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Management of the Bulbous Nose
Abstract
"Bulbous nose" is a term patients often use to describe a "ball" on the end of their nose. This ball can be caused by the abnormal anatomy of alar cartilage or by the overlying soft-tissue coverage. The purpose of this article is to analyze the different causes of bulbous noses and their treatment options. An analysis was done based on four decades of experience and long-term follow-up. We included 10 patients for our discussion. The relationship of the tip to the vault must be analyzed, because it can create optical illusions. For instance, a low bridge makes the tip appear larger; therefore, a bulbous nose may be relative. Similarly, excessive narrowing of the nasal base by alar wedges makes the tip appear wider. Intrinsic causes of a bulbous nose include skin, subcutaneous tissue (including the nasal superficial musculoaponeurotic system, ligaments, and fat), and the shape and direction of the individual crus. Nasal skin varies as to volume and ability to contract; therefore, the shape, direction, or divergence of the individual crura cannot undergo unlimited modifications. There are several surgical possibilities for a given problem. Making the diagnosis of the underlying abnormal anatomy is the most important step; then the most appropriate operation can be selected. Struts, sutures, resection, dome division, and/or dorsal augmentation are all viable options for the management of the bulbous nose.
... A bulbous nasal tip is commonly seen in Asians; its correction represents a significant portion of Asian rhinoplasties. Bulbous tip correction in Caucasians mainly aims at reducing excess lower lateral cartilage and performing suture techniques on well-developed lower lateral cartilage [1][2][3][4]. Asians with a bulbous tip have a small, weak lower lateral cartilage and nasal septum [5,6]. Therefore, there is a limit to how much one can project the lower lateral cartilage and push against the nasal tip skin and soft tissue, the so-called SSTE (skin soft tissue envelope). ...
... In addition, there is a high incidence of nasal SMAS (superficial musculoaponeurotic system) thickening [1]. Thus, reshaping and repositioning the lower lateral cartilage are often masked by a thick nasal skin envelope [1,2,7,8]. ...
... A simple surface evaluation of a broad or large nasal tip is insufficient to describe a bulbous tip. Classification using cartilage shape was previously introduced in the literatures [2,3,5], but such a definition provides a limited description of the actual appearance of the bulbous tip. Some authors have shown interest in SSTE and tried to explain "bulbous" as the unfavorable shadowing Da Arm Kim 1,5 , Jae Yong Jeong 2,3,5 , Sang Ha Oh 4,5 1 The Armed Forces Daejeon Hospital, Daejeon; 2 PLUS Aesthetic Surgery Clinic, Daejeon, Korea; 3 Background Correction of a bulbous tip is a difficult procedure in Asians, because their lower lateral cartilage is relatively small and structurally weak to support the thick skin soft tissue envelope (SSTE). ...
Background Correction of a bulbous tip is a difficult procedure in Asians, because their lower lateral cartilage is relatively small and structurally weak to support the thick skin soft tissue envelope (SSTE). Therefore, lower lateral cartilage manipulation alone yields inadequate bulbous tip correction. In this study, authors aim to provide a new bulbous tip definition reflecting nasal tip SSTE and categorization with a suitable surgical procedure. Methods One hundred sixty-three patients with tip rhinoplasty between January 2009 and December 2012 were studied who had a tip lobular width greater than 60% of the alar base width. Depending on cartilage size and characteristics of the nasal tip superficial musculoaponeurotic system (SMAS) with SSTE thickness, the following classifications were made: Group I: thin SSTE with a large lower lateral cartilage, Group II: thick SSTE with a small lower lateral cartilage, Group IIa: thick SSTE with loose SMAS, and Group IIb: thick SSTE with dense SMAS. We evaluated the degree of surgical improvement by comparing pre- and postoperative photographs. Results After comparing pre- and postoperative photos, we observed improvements in tip bulbosity by 11.7% in Group I (n=41), 11.9% in Group IIa (n=64), and 7.1% in Group IIb (n=58). Conclusions In Asians, nasal tip bulbosity is often due to excess SSTE. Therefore, a bulbous tip should be defined and evaluated based on its underlying SSTE. Adequate soft tissue resection in addition to lower lateral cartilage support and manipulation are warranted to achieve a refined tip.
