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Background This is the first study to evaluate the effect of premaxillary filler injection on nasal tip projection, upper lip projection, and upper lip vermilion height. Objectives The primary objective of this study was to analyze the change in nasal tip projection (measured by the Goode ratio) and the change in upper lip projection (measured by the Z angle) following premaxillary hyaluronic acid injection. A secondary objective was to measure the change in upper lip vermilion height. We hypothesized that treated subjects will show an increase in nasal tip projection, upper lip projection, and upper lip vermilion height. Methods Twenty volunteer patients with signs of perioral aging or poor upper lip projection were enrolled in this prospective cohort study and underwent premaxillary hyaluronic acid filler injection between November 2017 and June 2018. Nasal tip projection, upper lip projection, and upper lip vermilion height were assessed from baseline and posttreatment photographs based on the Goode ratio, Z angle, and lip vermilion height ratio, respectively. Results No significant change was noted between pre- and posttreatment Goode ratio measurements (P = 0.841). There was a significant decrease in Z angle and therefore significant increase in upper lip projection with treatment (P < 0.001). The lip vermilion height ratio demonstrated a trend of increased upper lip vermilion height but this did not achieve statistical significance (P = 0.561). Conclusions Premaxillary filler treatment resulted in a significant increase in upper lip projection. Premaxillary filler injection when performed in a safe manner is a valuable treatment option for perioral rejuvenation. Level of Evidence: 4

Background Current literature lacks a single cartilage graft to address problems in projection, rotation, and/or definition in mestizo patients that considers the alar cartilage structure, length, and shape characteristics of this population. Objectives The authors sought to describe a novel technique and evaluate the aesthetic outcomes of the combined auricular graft in mestizo patients undergoing primary rhinoplasty. Methods A retrospective cohort study of consecutive patients who underwent primary rhinoplasty using the combined auricular graft between January 2015 and June 2017 was performed. The minimum duration of follow-up was 6 months. Main outcomes were nasal tip projection and tip rotation angle. Results Among the 61 patients (38 women [62.2%] and 23 men [37.8%]; mean age, 29.3 ± 10.8 years), the mean differences in projection were statistically significant between T0 and T1, T0 and T2, and T0 and T3 (1.63, 1.39, and 1.32 mm, respectively). Thus, 80.9% of the increase in projection that had been achieved at T1 was maintained at T3 (P < 0.001). The relapse ratio measured 19.1% (mean difference T1-T3, 0.31 ± 0.10 mm). The mean tip rotation angle at T0 (111.69 ± 3.59°) significantly increased by 2.37 ± 3.13° (T3, 114.06 ± 2.50°, P < 0.001). Conclusions One single auricular cartilage graft can significantly improve projection and/or rotation by simultaneously addressing structure, length, and shape of lower lateral cartilages. Misbalance between the medial and lateral crura is avoided and retraction risks are prevented. Consequently, a more natural, precise, and accurate tip position is obtained. Level of Evidence: 4

Background A change in nasal tip rotation is a very common maneuver performed during rhinoplasty. Among the many techniques used to achieve this goal is the tongue-in-groove (TIG). Objectives This study addresses the long-term effect of the TIG on the nasal tip rotation 1 year after rhinoplasty. Methods The authors prospectively identified patients who were submitted to a rhinoplasty with a TIG maneuver over a period of 1 year. The angle of rotation was measured along the nostril axis angle. The data were analyzed using the t test and a linear regression model. Results Seventeen patients were included. The average preoperative tip rotation was 93.95° (SD, 3.12°). Immediate postoperative tip rotation averaged 114.47° (SD, 3.79°). At the 1-year follow-up appointment, the tip rotation averaged 106.55° (SD, 3.54°). There was a significant loss of rotation at the 1-year postoperative visit (P < 0.0001), with an average loss of 7.9° (SD, 3.25°), which amounted to 6.8%. The preoperative rotation didn't affect the amount of loss of rotation (P = 0.04). It can be estimated that, for every degree of rotation that is changed at surgery, the tip can be expected to lose 0.35 degrees over the first year. Conclusions TIG is a more dependable technique than the ones that rely on healing and contraction to obtain rotation. Our data demonstrated a significant loss of rotation during the first year. This suggests that the surgeon needs to slightly overcorrect the tip rotation to account for this loss. Level of Evidence 4

