tip. In addition, a number
of liquid fi llers like liquid silicone, hyaluronic
acid, and others have been used by a number of
a
b
Fig. 58.4 ( a ) Preoperative male patient. ( b ) Two years postoperative after suture nasal tip lift

841
58 Suture Nasal Tip Lift
authors. Botox paralyzes the depressor septi
muscle, thereby elevating the nasal tip tempo-
rarily, but injection has to be repeated after sev-
eral months to maintain the elevation.
One of the authors (MAS), along with
Ceuteaux, used an 18-gauge double pointed nee-
dle, a hook needle, and a Wallstein dissector for
nasal tip lift using Prolene 3/0 suture [ 8 ] . They
introduce the needle at the nasal tip and exit at the
nasofrontal angle on one side, then deep
periosteally crossing the nasofrontal angle and
exit again reentering at the same point and extend-
ing down to the nasal tip at the starting point.
Results of Shiffman and Ceuteaux are impres-
sive; however, edema was more prolonged using
the aforementioned technique and hematomas
have also been reported [ 8 ] . The author (HAK),
along with Enrique Hernandez-Perez and Jose
Enrique Hernandez-Perez, has used a similar
technique using a 16-gauge lumber puncture nee-
dle, but without hook needle [ 9 ] .
Suture nasal tip lift is the simplest of all sur-
gical techniques for lifting the nasal tip. The
complications are practically none, and satis-
faction rate of the patients is usually very high.
The ideal patient for suture nasal tip lift is one
having a long nose with pointed and drooping
or projected nasal tip. However, patients having
broad nose and broad nasal tip can also bene fi t
from this procedure, which leads to an eleva-
tion and sharpening of their nasal tip. In cases
of thick skin, where the skin is very much
adherent to the underlying cartilage and where
more lift is desired, needle tracts can be formed
via passing the needle through the same points
and following the same directions, prior to
suture lift. Undermining the skin with scissors
or 16/18-gauge needle is not necessary. The
results are excellent and long-term follow-up
shows persistence of results. Therefore, it is
immaterial if the needle is passed through carti-
lage or periosteum of the nasal bone. In either
a
b
Fig. 58.5 ( a ) Preoperative male patient. ( b ) Five years postoperative after suture nasal tip lift

842
H.A. Khawaja and M.A. Shiffman
case, the lift remains stable. Postoperatively,
fi brosis around the knots and tracts takes place.
The fi brosis and the knots at the nasal tip pre-
vent depressor septi muscle regeneration, while
fi brosis and scarring in the needle tracts, in the
cartilage, and in the periosteum of nasal bone
are factors which provide stability to the lift.
The amount of lift that has to be provided
depends on the desires of the patient, shape of
the nasal tip, and experience of the surgeon.
However, it is best to keep the lift mild to mod-
erate in order to prevent elongated nasal vesti-
bules, transverse wrinkles on the nasal dorsum,
and an ape-nose deformity. In the rare event of
patient being dissatis fi ed, the procedure can be
repeated or revised easily.
a
b
Fig. 58.6 ( a ) Preoperative female patient. ( b ) Postoperative after suture nasal tip lift

843
58 Suture Nasal Tip Lift
Conclusions
Suture nasal tip lift is a very simple noninva-
sive technique of lifting the nasal tip. It has
practically no complications, and satisfaction
rate of the patients is very high. It can be
repeated or revised very easily.
Acknowledgement
I (the author HAK) am grateful to
my daughter Zahra Hassan for having contributed the
computer-generated diagrams for this chapter.
Speci fi c thanks to Seung Jung, Son (Gemma), B.A., for
the magni fi cent illustrations.
References
1. Owsley TG, Taylor CO (1994) The use of Gore-Tex for
nasal augmentation: a retrospective analysis of 106
patients. Plast Reconstr Surg 94(2):241–247
2. Brown BL, Neel HB, Kern EB (1979) Implants of
supramid, proplast, plast-pore and silastic. Arch
Otolaryngol 105(10):605–609
3. Carruthers J, Carruthers A (1992) Treatment of glabel-
lar frown lines with C botulinum 1 A exotoxin.
J Dermatol Surg Oncol 18(1):17–21
4. Conley J, Baker DC (1979) Thread augmentation for
facial rhytides. Ann Plast Surg 32(2):118–126
5. Zarem HA (2002) Brow suspension, a minimally inva-
sive technique in facial rejuvenation. Discussion. Plast
Reconstr Surg 109(7):2533
6. Barton EE Jr, Kenkel JM (1997) Direct fi xation of the
malar pad. Aesthetic Plast Surg 21:239
7. Fournier PF (2002) Thread facelift. In: Meso-American
Academy of cosmetic surgery meeting, San Salvador,
May 2002
8. Shiffman MA, Mirrafati SJ, Lam SM (2008) Simpli fi ed
facial rejuvenation, 1st edn. Springer, Berlin, pp
321–324
9. Hernandez-Perez E, Hernandez-Perez JE, Khawaja
HA (2008) Transcutaneous lifting of the nose. Cosmet
Dermatol 21(10):547–550