... Correction of the bulbous tip varies according to the cause of the deformity. Typically, it has been achieved through a variety of cartilage-modifying maneuvers based on incision or excision of cartilaginous structures, generally the lateral crura (LC) and the middle crura (MC) of the LLC [5]. Many surgeons routinely resect the cephalic portion of the LC of the LLC. ...
... Collapse of this region produces nasal obstruction and typical nasal shape deformities. The importance of these complications has led to tailored surgical techniques to improve functional and aesthetic results [4,5,8,10]. ...
The term "bulbous nose" is used to describe a large or boxy nasal tip. Typically, correction of the bulbous tip has been achieved through a variety of cartilage-modifying maneuvers based on incision or excision of the lower lateral cartilage.
Horizontal reduction with a cephalic hinged flap of the lateral crura was used for 28 patients during open rhinoplasty. Effort was made to preserve the structural integrity of alar cartilage as much as possible with this technique.
The average follow-up period was 14 months. Satisfactory results were achieved. External nasal valve collapse and pinch deformity were not observed during the postoperative period.
The described technique improves nasal tip reduction while maintaining nasal tip support and strength. The hinged flap used with this technique can both prevent weakness of the lateral crura and support it.
... Cephalic malposition and weakness may lead to a long alar line, boxy nasal tip, parenthesis deformity of the alar rim and external nasal valve insufficiency during deep inspiration, in addition to alar retraction. [4][5][6][7] Alar retraction causes an unnatural alar rim and a more visible nostril. Techniques such as alar rim grafts, LC reposition, lateral crural strut grafts, composite grafts, and soft tissue advancement flaps have been used to correct alar retraction. ...
Objective: Cephalic malposition and weakness of the lateral crus may result in a long alar line, boxy nasal tip, parenthesis-deformity of the alar rim and external nasal valve insufficiency in deep inspiration, in addition to alar retraction. There is no gold standard method for correcting alar retraction and lateral crus deformities in rhinoplasty operations. Caudal extended lateral crural strut (CELCS) graft is a technique used to correct malposition of the lateral crus, to strengthen a weak lateral crus and to correct the alar rim retraction. An autologous septal cartilage graft may be used during CELCS.
Methods: CELCS graft was placed in 46 primary, open rhinoplasty procedures between 2014 and 2019. The graft was harvested from septal cartilage and placed on the lateral crus so that the cephalic areas overlapped while the caudal portion would extend into the pocket created in the caudal rim.
Results: Of the 46 patients, 30 (65.2%) were female and 16 (34.8%) were male. Median (range) age was 32 (23 to 41) years. All patients underwent CELCS graft, placed to correction cephalic malposition and alar rim retraction simultaneously. The average follow-up period was 12 months (9-15 months). Satisfactory results were achieved in all patients.
Conclusion: CELCS graft was a successful method to correct both lateral crus malposition and alar rim retraction simultaneously.
... Removing a strip of the medial crura gen erates stress on the caudal rim causing a concave shaping [2]. ...
English version of " Nichtchirurgisches Facelifting durch lange, mit Widerhaken versehene Schlingennähte" (PDF 0,4 MB)
... These include resection of the lateral crural tail to rotate the cartilage arch, reduction or relocation of the lateral crura, splinting the alar rim with autologous grafts, and various suture techniques. 2,16,[19][20][21][22][23][24][25] The aim of these surgical procedures is to reinforce the external valve, but each has unique benefits and drawbacks that should be considered during the preoperative assessment. Sheen 26 advocates treating alar malposition by excising the entire lateral crura and the domal segment of the middle crura, placing a centrally located multilayer tip graft, and reinserting the modified lateral crura laterally to support the alar rim. ...