Background In 1971, Janeke and Wright1 published a now classic study on the support of the nasal tip in which they found four areas of anatomic support. These findings led to the "tripod concept" of tip support. Recently, surgeons have begun repairing and/or preserving the nasal ligaments as a method to control tip projection and rotation. Therefore, a reassessment of the nasal ligaments and tip support is warranted. Objectives The present study was done to investigate the ligamentous and structural support of the nasal tip. Clinically, surgeons are aware of the role of the nasal ligaments and are beginning to utilize tip suture techniques to achieve greater tip refinement and long-term support. Methods Anatomic studies were conducted on 24 fresh cadavers at the time of autopsy. The two groups consisted of the following: (1) group 1 included dissection of 10 cadavers concentrated on the various ligaments of the nose; and (2) group 2 involved dissections of 14 cadavers analyzing the relationship between the alar domes and the anterior septal angle (ASA). Results Regarding the ligaments of the nose, we were able to consistently identify the following ligaments: (1) interdomal; (2) intercrural; (3) Pitanguy's midline; (4) pyriform; and (5) a scroll ligament complex consisting of the longitudinal and vertical scroll ligaments. We did not find two commonly accepted ligaments: (1) a "footplate ligament" from the footplate of the medial crus to the caudal septum; and (2) a "sesamoid ligament" attachment from the accessory cartilage to the pyriform aperture. Dissections done to study the relationship between the domes and ASA revealed that the domes projected an average of 5.7 mm (range, 2.2-9.6 mm) above the ASA and were longitudinally 5.5 mm (range, 2.9-9.5 mm) caudal to the ASA. Thus, there was no direct support from the ASA to the domes. Conclusions It is our recommendation that surgeons should consider preservation of the nasal ligaments whenever possible and utilize them to manipulate tip projection, position, and rotation. Awareness of the relationship between the dome and the caudal septum will hopefully minimize problems with the tongue-in-groove operation.

BACKGROUND The junction between upper and lower lateral cartilages, known as "the scroll area," is an important determinant of the spatial relationship between the middle and lower nasal thirds. OBJECTIVES We offer a graduated and reproducible surgical technique of scroll area management that takes into consideration anatomic, functional, and aesthetic relationships. METHODS This study was a retrospective review of the recorded intraoperative information to investigate the frequency of the use of scroll reconstruction techniques and perioperative parameters that relate to unintended component alterations in the scroll area. A total of 364 consecutive primary open approach rhinoplasty cases performed by the first author (O.B.) between July 2011 and September 2015 were included in the study. RESULTS Of the 364 cases who underwent primary open approach rhinoplasty, 329 received some form of scroll reconstruction. Scroll reconstruction was performed in all deviated cases, and 88% of straight noses. The most common technique for scroll reconstruction was overlapping repair (88.3%). As expected, both alar rim and alar crease asymmetries were very frequent in the deviated nose group, 89.4% and 75% respectively. Alar rim and alar crease asymmetries were frequent enough in the straight nose group to deserve special attention, 14.2% and 10.4% respectively. CONCLUSIONS With careful attention to anatomic details of the scroll area, nasal tip refinements can be performed with predictable safety and accuracy. Our approach is a graduated, reproducible, and individualized way of scroll area management that aims to create the ideal cartilage configuration while preventing unintended component alterations. LEVEL OF EVIDENCE: 4

Background The plunging tip refers to a deformity in which the nasal tip plunges on smiling. Objectives To understand the plunging tip, we have updated our series of 25 cosmetic rhinoplasty patients who complained of a plunging tip with a focus on the anatomic changes of the nose on smiling. Methods Twenty-five female cosmetic primary rhinoplasty patients who complained of a nasal tip that plunged on smiling were photographed in static and smiling sequences preoperatively and one year postoperatively. Different nasal angles and landmarks were measured to study changes of the nose. Results Pre- and postoperatively, there was no statistically significant difference in the changes in the nasal angles and landmarks on smiling. At one year postoperatively, 2 patients had nasal tips that continued to plunge on smiling; these patients had requested no increase in tip rotation preoperatively. Only 2 patients had columellar base muscles cut for reasons other than treating the plunging tip. Conclusions This is the first prospective, evidence-based study on the plunging tip. Measurements of the nose before and after surgery demonstrate that the nasal tip moves less than 1 mm and 1 degree on smiling. Treatment of the plunging tip illusion was effective by increasing the tip angle in repose. No columellar base muscles were cut to treat the plunging tip, and the nose moved just as much after surgery as before. Cutting or manipulating muscles is not necessary for treatment. To treat the illusion, the surgeon must increase tip rotation. Level of Evidence 2![Graphic][1] Therapeutic [1]: /embed/inline-graphic-1.gif