845
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_59, © Springer-Verlag Berlin Heidelberg 2013
59
59.1
Introduction
Reduction of the overprojected nasal tip is usu-
ally accomplished with maintenance of the
majority of the existing tip structure, with the
cartilage reduction primarily done laterally on
the ala through vertical division, resection, and
reapproximation or overlap. This is the standard,
low-risk approach that is usually successful with
good results [ 1 ] . However, these traditional sur-
gical maneuvers are not always effective in rec-
reating the natural shape of the nasal tip when
dealing with a pinched or pointed tip. The author
has devised a simple technique that decreases
the tip projection and most importantly creates
the natural bowing of the alar arch. The tech-
nique was fi rst developed and introduced
20 years ago and has since been re fi ned through
the execution of many rhinoplasties. It has
proven to be reliable and improves the predict-
ability of the reshaping and reduction of the tip.
59.2
Surgical Technique
The procedure is performed with an endonasal
approach. The dorsum is reduced fi rst. Medial
and lateral osteotomies and then infracture of the
bones are performed by any method. When a sat-
isfactory bony pyramid has been obtained, the
attention is focused on the tip. A rim incision
through the mucosa along the inferior border of
the alar cartilage is made, and the alar cartilage is
carefully dissected away from the skin including
the dome. It is then possible to deliver the alar
cartilage still attached medially and laterally at
its posterior extremities and with its lining lumi-
nal mucosa. A forceps is then used to spread out
the alar cartilage so it can be examined (Fig. 59.1 ).
The next step is crucial as many vertical parallel
incisions on the medial, middle, and lateral crura
are going to be made about 1.5 mm apart
(Fig. 59.2 ). Alternate spicules of cartilage can
then be excised, signi fi cantly reducing the acute
angle and the length of the arc of the cartilage
(Fig. 59.3 ). After the alternate cartilage spicules
have been excised, the result looks just like a
palisade fence (Fig. 59.4 ). The spaces between
the remaining spicules should be quite small and
uniform to avoid later irregularities. When the
forceps is removed, the perichondrium and the
lining mucosa contract so the cut ends of the car-
tilage all line up again. It is very important to
excise the redundant spicules very carefully to
leave the perichondrium and mucosa intact.
The alar cartilage is then returned into the tip,
and the same procedure is done on the other side.
Resection of Strips of Alar
Cartilages for the Dif fi cult
Projected Tip with Thin Skin
Abder-Rahman Mounir and Edward Latimer-Sayer
A. -R. Mounir , M.D., M.Sc. (*)
31 Sandiway Road , WA14 1HU Altrincham , UK
Cosmetic Plastic Surgeon, Abbey Pines Hospital ,
192 Altrincham Road, WA14 1HU Altrincham , UK
e-mail: cosmetic@london.com
E. Latimer-Sayer , B.Sc., M.B.B.S., FRCS
Cosmetic Plastic Surgeon, Highgate Private Hospital ,
17 View Road , London N6 4DJ , UK
e-mail: edward@latimer-sayer.co.uk

846
A.-R. Mounir and E. Latimer-Sayer
Signi fi cant asymmetries and distortions are easy
to correct by taking more spicules from the larger
side. It is important to remember that it is not the
spicules that are excised that produce the result,
but the spicules that are left behind. The overlap-
ping inferior triangle of the upper lateral cartilage
is then trimmed and the caudal edge of the sep-
tum excised as necessary to elevate the tip. Tip
elevation needs to be slightly overcorrected to
allow for tip descent due to gravity.
The membranous septum is then sutured to the
caudal edge of the septal cartilage using a mini-
mal number of sutures, and the upper edge of the
alar cartilage mucosa is sutured to the inferior tri-
angle of the upper lateral cartilage using a single
suture each side. It is not necessary to suture the
rim incision as skin apposition will be maintained
by the packing, and rim sutures tend to produce
alar notching. The external nares are then packed
with paraf fi n gauze. This packing is vital and
needs to be carefully done so the alar cartilages
are held against the external skin. At this point,
the alar cartilages are soft and will take up what-
ever shape they are allowed to. Steri-Strips are
applied to the dorsum stopping just above the tip,
and a single Steri-Strip is applied under the dome
and in the nasolabial angle. A splint is applied
over the dorsum so that its lower edge stops just
above the dome. The nasal packing is removed
the following morning before the patient is dis-
charged. The splint needs to remain in place for
10 days. During the months of recovery before the
fi nal result is seen, the patients are encouraged to
Fig. 59.1 Delivery technique to expose the alar cartilage
Fig. 59.2 Multiple transverse incisions after removing
the cephalic portion of the alar cartilage
Fig. 59.3 Decrease in projection and reshaping of the alar
cartilage by removing some spicules in alternate fashion
Fig. 59.4 End result is a palisade-shaped alar cartilage
(note the space between the spicules)

847
59 Resection of Strips of Alar Cartilages for the Dif fi cult Projected Tip with Thin Skin
massage and manipulate the nasal skin for a few
minutes twice a day. The just operated on alar
cartilage is very malleable and conforms to the
dressing, which is one of the reasons one should
insist on it being left in place for 10 days.
59.3
Complications
Quite often during the recovery period of several
months unequal scarring occurs so that one side
may become bulkier than the other. This either
settles with time or can be treated with small
injections of triamcinolone. Patients are carefully
instructed to massage and manipulate their nose
during the recovery period. Alar notching is a
rare problem and is often a late complication.
Since the use of this technique, fi ve patients
needed surgical correction because of notching.
Dorsal irregularities such as pollybeak deformity
did occur occasionally, but this is not a feature of
this tip. Stuffy nose after the operation is quite
common, due to the signi fi cant reduction in the
nasal volume postoperatively. It usually clears in
a few months.
The classic Goldman vertical dome division
(VDD) technique [ 2 ] tends to work well in patients
with thicker skin. However, vertical dome divi-
sion may result in a narrow, pinched tip in patients
with thin skin. Goldman’s intention was to avoid
an “unduly pointed nasal tip.” The original tech-
nique is highly focused on manipulation and repo-
sitioning on only the medial crura, with no attempt
to reconstruct the remaining lateral crural segment
and alar rim. Postoperatively, the medial crura and
columella are suf fi ciently stable to resist loss of
projection. Some loss of lateral support that could
result in lateral wall collapse and alar retraction
may occur. VDD is also associated with boss for-
mation. This is most frequently seen in patients
with thin skin and fi rm cartilages. Disruption of
the underlying vestibular mucosa and skin, such
as the Goldman technique, also predisposes the
patient to possible stenosis. Beyond the major
risks, other complications associated with VDD
include inadequate projection and rotation, infra-
tip lobule irregularities, nasal tip asymmetry, and
boss formation. With use of newer modi fi ed
techniques and caution, VDD can be used suc-
cessfully in nasal tip re fi nement with limited post-
operative complications and reliable long-term
results.
59.4
Discussion
Primarily this technique has been adapted to
facilitate the projection reduction of the tip.
However, it has been proven to be an excellent
method for reshaping the elongated pointed or
pinched tip. It is our contention that it is a myth
that the continuity of the alar cartilage must not
be interrupted. This is due to the belief that in the
long term, the transected alar cartilage will show
through the skin and produce an unacceptable
result. Because of that, it has been recommended
to always reconstruct the continuity of the alar
rim.
In the overprojecting pinched tip with thin
skin, if partial “multiple” excisions have been
made equally and symmetrically, cutting through
the pinched cartilage, the spring is released allow-
ing restoration of a more normal contour of the
tip. If the alar cartilage is transected many times,
by about eight or more parallel incisions about
1.5–2 mm apart, the cut ends do not show through
the skin. This is because none of the possible pro-
jecting pieces of cartilage can be more than a mil-
limeter or so long and the support of each spicule
is not strong enough to allow any of them to proj-
ect above the level of the others. However, care
should be taken to excise the same number of
spicules of the alar cartilage in alternate fashion
on each side and so both medial and lateral crura
are equally shortened. Indeed, it is agreed that
when all three legs of the tripod are equally
reduced [ 3 ] , there is no change in the rotation. If
there is asymmetry of the domes, the excision of
spicules can be done unequally. The idea is to cre-
ate a Macdonald’s “M” of good proportions.
Nevertheless, this technique opposes Conrad’s [ 1 ]
and Sa fi an’s [ 4 ] view that “redundant” vestibule is
inelastic, and that it might stick to the undersur-
face of the skin and prevents the edges of the car-
tilages from approaching each other thus giving
rise to the pinched and indented tip. The authors