... 7). The only exception are large, bulbous noses in which resection of hypertrophic tissues is unavoidable (29). Quite surprisingly, the scars along the alar borders are almost inconspicuous. ...
... The complexities of tip refinement surgery continue to be a topic of avid discussion due to the nuances involved in preoperative analysis, intraoperative technique, and oftenunpredictable postoperative healing. 6 As in dorsal hump management, effective control of nasal tip contour is integral to the success of the rhinoplasty operation. Though this procedure is often performed with an emphasis on tip narrowing via cartilage resection and suturing techniques, experienced surgeons advocate structural stabilization and grafting to yield more natural contours that are better able to withstand the forces of scar contracture. ...
Rhinoplasty patients often present with specific concerns and are frequently exacting in their demands and expectations of the surgical experience.
The authors assess the presenting complaints expressed during the rhinoplasty consultation process and compare the presentations of primary versus revision rhinoplasty patients.
A retrospective review of 400 consecutive rhinoplasty patients was performed. Demographic information and patient concerns regarding nasal appearance and function were recorded. Complaint frequencies (as well as rank order) were compared between primary and revision patients. Statistically significant associations were compared in more detail through logistic regression models.
Primary rhinoplasty patients were significantly more likely to cite "too large" and "dorsal hump" as motivating concerns. Conversely, revision rhinoplasty patients were far more likely to cite concern regarding a "crooked nose," "tip asymmetry," "wide or large nostrils," "dorsal sloop," and "columellar show." Revision rhinoplasty patients also complained of issues such as "alar retraction," "pointy tip," and "nasal scarring," which were almost negligible in frequency in the primary rhinoplasty group.
Patients presenting for primary rhinoplasty commonly seek a smaller, more refined nasal appearance. Patients with prior rhinoplasty operations are far more likely to raise concern regarding crookedness or asymmetries. By comparing the presentations of primary and revision rhinoplasty patients-and delineating the common indications for revision operations-novice rhinoplasty surgeons may be able to avoid certain pitfalls at the outset, thereby reducing their revision rates. The data may also assist surgeons in developing a more targeted approach to the consultation process in the revision setting.
... The patient's skin, subcutaneous tissue, nasal superficial musculoaponeurotic system, ligaments, lower lateral cartilages (LLC), and alar rims can all be implicated in disharmonious tip and nasal morphology. 4 This article discusses the operative experience of a single rhinoplasty surgeon (DE), with the aim of quantifying the degree of change in tip width associated with various narrowing techniques. The relationship between nasal skin thickness and tip narrowing will also be assessed. ...
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.
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.
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.
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).
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.
... "Boxy" and "ball" nasal tips are widely recognized to be aesthetically complex surgical problems; each has inspired imaginative solutions to correct the deformities that they impart. [1][2][3][4][5][6][7][8][9][10][11][12][13][14] It is my thesis, however, that the overwhelming majority of boxy and ball tips have an importance outside the lobule that has been understated in the surgical literature: namely, that both represent variations of alar cartilage malposition, 15 in which the lateral crus is cephalically rotated along an axis that points toward the medial canthus of the eye rather than the lateral canthus. The data that will be presented in this article indicate that the incidence of either boxy or ball tips is uncommon in patients with orthotopic alar cartilages (those whose lateral crural axes point toward the lateral canthi); that boxy and ball tips most often occur as foreshortened variants of alar cartilage malposition; and furthermore that the major importance of either the boxy or the ball tip is not only its cosmetic configuration within the tip lobule but also its functional ramifications outside the lobule at the external nasal valve. ...
Although "boxy" and "ball" nasal tips have received considerable attention in the rhinoplasty literature, their association with cephalic rotation of the alar cartilage lateral crura ("malposition") has not been emphasized. The thesis of this article is that most boxy and ball tips are not unique entities but rather constitute anatomical variants of alar cartilage malposition.
Data were generated from a review of 100 consecutive primary and 100 consecutive secondary rhinoplasty patients on whom the author had operated before February of 1999.