Background: An important consideration in rhinoplasty is maintenance of the applied tip rotation. Different techniques have been proposed to accomplish this. Loss of rotation after surgery not only results in a derotated tip but also can create a supratip deformity. Objectives: As a supplement to dorsal reconstruction, the authors introduced and applied the lateral crural rein flap technique, whereby cartilage flaps are created from the cephalic portion of the lateral crura to control and stabilize tip rotation. Methods: Eleven patients underwent primary open-approach rhinoplasty that included the lateral crural rein technique; the mean follow-up time was 18 months. Excess cephalic portions of the lateral crura were prepared as medial crura-based cartilaginous flaps and were incorporated into the nasal dorsum (similar to spreader grafts) and stabilized to achieve the desired tip rotation. Results: The lateral crural rein flap technique provided stability to the nasal tip while minimizing derotation in the postoperative period. Long-term follow-up revealed maintenance of the nasal tip rotation and symmetric dorsal aesthetic lines. Conclusions: The lateral crural rein flap technique is effective for controlling nasal tip rotation while reducing lateral crural cephalic excess. Longevity of the applied tip rotation is reinforced by secure attachment of the lower nasal cartilage complex to the midvault structures. Level of Evidence: 4 ![Graphic][1] [1]: /embed/inline-graphic-1.gif

BACKGROUND Following primary rhinoplasty, the nasal tip may become wider on front view, possibly due to splaying of the lateral crura. OBJECTIVES The authors describe a technique, the "supratip-plasty," to create an all-cartilaginous supratip that resists splaying and postoperative broadening of the nasal tip complex. METHODS Thirteen consecutive primary rhinoplasty patients (10 women; 3 men) with broad nasal tips received a supratip-plasty (which preserved the cephalic part of the lateral crus, reducing it in size and securing it to the dorsal septum, resulting in a completely cartilaginous tip framework) and were followed for 11 to 17 months. Since the frontal tip width (TW) is relative to the frontal nasal base width (NBW), the TW/NBW ratio was contrasted to that of 19 unoperated aesthetically pleasing nasal tips. RESULTS Of the 13 cases, all but 1 were considered to have a good result. The preoperative mean TW/NBW ratio was 0.68. The postoperative mean was 0.53, compared with 0.48 in the unoperated aesthetic tip group. No tip revisions were necessary; however, 2 patients did require revisionary surgery for nontip problems. CONCLUSIONS Preserving a cephalic island of lateral crus, trimming it to fit the new supratip contour following suture tip-plasty, and securing it to the septum provides a completely cartilaginous nasal tip framework that tends not to widen postoperatively.

BACKGROUND Congenital deficiencies of the alar cartilages are rare and often visible at birth but can occasionally present later. OBJECTIVES The authors review the anatomical development and discuss the incidence and treatment of congenital defects within the alar cartilages seen in rhinoplasty cases. METHODS The charts of 869 consecutive patients who underwent open rhinoplasty were retrospectively reviewed, and 8 cases of congenital defects of the alar cartilage within the middle crura were identified. Intraoperative photographs were taken of the alar deformities, and each patient underwent surgical correction. To simplify analysis, a classification of the defects was developed. A division was a cleft in the continuity of the alar cartilage with the 2 ends separate. A gap was a true absence of cartilage ranging from 1 to 4 mm, which can be accurately assessed in unilateral cases. A segmental loss was a defect greater than 4 mm. RESULTS The 8 cases of deformity could be classified as 4 divisions, 3 gaps, and 1 segmental loss. None of the patients had a history of prior nasal trauma or nasal surgery. Six patients were women and 2 patients were men. In all cases, adequate projection and stability were achieved with a columellar strut. Asymmetry was minimized through concealer or tip grafts. There were no complications. CONCLUSIONS Surgeons performing rhinoplasty surgery will encounter and should be prepared to deal with unexpected congenital defects of the alar cartilage. These defects within the middle crura will require stabilization with a columellar strut and, often, coverage with a concealer tip graft. We speculate that the cause of these defects is a disruption of the hedgehog signals that may arrest the condensation or block the differentiation of the underlying neural crest cells.

The complex issue of obtaining an aesthetically pleasing and structurally stable nasal tip brings into play a vast array of maneuvers and techniques, often performed through an open approach.1 Although these approaches are numerous and different, they all share the attainment of a stable tip cartilaginous structure, and then, if necessary, some sort of refinement or camouflage on top. An obvious situation in which such camouflage is unnecessary is the thick-skinned patient for whom sharp definition intrinsically may be welcome. As epitomized by Daniel,2,3 the ideal tip configuration will usually resemble a gently opened diamond. A similar concept is found, often with different suture terminology, in the work of other well-known surgeons.4,5 After appropriate repositioning, tensioning, or stiffening of the lateral crura as necessary, transdomal and interdomal sutures will be used to appropriately shape the domes and allow the gentle anterior domal divergence that will be stabilized by posterior dome equalization sutures. Some final camouflage may be necessary at this point. Various grafts are commonly utilized for this purpose, including segments from the cephalic trim, intercrural soft tissue, crushed cartilage, or even deep temporal fascia if harvested for other reasons.6,7 A specific drawback that will oftentimes detract somewhat from the result of an otherwise well-executed rhinoseptoplasty is a residual V-shaped infralobular cleft, extending from between the domes to the middle and medial crura. This is obviously more evident with thin skin and can be bothersome to the patient preoperatively. In such a patient, the surgeon must note the necessity of gently filling the gap between the new domes, as well as the indentation in continuity that flows below the columellar lobular angle and resides between the medial crural segments along the columella. Beginning in 2014, the senior author (E.R.) noticed …