848
A.-R. Mounir and E. Latimer-Sayer
fi nd that these structures contract very well and a
dramatic shortening is observed at operation.
Smith [ 5 ] suggested that the preservation of
perichondrium and mucosa is paramount to sup-
port the cartilage and to prevent dislocation. The
combination of multiple incisions and the exci-
sion of some spicules will break the intrinsic
“spring” forces of the alar cartilage and make
them easy to reshape. The skin envelope will
adhere like a biological cast over the altered tip
framework and makes the surgical changes per-
manent. In the presence of thin skin, the retrac-
tion of the soft tissue envelope is excellent and
usually no alar base and/or columellar skin
excision is needed. It is important to stress that
this technique works mainly for Caucasian noses
presenting a thin skin (Fitzpatrick type one or
two).
Usually, the integrity of the alar cartilage is
restored and any signs of the transverse incisions
disappear after 1 year. This has been con fi rmed in
those few cases when revision of the tip was nec-
essary. This goes also with Kaiser’s [ 6 ] fi ndings,
where they suggested that after submucosal
resection of the human nasal septum, it might be
possible for new cartilage tissue to develop pro-
vided the mucosa is well approximated.
In regard to functionality, the resulting conse-
quences are similar to any rhinoplasty technique. In
terms of the patient satisfaction in the authors’
series of patients, over 70% were secondary rhino-
plasties. There was a revision rate of 5%. This tech-
nique provides most patients with long-standing
satisfaction. In terms of secondary rhinoplasty
patients, 75% experienced a signi fi cant improve-
ment in nasal performance by revision rhinoplasty.
Fig. 59.5 ( a ) Preoperative 27-year-old female with a narrow angle of divergence and overprojecting tip. ( b ) Seventy
six days following removal of three spicules from each side of the alar cartilage. Note lowering of the dorsum
a
b

849
59 Resection of Strips of Alar Cartilages for the Dif fi cult Projected Tip with Thin Skin
The technique has its limitations. In those
patients who have thick, bulky skin, it thickens it
further. Also, the tip does tend to take on a rounded
shape.
Conclusions
Different surgical approaches are available
when it comes to reduce the projection of the tip,
but few methods are available to reshape of
the pinched and pointed tip. Presently, the
general tendency is to use cartilage grafting
when available. It has been proven to be an
excellent tool when the skin is not too thin and
so the skin does not present a challenge in
term of graft visibility. Removing spicules of
alar cartilage to correct the cosmetic pathol-
ogy is a technique to be seen as one of a myr-
iad of techniques to manage the severe pointed
tip. The procedure is recommended as a rela-
tively simple technique, and long-term results
are predictable and acceptable aesthetically
(Figs. 59.5 , 59.6 , 59.7 , and 59.8 ).
a
Fig. 59.6 ( a ) Preoperative after prior rhinoplasty. Patient was left with pinched and overprojecting tip. ( b ) Twenty
three months postoperative after three spicules have been removed from each dome

850
A.-R. Mounir and E. Latimer-Sayer
b
Fig. 59.6 (continued)

851
59 Resection of Strips of Alar Cartilages for the Dif fi cult Projected Tip with Thin Skin
Fig. 59.7 ( a ) Preoperative after prior rhinoplasty leaving the patient with overprojecting and pinched tip.
( b ) Four weeks postoperatively following removal of three spicules from each dome
b
a

852
A.-R. Mounir and E. Latimer-Sayer
References
1. Conrad K (1981) Nasal tip reduction – predictable part
of rhinoplasty. J Otolaryngol 10(6):420–432
2. Rich JS, Friedman WH, Pearlman SJ (1991) The effects
of lower lateral cartilage excision on nasal tip projec-
tion. Arch Otolaryngol Head Neck Surg 117(1):56–59
3. Close LG, Schaefer SD, Schultz BA (1987) The over-
projecting nasal tip: precise reduction without rotation.
Laryngoscope 97(8 Pt 1):931–936
4. Sa fi an J (1970) The split-cartilage tip technique of
rhinoplasty. Plast Reconstr Surg 45(3):217–220
5. Smith TW (1978) Reliable methods of tip reduction.
Arch Otolaryngol 104(10):564–569
6. Kaiser ML, Karam AM, Sepehr A, Wong H, Liaw LH,
Vokes DE, Wong BJ (2006) Cartilage regeneration
in the rabbit nasal septum. Laryngoscope 116(10):
1730–1734
a
b
Fig. 59.8 ( a ) Preoperative after prior rhinoplasty leaving the patient with overprojecting and pinched tip. ( b ) Three
weeks postoperatively following removal of three spicules from each dome