The majority of the patients (68 percent of primary rhinoplasty patients and 87 percent of secondary patients) studied had alar cartilage malposition (axes toward the medial rather than the lateral canthi) (p < 0.001). Orthotopic lateral crura were significantly more common than malpositioned lateral crura among primary patients (p < 0.001); conversely, the frequency of malpositioned crura was significantly higher in secondary patients than in primary patients (p < 0.001). Most of the primary and secondary patients with malposition (74 percent and 72 percent, respectively) had boxy or ball tips. Among patients with alar cartilage malposition, ball tips were most common (31 percent of primary patients and 36 percent of secondary patients); boxy tips were second-most common (19 percent of primary patients and 27 percent of secondary patients); the remaining patients had lateral crura that were considered to be "flat" (18 percent and 24 percent, respectively). The most common configuration among primary patients was the malpositioned boxy or ball tip with inadequate projection (54 percent). All primary and secondary rhinoplasty patients with alar cartilage malposition, regardless of tip lobular configuration, had incompetence at their external nasal valves; valvular reconstruction at least doubled the geometric mean nasal airflow in most patients. In primary patients, treatment for each variant was identical: lateral crural resection, crushing, and replacement along the alar rim. Some secondary patients also required composite grafts.
The morphological and functional results of this study indicate that the surgeon seeing a patient with a boxy or ball tip can predict that the patient has seven times the likelihood of having malpositioned, rather than orthotopic, lateral crura. The importance of most boxy and ball tips is therefore not only the lobular deformity itself but also the functional deficit associated with it.
Bulbous tip is one of the challenging problems and a chief complaint of Asians. It is necessary to establish a thorough operative plan through preoperative analysis based on an overall understanding of Asian anatomical characteristics that are different from those of Caucasians. Various operative techniques focused on the condition of thick SSTE and modern cartilaginous tip plasty should be performed to correct this.
There have been a variety of techniques describing nasal tip refinement. The cephalic trim has long been accepted as a means for shaping the nasal tip, but it has been misinterpreted by many surgeons. The improper use of a cephalic trim poses potential long-term sequelae. During analysis of the nasal tip, several anatomic findings must be noted to ensure appropriate correction as well as to avoid pitfalls. These findings include the type of boxy tip or bulbous tip, cartilage strength, and the skin quality. The goal of this article is to describe five types of cephalic trim techniques to assist in refining the nasal tip and an algorithm for selection of the appropriate technique based on these anatomic findings.
Importance
Alar rim retraction is the most common unintended consequence of tissue remodeling that results from overresection of the cephalic lateral crural cartilage; however, the complex tissue remodeling process that produces this shape change is not well understood.Objectives
To simulate how resection of cephalic trim alters the stress distribution within the human nose in response to tip depression (palpation) and to simulate the internal forces generated after cephalic trim that may lead to alar rim retraction cephalically and upward rotation of the nasal tip.Design, Setting, and Participants
A multicomponent finite element model was derived from maxillofacial computed tomography with 1-mm axial resolution. The 3-dimensional editing function in the medical imaging software was used to trim the cephalic portion of the lower lateral cartilage to emulate that performed in typical rhinoplasty. Three models were created: a control, a conservative trim, and an aggressive trim. Each simulated model was imported to a software program that performs mechanical simulations, and material properties were assigned. First, nasal tip depression (palpation) was simulated, and the resulting stress distribution was calculated for each model. Second, long-term tissue migration was simulated on conservative and aggressive trim models by placing normal and shear force vectors along the caudal and cephalic borders of the tissue defect.Results
The von Mises stress distribution created by a 5-mm tip depression revealed consistent findings among all 3 simulations, with regions of high stress being concentrated to the medial portion of the intermediate crus and the caudal septum. Nasal tip reaction force marginally decreased as more lower lateral cartilage tissue was resected. Conservative and aggressive cephalic trim models produced some degree of alar rim retraction and tip rotation, which increased with the magnitude of the force applied to the region of the tissue defect.Conclusions and Relevance
Cephalic trim was performed on a computerized composite model of the human nose to simulate conservative and aggressive trims. Internal forces were applied to each model to emulate the tissue migration that results from decades of wound healing. Our simulations reveal that the degree of tip rotation and alar rim retraction is dependent on the amount of cartilage that was resected owing to cephalic trim. Tip reaction force is marginally reduced with increasing tissue volume resection.Level of Evidence
NA.