Background: The aesthetics of the human nose is highly dependent on the complex structure of the lower lateral cartilages (LLC). Understanding optimum shape and mechanical properties of the LLC is pivotal to achieving satisfactory results in nasal tip rhinoplasty.Objective: The authors introduce an ex vivo animal model to replicate the shape and mechanics of human nasal LLC as a tool for research and surgical education.Methods: Seven fresh pig heads were obtained from a local butcher shop. Nasal cartilage was harvested in a replicable manner and fashioned into appropriate shapes and dimensions based on the authors' human cadaver studies. Sutures were placed to approximate the cartilage pairs into appropriate human anatomical position.Results: The porcine cartilage model replicated analogous structures, including the medial crura and the lateral crura, with appropriate cephalic orientation and domal angles. The anterior-posterior dimensions of the medial crura, intermediate crura, and lateral crura were 4 mm, 6 mm, and 10 mm, respectively. Cartilage thickness was approximately 1 mm throughout the specimen. Cephalic orientation of the lateral crura was sculpted to 45°. The average angle of divergence was 54° and varied according to the physiological shape of the porcine nasal vault (range, 43-74°). Average interdomal distance was 13.3 mm (range, 9-18 mm), and average domal width was 6.2 mm (range, 5-7 mm).Conclusions: This novel porcine model mimics human LLC and is inexpensive, easy to construct, and highly replicable. This model can be used as a valuable educational resource for training novice surgeons in the principles of nasal tip rhinoplasty. Additionally, our construct has broad applications in studying LLC geometry and mechanics. © 2011 The American Society for Aesthetic Plastic Surgery, Inc.

Background The mestizo patient usually has a small nose with a wide base, round nostrils, and a convex dorsum. The alar cartilages are weak, thin, and short, providing deficient structural support and poor definition of the nasal tip. Cartilage grafts in the nasal tip are very often used to correct this condition, but a common problem of this procedure is the cephalic or lateral rotation of these grafts. Objective We used an angulated extended columellar graft to give columellar support and projection to nasal tip grafts for better control and prediction of the position and effect of these grafts. Methods The surgical protocol included a medical history, development of a surgical plan by analysis of the deformity, and the use of pre- and postoperative photographs taken at both intermediate and long-term follow-up visits for evaluation of the results. Results Sixty-seven patients underwent surgery using this procedure, 56 with an open technique and 11 with a closed technique. Follow-up ranged from 6 months to 4 years. The results obtained were satisfactory, showing better control and prediction of the shape of the nasal tip. Conclusions The angulated extended columellar graft provides better control of the projection and angularity of cartilage grafts placed in the nasal tip. (Aesthetic Surg J 2009;29:98–105.)

Nasal tip bulbosity, or convexity, has been one of the most difficult problems to correct during rhinoplasty. Excision of cartilage from the cephalic part of the lateral crus has helped. However, complete correction of the deformity is not always possible with this maneuver alone. Suture techniques have also helped to improve outcomes. Twelve years ago, the lateral crus mattress suture was introduced as a way of converting the lateral crus to a flat, straight segment with resultant correction of the convexity. Since then, this suture technique has been employed in most primary and some secondary rhinoplasties and has stood the test of time. We report our experience with this technique, including a slight modification to facilitate its application when the cartilage is unusually narrow or when the original technique is difficult to complete. In addition, the suture technique for the less concave lateral crura is redescribed. It, too, has withstood the test of time.