853
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_60, © Springer-Verlag Berlin Heidelberg 2013
60
60.1
Introduction
Creating a balanced and aesthetically pleasing
nasal tip is one of the most challenging and unpre-
dictable aspects of primary rhinoplasty. However,
as with all successful rhinoplasty, accurate preop-
erative analysis and planning is critical. In reality,
the complex and dynamic interactions that occur
between the tip structures, dorsum, and overly-
ing soft tissues change constantly throughout the
operation [ 1– 7 ] . Therefore, measurements and
other objective preoperative evaluations should
be used as a guide and general “road map,” rather
than the de fi nitive recipe in fi nesse tip shape
[ 2, 4, 6 ] . Preoperatively, it is more important to
realize and document the potential morphologi-
cal pitfalls that may present intraoperatively. For
example, soft triangle facets that are profound
may warrant both specialized grafting before clo-
sure and less tip projection than dictated by the
preoperative views alone. In this chapter, we will
focus on actual “tip shaping” unto itself and not
so much tip projection or tip rotation. While tip
contour is intimately connected to both position/
projection, a pleasing tip shape can be judged
in isolation and broken down into its individual
components. However, a comprehensive discus-
sion on nasal tip contouring mandates attention
to its shape, projection, position, as well as its
relation to other nasal structures.
Tip shape is best viewed on the frontal and
basal views, while projection/position is best
seen on lateral and basal views. The presence of
domal asymmetry, speci fi c tip morphology (boxy
or bulbous tip), degree of nostril show, columel-
lar excess, caudal septal excess/insuf fi ciency, and
a plunging (static) or hyperdynamic tip (ani-
mated) are noted. Animated views should be
attained to diagnose depressor septi nasi hyperac-
tivity resulting in nasal tip ptosis.
A comprehensive naso-facial analysis is
always the starting point and establishing a nose-
lip-chin plane (NLCP) with ideal chin projection
(in females) is de fi ned as 3 mm posterior to a
plumb line drawn perpendicular to the natural
horizontal Frankfort plane (Fig. 60.1 ) [ 2, 4, 6 ] .
Tip projection is best assessed on the lateral view
and is determined by the amount of tip volume
that rests anterior to a vertical line drawn adja-
cent to the most projecting part of the upper lip.
Fifty to sixty percent of the tip should lie anterior
to this vertical line (Fig. 60.2 ) [ 2 ] . If less than
50% of the tip projects anterior to this reference
line, the tip lacks proper projection. Tip projec-
tion can also be measured as 0.67 times the ideal
nasal length (Fig. 60.2 ).
Tip Shaping in Primary Rhinoplasty
Ashkan Ghavami
A. Ghavami, M.D.
Ghavami Plastic Surgery, UCLA David Geffen School of
Medicine, Los Angeles, CA , USA
433 N. Camden Drive, Suite 780,
Beverly Hills, CA 90210, USA
e-mail: ashghavami@yahoo.com

854
A. Ghavami
Natural
horizontal
Frankfort
plane
3 mm
Fig. 60.1 Nose-lip-chin relationship [ 48 ]
a
b
Fig. 60.2 ( a ) Tip projection assessed. At least 50% of the tip should be anterior to the vertical reference line. ( b ) Tip
projection is 0.67 of the nasal length [ 48 ]

855
60 Tip Shaping in Primary Rhinoplasty
Nasolabial angle and alar-columellar balance
should be evaluated using established criteria.
Keep in mind that maneuvers that increase tip
projection usually affect the nasolabial and colu-
mellar-labial angles. After comprehensive naso-
facial analysis, surgical goals are noted, the plan
is reviewed with the patient, all questions are
answered, and informed consent is obtained.
60.2
Skin and Soft Tissue
The overlying skin envelope needs to be assessed
before attempts at tip shaping. It is no use to per-
form a myriad of complex tip-shaping maneuvers
and hide it all under a thick “blanket” of skin.
Similarly, if signi fi cant tip re fi nement is required,
the author does not recommend a closed (endo-
nasal) approach [ 8, 9 ] . There are regions of nasal
skin and soft tissue that can be selectively (and
safely) defatted or debulked to allow for underly-
ing structures to become more conspicuous where
desired. The nasal tip blood supply and structural
supports of tip strength should be understood
[ 10– 12 ] . Furthermore, the soft tissue can also be
augmented or left thicker in areas that may not
need to be as visible. Temporal fascia and
Alloderm TM (LifeCell Corp., Branchburg, NJ) are
both effective materials that can be used for soft
tissue envelope augmentation.
Debulking the soft tissue is indicated in thick-
skinned noses, typically “ethnic” noses [ 13– 16 ] .
It is important to not simply defat the entire tip
envelope but to be selective and safe. Safety ema-
nates from preservation of the subdermal plexus.
There should remain a thick uniform “cobble-
stone” appearance to the soft tissue left behind
after debulking the tip skin. The author has never
had any tip necrosis or skin loss issues because of
strict adherence to this principle. During preop-
erative analysis, the nasal tip should be massaged
and palpated to evaluate the inherent strength of
the cartilages that comprise the tip complex and
to appraise tip skin thickness. The surgeon should
anticipate what changes may occur in the soft tis-
sue coverage during tip shaping. For example,
will the tip skin be thick or just right in the sup-
ratip after the caudal-dorsal septum is reduced
and a cephalic trim is performed? During the
rhinoplasty, this area can be debulked, quilting/
tacking sutures placed (5-0 Chromic gut), or it
may require crushed cartilage or fascia augmen-
tation to avoid a sharp step-off.
The domes can be made to be more projecting
and visible with a combination of “visible” onlay
grafts and selective soft tissue thinning at their
apices. Debulking is performed by exposing the
underlying skin surface and using curved scissors
to meticulously trim away the looser, areolar
fi brofatty tissue. It is important to perform all
skin soft tissue alterations after completion of
structural tip-shaping maneuvers. Occasionally,
some camou fl age grafts may be necessary to
place underneath the “new” skin envelope to
achieve overall nasal balance. These grafts can
consist of crushed cartilage, cephalic trim rem-
nants, Alloderm TM (LifeCell Corp., Branchburg,
NJ), and/or temporal fascia. It is also important to
leave behind thicker soft tissue in areas that need
volume. For example, the infratip region may
need an infratip shield graft to create proper vol-
ume and infratip breakpoints.
Lastly, a harmonious transition from the dor-
sum to the tip is necessary to allow the new tip
contour to blend and not appear “segmentalized”
from other nasal components. The author prefers
temporal fascia to cover the dorsum and tip in
thick-skinned patients so that harsh edges of car-
tilage do not become undesirably visible long
term. Alloderm TM (LifeCell Corp., Branchburg,
NJ) can also be used (on the dorsum and suptra-
tip) and tends to add more thickness than fascia
but may not be suitable for the tip complex
itself.
60.3
Dorsum/Septum/Tip Balance
Shaping the tip requires that its dynamic relation-
ship to the other nasal segments is also balanced
[ 17, 18 ] . It would be a grave error to create a
beautiful tip and then have a dorsum that is too
high caudally or a septum that is excessively long
or short. Prior to implementing fi nal tip-shaping
techniques, appropriate dorsal aesthetic lines,
dorsal height (reduction or augmentation), and

856
A. Ghavami
caudal length must be established and stabilized.
This sets the stage for tip complex projection,
position, and shape.
Numerous pitfalls to tip shaping are present
that have nothing to do with the inherent struc-
tures of the tip cartilages but rather the relation-
ship of these components to the adjacent nasal
regions (Table 60.1 ) [ 18 ] . For example, if the cau-
dal septum is left too long, then the infratip vol-
ume and columella will be excessively protuberant.
This detracts from tip re fi nement efforts since
attention is now drawn to the hanging columella.
Alar width and sill excess, or lack thereof, can
also make the nasal tip appear too narrow or too
wide, respectively. After tip shaping has been
accomplished, the fi nal maneuvers should be
directed at alar bulkiness ( fl aring) or increased
interalar distance (excess sill). Increased interalar
distance requires sill excision, while excess fl are
indicates “Weir-type” wedge excisions. Once the
relationships between the dorsum, alae, and sep-
tum have been established, then fi nal tip shape
can be assessed. This is a good point in the proce-
dure to add to or subtract (less common) from the
tip to further soften subtle tip contours such as in
the region of the soft triangle.
60.4
Tip Projection and Position
The position of the nasal tip relative to the dorsal
and caudal septum is the foundation for tip shap-
ing. The tip needs to be in proportion to the nose
and face before tip contour can be realized. Tip
shape and projection are closely related [ 17, 19– 23 ] .
Table 60.2 lists the effects of various interven-
tions on tip shaping and tip projection.
Septal modi fi cations need to be made fi rst
with respect to height and length [ 24 ] . For exam-
ple, if the nose is too long, caudal septal resection
and other tip elevation maneuvers must be made
before the subtleties of nasal tip shape can be
altered. This decreases the risk of judgment errors
on tip contour modi fi cations. As an example, if
the tip is not properly projected and positioned
relative to the dorsum, then transdomal sutures
and/or onlay dome grafts may not be required. If
they are indicated, they can be more subtle (i.e.,
less knot force or less bite distance). Tip shape
can be addressed after the dorsum has been
reduced or augmented and the septum shortened
or lengthened. Figure 60.3 depicts a useful algo-
rithmic guide in shaping the nasal tip, once the
position has been set.
Table 60.1 Pitfalls in tip shaping-external
Cause
Result
Dorsum height excess
Poor supratip break/illusion of insuf fi cient projection
Dorsal height too shallow
Excess/sharp supratip break/illusion of excess domal projection
Caudal (septal) excess
Caudal shift of tip point(s)/elongated tip appearance
Caudal (septal) retraction
Plunging caudal tip point(s)
Alar/sill excess
Tip appears too narrow
Excessive alar/sill reduction
Tip appears too wide/bulky
Note : The above causalities imply that the tip itself has been shaped appropriately and the remaining structures were
poorly addressed or not addressed
Table 60.2 Techniques that affect tip re fi nement and
projection
Technique
Tip shaping
Tip
projection
Dorsal reduction
+
↑
Caudal septal reduction
+/−
↑/↓
Cephalic trim
+
↓
Columellar strut
+
↑
Septal extension graft
+
↑
Medial crura suture
+
↑/↓
Transdomal suture
+
↑
Interdomal suture
+/−
↑/↓
Medial crura septal suture +
↑/↓
Alar base resection
+/−
↓
Dome onlay grafts
+
↑
(+) Signi fi es a positive/bene fi cial effect on tip shaping
(−) Signi fi es a negative effect or blunting of tip contouring
efforts
(+/−) Denotes either a bene fi cial or detrimental effect on
tip shaping

857
60 Tip Shaping in Primary Rhinoplasty
A columellar strut graft is essential in sta-
bilizing the tip complex when the native crura
are not stout enough. Intraoperative palpation
of tip strength and observed tip projection dic-
tates its necessity. The strut should be invisible
and strengthen the medial crural contribution to
tripod stability. It is approximately 4 × 25 mm
in size, but its size should be customized based
on need. If there is a paucity of donor cartilage,
the strut can be positioned to “ fl oat” even fur-
ther away from the nasal spine. “Fixed” struts
are rarely indicated in primary rhinoplasty.
The medial crura are secured to the strut graft
with 5-0 clear polydioxanone (PDS) horizon-
tal mattress sutures. A fl oating columellar strut
graft can provide 1–3 mm of additional tip
projection.
Tip projection and position should be assessed
according to standard methods but also require
continual intraoperative reinspection. As stated
earlier, nasal shape is dynamic and morphs
throughout the operative sequence, as each and
every technique is implemented. Preoperative
plans are often modi fi ed. Nevertheless, proper
preoperative evaluation should dictate the basic
maneuvers necessary with relation to the dorsal
height, tip projection, and amount of tip rota-
tion required. These signi fi cant modi fi cations
should be made followed by fi nesse and fi nal tip
contouring.
Intrinsic tip shaping begins with assessment
of the nasal tripod (lower lateral crura and
medial crura) with respect to the length/width
of its components. Any changes in length and
width should be made fi rst. Most commonly, in
long noses with plunging tips, the lower lateral
crura (LLC) may require transection and over-
lap with repositioning (Fig. 60.4 ). The orientation
Assessment of tip projection/refinement and
nostril/tip/balance
Normal tip projection
No operative intervenation
Lateral crural malposition
• Lateral crural strut graft
• Alar contour graft
Inadequate tip projection/refinement
Cephalic trim
Invisible/nonpalpable techniques
• Intercrural columellar strut
• Septal extension graft
Medial crural suture
Transdomal suture
Interdomal suture
Medial crural septal suture
Complete
Adequate
Reassess tip
Projection/refinement (Intraop)
and
nostril/tip/balance
Inadequate
Visible/palpable techniques
(If inadequate tip projection
and/or refinement)
and/or
Nostril shaping techniques
(If nostril/tip/imbalance)
Tip grafts*
• Analytical (0.67xideal nasal lenth)
• Aesthetic (50−60% anterior to upper lip vertical)
• Aesthetic nostril/tip/ratio (2:1)
Fig. 60.3 Tip-shaping algorithm (Modi fi ed with permission from Ghavami et al. [ 17 ] )