The study on the characteristics of the nasal tip cartilages of Black Southern Africans presents an interesting insight into what might be seen when operating on this specific ethnic population and might be helpful in preoperative planning.1 However, the world is rapidly more mobile, and our facial and nasal characteristics are morphed daily as we migrate, procreate, and share genes, making pure ethnic populations a thing of the past for most surgeons worldwide.2 In the United States we see so many advertisements now for DNA analysis and find that most of us are a mix of many ethnic characteristics. In the majority of cases, surgeons cannot accurately predict preoperatively what nasal anatomy they will encounter or what maneuvers may be necessary based on a patient’s name, country of …

Background: Preoperative planning of nasal tip surgery requires an accurate assessment of the nasal tip cartilages configuration. The current literature lacks any evidence on the accuracy of preoperative assessment of the lower lateral cartilages (LLC) shape. Objective: This study was designed to determine the accuracy of the LLC shape and configuration assessment prior to dissection. Methods: The configuration of the lateral, middle, and medial crura was assessed on 42 LLC (21 cadavers) prior to dissection by way of observation and palpation. The findings were then compared with those observed after LLC exposure through an open-approach dissection. Results: The accuracy of predissection LLC shape assessment was 42 of 42 (100%), 32 of 42 (76%), and 12 of 42 (29%) for medial, middle, and lateral crus, respectively. Conclusions: The configuration of the lateral crus of LLC cannot be accurately assessed prior to exposure of the cartilage. A rhinoplastic surgeon who embarks on nasal tip surgery should be familiar with a number of techniques to address any tip deformity encountered after exposure, as the preoperative clinical and photographic assessments cannot reliably demonstrate the type of LLC deformity.

Background: Surgeons performing rhinoplasty are increasingly faced with secondary procedures in graft-depleted patients. Objective: A method is described for recycling resected distal dorsum as a Sheen tip graft. Methods: Each of 16 primary rhinoplasty patients was treated with a Sheen graft to the nasal tip harvested from the distal cartilaginous dorsum; the dorsal cartilaginous hump was removed without dorsal mucosal disruption. Intact dorsal vestibular mucosa acts as a mucosal spreader graft by adding width between the dorsum and the resected upper lateral cartilages. The hump must be large enough that resection of the distal dorsum will not result in overresection of the midvault. Results: Postoperative photographic analysis of each of the 16 patients after 1 to 5 years of follow-up shows increased nasal tip projection, establishment of a tip-defining point, and a double break (a supratip and infralobular break). No graft absorption was clinically noted. Conclusions: Recycling of the distal dorsum as a Sheen graft in selected patients results in an aesthetic contour. This method limits surgical dissection to a single donor area, saves time, preserves the septum, avoids potential septal perforation or hematoma, and decreases hemorrhage and edema.

Ronald P. Gruber, MD Nicolas Tabbal, MD Jack H. Sheen, MD Dean Toriumi, MD Dr. Gruber: The first patient (Figure 1) is a 45-year-old man with a history of cocaine use. He presents with symptoms of whistling and a dropped nasal tip, and he also complains of difficulty breathing. To facilitate breathing, this patient manually pushes up the tip of his nose. He has a caudally located 2- to 3-cm perforation, which leaves him with a 1-cm horizontal strut and a 1-cm caudal (columellar) strut. Dr. Sheen, how does this compare with your experience in seeing patients with a history of cocaine use? Figure 1 A , Front, B , lateral, and C , intranasal views of a 45-year-old man with a history of cocaine use. He presents with symptoms of whistling and a dropped tip and complains of difficulty breathing. He has a caudally-located 2-cm perforation. Dr. Sheen: Of the 18 to 20 cocaine noses that I have reconstructed, only 1 was in a male patient; he had mid-vault collapse associated with a large perforation. The rest of the patients were female. I also treated one man who had complete erosion of the caudal septum, membranous septum, and columella and had only 1 mm of skin remaining, so he literally had no caudal support. However, what you describe here is somewhat different. If this patient has a significant amount of caudal septum remaining, it is unlikely that cocaine use caused his present condition. Has he had prior surgery? Dr. Gruber: No, he has not. Dr. Sheen: When I see a patient with this type of problem, I ask to see photographs that were taken before the nasal deformity developed to compare the original state of the nose with its current condition. I do not believe that this 2-cm perforation would produce …

Background: Effective control and refinement of the nasal tip is an integral component of the rhinoplasty operation. A multitude of techniques exist to complement the rhinoplasty surgeon’s approach, but attaining consistent and long-lasting results is still challenging due to the complex interplay between nasal anatomy and surgical technique. Objectives: The authors sought to determine whether the degree of tip narrowing with rhinoplasty is associated with the narrowing technique selected by the surgeon and whether there is an association between skin thickness and tip narrowing. Methods: A retrospective chart review was conducted of all patients undergoing rhinoplasty in a single-surgeon practice between April 2004 and November 2006. Demographic information and specific operative techniques were recorded. Standard basal views of pre- and postoperative photographs were examined by two blinded observers, who measured nasal tip width relative to interpupillary distance with imaging software. Skin thickness was assessed and categorized by a surgical expert according to Fitzpatrick classification. Results: Forty patients were identified with adequate follow-up and complete data sets. A statistically significant reduction in tip width pre- and postoperatively was seen ( P = .041). No significant difference in tip narrowing between various techniques was found ( P = .309), and no significant association between tip narrowing and skin thickness was identified ( P = .186). Conclusions: Although tip-narrowing techniques are effective in rhinoplasty, the specific technique employed may not be clinically relevant. Furthermore, skin thickness may not be as significant a factor in tip narrowing as is commonly believed.