858
A. Ghavami
of the lower lateral crura is also critical. One
side inevitably tends to collapse more than the
other after the scroll area has been disrupted
from cephalic resection. Dissection of the liga-
mentous attachments of the nasal tip complex
can result in both de-projection and migration
of the individual crura. For example, the caudal
edge of one or both of the lower lateral crura
can migrate posteriorly, which creates a more
vertical orientation in the LLC. This can cause
external valve collapse and further weakening
of alar arch support after tip sutures are placed.
Tip-shaping sutures can produce distraction
forces on the LLC, and LLC strengthening with
struts and/or LLC turnover fl aps may become
necessary. Tip sutures should not be placed
dogmatically or routinely.
The LLCs should also be assessed for any
asymmetries and contour abnormalities [ 25 ] . The
magnitude of the convexity/concavity, length/
width dimensions, and position and symmetry of
the LLC and medial crura are all noted. The
medial crura must also be of appropriate length
and be stable. Short and/or weak medial crura
can result in poor tip shaping if the differential
between dorsal septal height and domal height is
reduced over time. Once again, the key is that
effective tip shaping is not possible if the indi-
vidual components of the tip complex are faulty
and not addressed primarily.
60.5
Domes
The domes of the nasal tip have been overly
simpli fi ed in previous literature. Complex inter-
actions can present themselves during tip shaping
and can be a challenge to simple maneuvers such
as tip-shaping sutures [ 17, 25 ] . The middle crura
represent the actual domal region and are impor-
tant, but dome de fi nition begins with resizing of
the lower lateral and middle cartilages. The only
excisional technique used should be that of
cephalic trimming to treat excess with that of the
LLC and to aid in their reorientation. Cephalic
trimming should always be conservative, and
preservation of more than the standard 6 mm rim
strip may be indicated. The lower lateral turnover
fl ap is an elegant way to improve LLC strength
and correct unwanted convexity and concavity
(Fig. 60.5 ) [ 26 ] . If the LLC are weak or malposi-
tioned, then middle crural shaping (dome) will
worsen outcomes. For example, placing trans-
domal and/or interdomal sutures can medialize
the LLC and buckle them. This can set the stage
for alar retraction and external valve collapse.
Transdomal and interdomal sutures are effec-
tive methods and are commonly used to re fi ne
bulbous/boxy tips [ 17, 27– 39 ] . Placement of these
sutures needs to be meticulous. Unsatisfactory
“pulling” and dynamic forces from each suture
on the remaining cartilages should be continu-
ally evaluated. There should be no hesitation
to remove and re-suture to alter the vectors of
pull. A common undesired effect is that of alar
retraction and exaggeration of soft triangle facet-
ing when transdomal sutures span too great a
distance, are pulled too tight, and/or are placed
with a cephalically oriented vector. Tip sutures
are the basic tenets in nondestructive and invis-
ible tip-shaping techniques. Refer to the algo-
rithm (Fig. 60.3 ) for the recommended sequence
in tip-shaping methods. After the tip complex is
stabilized and positioned, the LLC and medial
crural length is treated, then direct re fi nement
in intrinsic tip shape can commence. This starts
with the cephalic trim (or an LLC turnover fl ap),
continues with tip suturing techniques, and ends
with customized tip graft placement [ 17 ] .
Fig. 60.4 In long noses with plunging tips, the lower lateral
crura ( LLC ) may require transection and overlap with
repositioning

859
60 Tip Shaping in Primary Rhinoplasty
60.6
Medial Crural Suture
Medial crural sutures are the fi rst tip sutures placed
[ 17, 27, 33, 37– 39 ] . They are used in isolation to
correct medial crural asymmetries, reduce fl aring,
and control the overall volume of the columella.
Flaring is controlled by posterior placement of
medical crural mattress sutures along with inter-
crural soft tissue removal. Usually, medial crural
sutures are placed in the middle third and secured
to a columellar strut. Twenty- fi ve-gauge needle
fi xation aids in securing struts while sutures are
placed. Securing and repositioning the medial
crura to the columellar strut and/or caudal septum
can increase tip projection and con fi rm tip com-
plex stability (Fig. 60.6 ). This now establishes a
stout tip complex base which provides for more
control in further tip re fi nement.
60.7
Transdomal Suture
The transdomal suture is the most complicated
suture to place. Its effects can be subtle or
signi fi cant depending on the style of placement
[ 17, 27– 39 ] . This is a horizontal mattress suture
a
b
Fig. 60.5 ( a , b ) The lower lateral turnover fl ap to improve LLC strength and correct unwanted convexity and concavity
Fig. 60.6 Medial crural-columellar suture [ 48 ]