Background: Dorsal hump reduction is a common complaint among primary cosmetic rhinoplasty patients. Newer techniques for addressing the dorsal hump focus on the preservation, reinforcement, or modification of existing structures. Objectives: The authors describe their technique of a “dorsal columellar strut,” an innovative use of dorsal nasal cartilage from hump removal for a columellar strut. Combined with other cartilage-conserving techniques, this forgoes the morbidity and operative time of a septal cartilage harvest while preserving—and possibly increasing—tip support. Methods: Candidates for this procedure are selected based on a number of criteria. Ideally, the patient is one who requires 3 mm or more of dorsal hump reduction with tip reshaping and refinement. Each patient is treated using the open technique with a stair-step columellar incision, combined with an infracartilaginous incision. Results: With the addition of the authors’ cartilage-conserving techniques (autospreader flap, lower lateral turnover, and tip suturing), patients experience successful reshaping of the middle vault and nasal tip. Conclusions: In well-selected patients, the authors have found their technique to be efficient, effective, and aesthetic. The precise dorsal reduction allows surgeons to use the cartilage fragment as a dorsal columellar strut, foregoing the standard septal harvest and reducing operative time and patient morbidity.

In treating nasal-tip deformities, the authors use the tripod concept to anatomically simulate the paired lower lateral cartilage complexes. They recommend using rib cartilage to obtain predictable and reproducible results.

James W. Fox IV, MD Rollin K. Daniel, MD Stephen W. Perkins, MD Nicolas Tabbal, MD Dr. Fox: Rhinoplasty is the most difficult operation in aesthetic plastic surgery, and I think we would all agree that the most difficult part of the procedure involves the tip of the nose, our subject for this panel. The first patient is a 16-year-old teenager with the familiar complaint, “I hate my nose, it is too big and blobby” (Figure 1). Doctor Tabbal, what would you recommend to this young woman with thick skin? Figure 1 This 16-year-old teenager complains, “I hate my nose; it is too big and too blobby.” Dr. Tabbal: What strikes me is the disproportion in her nasal balance. The nasal lobule is significantly more prominent than the upper half of the nose, which is somewhat narrow. The nasal tip is slightly deviated to the left and is quite heavy looking with effaced lower lateral cartilages. I suspect that the tip volume is primarily related to the quality of the soft tissues rather than the volume or shape of the alar cartilages. In order to achieve the desired tip refinement in this patient, I would rely on a reduction of the volume of the alar cartilages, combined with centralization of the tip and enhancement of the tip defining points through use of the open rhinoplasty approach and tip suture techniques. I see no need for cartilage grafting in this case because tip projection appears to be quite adequate. Dr. Fox: Dr. Perkins, does the width of this patient's nose at the base need to be addressed with regard to getting the tip into balance? Dr. Perkins: Looking at her frontal view, she has fairly wide-set eyes. Her inner canthi are wide enough to accommodate the width of her alar base, which is …

Background: Commonly used techniques for achieving nasal tip projection and refinement are adequate for most primary rhinoplasty patients, but they may result in undesirable tip bifidity and visible lower lateral cartilage angularity, especially in patients with thin skin. Objective: We report the use of “like” local tissues, cephalic trim cartilage remnants of the lower lateral cartilages, as invisible tip grafts to soften any angular cartilage edges or tip bifidity. Methods: The cartilaginous framework was exposed by using the open rhinoplasty approach. Lower lateral cartilages were separated from upper lateral cartilages, the caudal septum at the anterior septal angle, and from each other. A cephalic trim was performed as necessary, with the cartilaginous segments preserved for use as a cap graft. Interdomal sutures and transdermal sutures were used either alone or in combination to set the desired tip projection. If tip bifidity was visible through thin nasal tip skin, a cephalic trim cap graft was placed. Results: The procedure can achieve a well-unified nasal tip with no evidence of bifidity, angularity, or cartilage graft visibility. Conclusion: Use of this technique to improve nasal tip projection can avoid undesirable tip bifidity and visible lower lateral cartilage angularity in patients with thin nasal skin. ( Aesthetic Surg J 2002;22:39-45.)