860
A. Ghavami
placed through the lateral and medial aspects of
the middle crura (domes) (Fig. 60.7 ). If the suture
bites are placed further away from the domal
apex, there will be more LLC recruitment and a
sharper lateral genu drop off. This may be desir-
able in some situations such as with thick-skinned
ethnic noses. Exaggerated and more aggressive
techniques can be employed with thicker skin
envelopes. However, the surgeon should keep in
mind that often the cartilages in these patients are
inherently weak. Therefore, struts and grafts are
generously required.
The vector of pull is important when placing
and tightening the transdomal suture. Caudal or
cephalad placement of the suture will rotate the
lateral crura, respectively. While the tip can be
projected incrementally with transdomal sutur-
ing, care must be taken to not create untoward
effects such as alar retraction and soft triangle
distortion. Transdomal sutures create a nice plat-
form for onlay tip grafts to rest upon. If onlay tip
grafts are to be used, the actual domal shape cre-
ated by the transdomal technique becomes essen-
tially negligible since the onlay graft becomes the
dominating structure visible.
60.8
Interdomal Suture
An interdomal suture is a horizontal mattress
suture placed between the domes (Fig. 60.8 )
[ 17, 27– 29, 32– 39 ] . Transdomal sutures are
almost always placed before interdomal sutures
are placed [ 17 ] . The two work together in a syner-
gistic manner and can decrease the interdomal
angle (angle of divergence) but can also decrease
tip projection by fl attening the middle crura from
their force of pull. Tying together the long suture
ends of two transdomal sutures is a common and
simpli fi ed method of interdomal suture place-
ment. The author does not prefer this approach
because differential and individual placement
allows for better symmetry in dome height and
position.
Interdomal sutures serve to narrow the angle
of domal divergence, medialize the tip-de fi ning
points, and increase or decrease tip projection. It
is important to avoid tip uni fi cation. Separate
domal units must be present for aesthetic tip
shaping. Lastly, interdomal sutures should be
placed slightly posterior to the domes in most
situations. This provides some separation of the
domal apices.
60.9
Medial Crural-Septal Suture
The most common medial crural suture exists
along with a columellar strut [ 17, 27– 29, 32– 39 ] .
However, if the medial crura are stout and strong,
then medial crural sutures can be used in isola-
tion to create a strong bilaminar leg to the nasal
tip tripod. If tip rotation, columella-labial angle
modi fi cations, columellar elevation, and/or infra-
tip repositioning is indicated, medial crural-septal
sutures can be placed (Fig. 60.6 ). This modi fi cation
Fig. 60.7 Transdomal suture [ 48 ]

861
60 Tip Shaping in Primary Rhinoplasty
secures the medial crura to the caudal septum and
can increase or decrease nasal tip position. For
example, if the medial crura are secured to an
anterior position on the caudal septum, the tip
will rotate in a cephalad direction and tip projec-
tion increases. This suture should never be
secured too tightly and can be placed as a “span-
ning” suture. Desired effects can be temporary
(during initial healing phases) or more permanent
if a nylon or Prolene suture is used.
The author rarely uses the septal modi fi cation
of this suture. However, a strong indication for
the medial crural-septal suture is that of a severely
droopy tip. Regardless of what suture is used, it is
unknown actually how long this suture itself
holds the medial crura and columella up against
the caudal septum. Nasal lining resection is a
useful adjunct to raising the tip or columella and
adds immensely to the longevity of the medial
crural-septal suture effect.
60.10 Grafts
Rather than belabor on the numerous types and
shapes of grafts described, the most useful and
commonly used types are described. Onlay tip
grafts and infratip grafts are the most common
“workhorses” indicated in fi nal tip shaping [ 17,
23 ] . It is important that the grafts are of the appro-
priate thickness and beveled or crushed at their
edges. Unsightly graft edges that start to reveal
themselves in the fi nal stages of healing are an
easily avoided indication for revision surgery. If
the domal segments and native tip complex struc-
tures lend to smooth and aesthetic breakpoints
and tip contour, then grafting is not indicated.
More often than not, tip-shaping sutures are not
enough unto themselves in creating optimal tip
shape and projection.
An onlay tip graft shaped like “sunglasses” or
an in fi nity symbol is very useful for enhancing
domal shape and tip-de fi ning points. These grafts
can also increase tip projection to a small or
greater degree, dependent on the thickness of the
graft. It is not uncommon to have to soften the
lateral edges with a “Ruben” crusher or to bevel
edges using a #10 blade. The author secures all
grafts with 5-0 PDS at multiple points to avoid
graft migration, rotation, or buckling. Once the
graft is secured, then the skin is redraped to assess
the need for further contour grafting. The combi-
nation of an onlay dome graft and an infratip
“shield” graft is very common and can create a
nice harmonious transition from the columella/
infratip to the domes and fi nally the supratip
breakpoint (Fig. 60.9 ).
Infratip shield or other types of grafts must not
be too wide. A widened columella is usually very
displeasing and can make the tip look heavy.
Infratip grafts are indicated when infratip volume
and projection are lacking or when infratip break-
points are dull and weak [ 23 ] . The infratip
Fig. 60.8 Interdomal suture [ 48 ]
Fig. 60.9 Combination of an onlay dome graft and an
infratip “shield” graft

862
A. Ghavami
breakpoint can be further exaggerated by scoring
the shield graft to its surface which allows it to bend
predictably right at the desired breakpoint. At the
tip, the graft can either abut the dome graft or native
domes at their apices, or it can project beyond this
point. In thick-skinned patients, more extensive and
aggressive techniques are indicated (Fig. 60.10 ).
One of these is that of thicker and more projecting
grafts. In these patients, there is less worry of sub-
sequent graft edges becoming too visible.
In addition to the LLC strut graft, the alar
contour graft was a signi fi cant contribution to
rhinoplasty [ 40, 41 ] . However, despite securing
of this graft with sutures or creation of a tight
soft tissue pocket along the rims, these can easily
move postoperatively. They are extremely useful
in preventing unwanted notching of the alae or
soft triangle region. When signi fi cant tip projec-
tion is created, these grafts help soften the transi-
tion from the nasal tip to the alar rims. Placing
them along the soft triangle can aid in preventing
soft triangle notching, but soft triangle grafts
may also be needed. The author feels it is critical
to suture these grafts at least two points to the
adjacent soft tissue; otherwise, migration and
displacement can occur. Subdomal grafts are
also fi nesse grafts that can help neutralize posi-
tion and shape of the domes when the domal
segments and LLC do not want to cooperate in
their position [ 42, 43 ] . They can be placed before
or after other strut grafts but are best placed
before dome sutures are placed.
Soft triangle grafts using remnant septal car-
tilage, crushed cartilage, and cephalic trim rem-
nants are important to prevent notching or sharp
contours/depressions in this region postopera-
tively. While they are not discussed often in the
literature, the author sees them as a vital aspect
of creating an aesthetic tip shape while main-
taining “softness” to the soft triangle. Inherently,
the soft triangle does not have a cartilage.
However, after rhinoplasty, the dynamics
change and regions next to the soft triangle can
overpower this inherently weak “skin-only” tri-
angular space. Securing custom-cut grafts to
this region before closure or placing crushed
cartilage remnants after closure in a pocket in
the region of the soft triangles is indicated when
a depression is noted. Rarely, some patients
who present with strong soft triangle facets pre-
operatively want them maintained. Therefore, it
is important to discuss this with the patient
before adding volume or camou fl aging of the
facets is undertaken. The soft triangle is directly
responsible for enhancing or detracting from
the proper nostril/tip balance [ 44, 45 ] .
a
b
Fig. 60.10 ( a , b ) In thick-skinned patients, more extensive and aggressive techniques are indicated

863
60 Tip Shaping in Primary Rhinoplasty
60.11 Depressor Septi Nasi Muscle
The depressor septi nasi muscle serves an impor-
tant role in tip shaping in that it can reduce tip
projection and the newly re fi ned tip element
[ 46, 47 ] . When the depressor muscle is overac-
tive, the nasal tip can be pulled caudal and pos-
terior. This splays and fl attens the domes and
tip highlight points. Resection of this muscle at
its location in between the medial crura and
domes is indicated when it is overactive and
detracts from tip shape. It can also be transected
and re-apposed behind the frenulum to improve
upper lip pout. Depressor hyperactivity is seen
most often in long droopy tips that appear lon-
ger upon animation. Often, its dynamic action
can be seen upon regular orbicularis oris mus-
cle animation during regular speech, especially
if the depressor is attached to the orbicularis
and not the periosteal surface of the nasal spine
or premaxilla.
60.12 Tip-Shaping Finesse
Once the foundation for tip shape has been set
with the above techniques, reevaluation of the tip
re fi nement, tip position/projection, soft tissue
envelope, and relation to other nasal segments is
performed. At this point, fi nal assessment of alar
base fl are and interalar distance can be made. If
indicated, the amount alar and/or sill resection is
marked and injected with local anesthetic con-
taining epinephrine. At this point, fi nal tip shape
must be optimized. It is helpful to perform a
washout and gently squeeze out residual blood
with the skin draped to see the true tip shape. Any
undesirable contours must be addressed prior to
skin and vestibule closure.
Common “last minute” fi nesse maneuvers
include but are not limited to soft triangle grafts,
soft triangle lining excision, crushed or cephalic
remnant grafting to paradomal regions (to create
soft transitions in the genus), and visible trim-
ming of graft edges [ 39, 44, 45 ] . If a graft edge
appears sharp and is not desired to be visible,
then it must be treated now. While these rough
transition points may not be noticeable during the
early healing phases, they may haunt you and the
patient over time. This is most troublesome in
thin-skinned patients. If necessary, temporal fas-
cia can be draped over speci fi c tip elements or
over the entire tip complex when a thin skin enve-
lope is unrelenting.
Final taping of the nasal skin must be precise
and is important in stabilizing the skin envelope
against the new tip constructs (Fig. 60.11 ).
a
b
Fig. 60.11 ( a , b ) Final taping of the nasal skin

864
A. Ghavami
Case 1 (Fig. 60.12 )
The patient required a component dorsal reduc-
tion, tip elevation, and projection, as well as
fi nesse tip shaping. Transdomal, interdomal, and
medical crural sutures were used without a colu-
mellar strut. An onlay “sunglass” graft was used
for the domes as well as a soft, crushed infratip
lobular shield graft to de fi ne the breakpoints.
a
b
Fig. 60.12 ( a ) Preoperative patient. ( b ) Postoperative
after component dorsal reduction, tip elevation and pro-
jection, and fi nesse tip shaping; transdomal, interdomal,
and medical crural sutures without a columellar strut, an
onlay “sunglass” graft for the domes, and a soft, crushed
infratip lobular shield graft to de fi ne the breakpoints
60.13 Cases

865
60 Tip Shaping in Primary Rhinoplasty
Case 2 (Fig. 60.13 )
a
b
Fig. 60.13 ( a ) Preoperative Armenian-Persian patient
who had a tip shape with soft triangle facets and a
strong dorsal hump with hyperdynamic tip ptosis. ( b )
Postoperative following soft triangle grafts used to off-
set the facets which otherwise would have been exag-
gerated with the narrowing and re fi nement of the tip; tip
suture methods along with an 8-mm component dorsal
reduction, caudal septal resection, spreader grafts, cor-
rection of her major alar malposition with release of
LLC attachments and placement of alar contour grafts,
and resection of depressor nasi septi muscle
This ethnic, Armenian-Persian patient who had
a very challenging tip shape with soft triangle
facets and a strong dorsal hump with hyperdy-
namic tip ptosis. Animated views are also shown
to demonstrate the drastic improvement in tip
position and shape. Soft triangle grafts were
used to offset the facets which otherwise would
have been exaggerated with the narrowing and
re fi nement of the tip. All tip suture methods were
utilized along with an 8-mm component dorsal
reduction, caudal septal resection, and spreader
grafts. She also had correction of her major alar
malposition with release of LLC attachments
and placement of alar contour grafts. The depres-
sor nasi septi muscle was resected as well.

866
A. Ghavami
Case 3 (Fig. 60.14 )
a
b
Fig. 60.14 ( a ) Preoperative Hispanic patient who
required subtle tip re fi nement and less signi fi cant dor-
sal resection. ( b ) Postoperative after onlay tip graft
was crushed and placed on the domes after trans-
domal, interdomal, and medial crural/columellar strut
sutures were placed; cephalic trim remnant was placed
over her medial crura which abutted the onlay dome
graft in order to soften her infratip breakpoints; and
correction of dynamic ptosis with depressor nasi septi
resection
This Hispanic patient who required subtle tip
re fi nement and less signi fi cant dorsal resection.
An onlay tip graft was crushed and placed on
the domes after transdomal, interdomal, and
medial crural/columellar strut sutures were
placed. A cephalic trim remnant was placed
over her medial crura which abutted the onlay
dome graft in order to soften her infratip break-
points. She did not desire infratip volume and
wanted an elevated columella. Dynamic ptosis
was also corrected with depressor nasi septi
resection.

867
60 Tip Shaping in Primary Rhinoplasty
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