Background Cartilage grafts are frequently too small to serve as dorsal grafts so that several segments must be secured together to achieve adequate dimensions. The suturing of graft segments is time-consuming and difficult. Objective This study examines the use of 2-octyl cyanoacrylate for the prefabrication and fixation of nasal cartilage grafts. Methods 2-octyl cyanoacrylate was used to prefabricate cartilage grafts and secure nasal tip grafts in 9 patients who underwent open rhinoplasty. Results Cartilage grafts appeared to maintain their volume and position. There was no evidence that 2-octyl cyanoacrylate led to inflammation, erythema, or fibrosis. Conclusions 2-octyl cyanoacrylate is an effective method for prefabricating and securing nasal cartilage grafts. There were no negative sequelae associated with its use in this series of patients.

Among the most frustrating cases in rhinoplasty is one in which the patient does not respond to standard rhinoplasty techniques. Utilizing the closed technique without anesthetic injection or distortion of the nasal tip or dorsum, the surgeon can see the definition and projection of the nasal tip at the time of surgery. Good nasal tip definition with adequate nasal tip projection is the goal and is what will make your rhinoplasty successful. What you see is what you get! The frustration occurs when what you see, you don't like. Thick sebaceous nasal skin is certainly one of the most frustrating challenges. All of the rhinoplasty techniques to achieve adequate nasal tip definition may not work. Frequently doctors will accept the result as the best …

Using soft tissue fillers to correct postrhinoplasty deformities in the nose is appealing. Fillers are minimally invasive and can potentially help patients who are concerned with the financial expense, anesthetic risk, or downtime generally associated with a surgical intervention. A variety of filler materials are currently available and have been used for facial soft tissue augmentation. Of these, hyaluronic acid (HA) derivatives, calcium hydroxylapatite gel (CaHA), and silicone have most frequently been used for treating nasal deformities. While effective, silicone is known to cause severe granulomatous reactions in some patients and should be avoided. HA and CaHA are likely safer, but still may occasionally lead to complications such as infection, thinning of the skin envelope, and necrosis. Nasal injection technique must include sub-SMAS placement to eliminate visible or palpable nodularity. Restricting the use of fillers to the nasal dorsum and sidewalls minimizes complications because more adverse events occur after injections to the nasal tip and alae. We believe that HA and CaHA are acceptable for the treatment of postrhinoplasty deformities in carefully selected patients; however, patients who are treated must be followed closely for complications. The use of any soft tissue filler in the nose should always be approached with great caution and with a thorough consideration of a patient's individual circumstances.

Nasal tip ptosis (“drooping” or long nose) occurs when the tip of the nose is more caudal than what is deemed ideal. Intrinsic factors, such as elongated or caudally-rotated lower lateral cartilages, can lead to nasal tip ptosis. Extrinsic factors, such as elongated upper lateral cartilages or excessive caudal anterior septum and heavy nasal skin, can push the nasal tip caudally and lead to drooping of the nasal tip. The loss of maxillary or nasal spine support may enhance the potential for tip ptosis. In addition, a hyperactive depressor nasi septi could, as a result of continuous pull on the tip, result in tip ptosis. Aging or previous nasal procedures (such as the Goldman-type tip surgery) where the continuity of the lateral and medial crura of the lower lateral cartilages have been violated may cause a weakening of the tip-supporting mechanisms and de-rotation of the nasal tip. Correction of this deformity is challenging and rewarding; it can resolve both the cosmetic deformity and nasal obstruction symptoms related to this entity. The goal of this article is to present our current principles of diagnosis and treatment of nasal tip ptosis, as well as to introduce and algorithm of preferred methods and techniques for its reliable and stable correction. Results Correction of the nasal tip ptosis requires accurate diagnosis, a recognition of the interplay between various anatomic components, specific strategy planning, and a correction of anatomic abnormalities.

Ensuring consistent and reproducible results during cosmetic tip rhinoplasty can be extremely difficult. The unpredictable forces of wound contracture and scarring have humbled even the most experienced rhinoplasty surgeons in various cases throughout their careers. Armed with a knowledge of tip dynamics, however, one can combat the various nasal tip deformities with reasonable accuracy. In this article, we present techniques that are specifically used to correct tip overprojection and tip ptosis. The medial crural tuck-up is a procedure that can be used to deproject the nose while maintaining an overall harmonious tip aesthetic. The lower to upper lateral cartilage suspension has been used in our practice to specifically modify the droopy nasal tip. Both procedures have produced excellent long-term results.

Background Reducing lateral nasal tip width in order to optimize shape while still maintaining function presents a challenge to the operating surgeon. Techniques for the reduction of tip width are typically limited to resection, plication, or medial augmentation of the lower lateral cartilages (LLC). Objective This study describes a reduction of both the length and width of the lateral half of the upper lateral cartilages (ULC) to effect a change in nasal tip shape in selected individuals. Methods Between January 2003 and February 2005, we reviewed the records of 217 patients undergoing primary rhinoplasty; of these, 43 patients underwent partial resection of the ULC to alter nasal tip shape. In this selected group of patients, resection of a portion of the ULC infralaterally was performed, along with partial resection of the LLC. Results No patients noted increased difficulty breathing postoperatively, so nasal valve function was maintained. Reduction of superior lateral tip width was observed in all patients. Conclusions Judicious modification of the lateral portion of the ULC — taking care to maintain adequate length and breadth of the medial portion of the cartilage in selected individuals — results in significant improvement in nasal tip width. A specific subset of our patients, approximately 20%, benefited from this approach. Conservative resection of the ULC can enhance nasal tip shape. While clearly not applicable in the majority of patients, the described technique represents a useful addition to the algorithm we may employ in determining the surgical approach in patients seeking aesthetic rhinoplasty.

The authors use 5 basic suture techniques in tip plasty: transdomal, interdomal, lateral crural mattress, columella-septal, and intercrural, incorporating these techniques into a simple algorithm to control tip cartilage shape. They then introduce the universal horizontal mattress suture, designed to control all undesirable nasal cartilage convexities/concavities, and provide a new suturing technique that can be applied in all patients in whom a change of cartilage shape, including tip cartilages, is desired. They also apply these suture techniques in patients undergoing closed and secondary rhinoplasty.

Learning objectives The reader is presumed to have knowledge of the basic concepts and surgical procedures of rhinoplasty. After studying this article, the participant should be able to: 1. Describe the anatomic components responsible for the boxy nasal tip appearance. 2. Summarize the principles of suture reformation in converting the lower lateral cartilage convexity into a predictable concavity. 3. Plan the application of additional grafts and maneuvers to enhance nasal tip appearance. Physicians may earn 1 AMA PRA Category 1 credit™ by successfully completing the examination based on material covered in this article. The examination begins on page 306 . ASAPS members can also complete this CME examination online by logging onto the ASAPS Members-Only Web site ( http://www.surgery.org/members ) and clicking on “Online Clinical Education” in the menu bar. The author uses a dome-binding suture to reform the heavy appearance of the boxy nasal tip by reshaping the convex lower lateral cartilage into a more refined concave shape. This procedure is performed with a straight needle and permanent suture, undermining of dome mucosa, meticulous contamination prevention, and incremental lowering of the unitized dome height for tip refinement.

Contour of the nose is determined by a series of shadows and highlights that emphasize the shape of the nose.1 The desired contours are curvilinear with smooth transitions from dorsum to mid-vault to nasal tip. Control of nasal contour requires precise management of the underlying nasal structures. The structure approach to rhinoplasty employs conservative reduction of the cartilage structures and reshaping using cartilage grafting.2 Cartilage grafts such as spreader grafts and lateral crural strut grafts help to control the shape of the middle nasal vault and lower third of the nose, respectively.3,4 Such grafts have helped surgeons improve their long-term outcomes as well as link nasal aesthetics and surgical technique. In the article entitled, “Rhinoplasty: Surface Aesthetics and Surgical Technique,” Dr Cakir and his coauthors have described how the nasal contour is composed of a series of polygons as aesthetic units and linked these concepts to their own techniques. The ideal contour on frontal view is typically described as having bilateral divergent concave lines that create symmetric “brow tip aesthetic lines.”5–7 In contrast, the authors describe the frontal view as a series of polygons, with a superior polygon that is narrow at the radix and widens toward the middle nasal vault and an inferior polygon that narrows at the supratip. This series of shapes more closely represents the shape of the underlying nasal structures (nasion, nasal bones, and upper lateral cartilages) rather than the superficial nasal contour. Transitions in skin thickness—from thick in the radix region, to …

In more than 35 years of practice, one of my most difficult rhinoplasty problems has been the management of patients with thick, heavy, sebaceous skin. Many of these patients have had previous rhinoplasties and are unhappy with their results and sometimes with their surgeon. These dissatisfied patients may roam the globe in search of the magic consultation that will give them hope for a thinner nasal tip with nice definition. The main problem is that the thick sebaceous skin causes poor nasal tip definition, inadequate nasal tip projection, and a high supratip deformity. Sculpturing the lower lateral cartilage, removing the cephalad portion of lower lateral cartilage with all fibrofatty tissue, and lowering the high supratip septum is certainly necessary …