Background:
Cephalic malposition of the lower lateral cartilage (CMLLC) is a relatively common anatomical variant, particularly in Middle Eastern patients. The characteristics of CMLLC include long alar creases, a boxy and ball-shaped nasal tip, parenthesis tip deformity and external valvular incompetence. The gold standard for correcting CMLLC is the lateral crural strut graft (Gunter graft), but many patients experience problems after this technique.
Objective:
To evaluate the efficacy of the repositioned lateral crural flap (RLCF) technique in correcting CMLLC, and to discuss the cosmetic and functional results.
Methods:
In the present study, 123 primary septorhinoplasty operations using the RLCF technique were performed between May 2012 and March 2013. The mean follow-up period was 11.4 months (range nine to 24 months). Four parameters were measured and compared pre- and postoperatively: the angle between the line connecting the maximum convexity of the lower lateral cartilage (LLC) to the tip-defining point and midline on each side (angle of rotation); the total distance between the maximum convexity of LLC right and left to midline (representing the size of the parenthesis deformity); satisfaction scale rating of the patients' nasal tip appearance; and the satisfaction scale rating of patients' breathing through their nostrils.
Results:
The mean angle of the LLC to the midline significantly increased and the mean distance between the maximum convexities was significantly reduced, indicating correction of the malposition and reduction of the parenthesis deformity, respectively. The mean satisfactory scale ratings of nasal tip appearance and breathing quality were also significantly improved.
Conclusion:
CMLLC can be corrected using the RLCF technique, resulting in both aesthetic and functional improvements.
Among other techniques, both the open and closed approaches are available in the field of rhinoplasty. The rhinoplasty is an efficient technique that can be used with the whole range of anatomical nose variations. It allows a more accurate intra-operative evaluation, a shorter surgical time, and a faster recovery than the open approach. The technical strategy presented here includes the following: step-by-step gentle lowering of the dorsum by a rasp and not by resection, tip refining by adequate resection of the cephalic alar cartilages, the use of the tongue-in-groove technique and septal extension graft to achieve an accurate and long-lasting tip projection, and the routine insertion of spreader grafts. Pleasant aesthetic results are achieved using this 5-step process even in very difficult cases.
The English full-text version of this article is available at SpringerLink (under “Supplement”).
Background: Health care depends, in part, on the ability of a practitioner to see signs of disease and to see how to treat it. Visual illusions, therefore, could affect health care. Yet there is very little prospective evidence that illusions can influence treatment. We sought such evidence.
Methods and Results: We simulated treatment using dentistry as a model system. We supplied eight, practicing, specialist dentists, endodontists, with at least 21 isolated teeth each, randomly sampled from a much larger sample of teeth they were likely to encounter. Teeth contained holes and we asked the endodontists to cut cavities in preparation for filling. Each tooth presented a more or less potent version of a visual illusion of size, the Delboeuf illusion, that made the holes appear smaller than they were. Endodontists and the persons measuring the cavities were blind to the parameters of the illusion. We found that the size of cavity endodontists made was linearly related to the potency of the Delboeuf illusion (p,.01) with an effect size (Cohen’s d) of 1.41. When the illusion made the holes appear smaller, the endodontists made cavities larger than needed.
Conclusions: The visual context in which treatment takes place can influence the treatment. Undesirable effects of visual illusions could be counteracted by a health practitioner’s being aware of them and by using measurement.
Historically, one of the most persistent challenges to the rhinoplasty surgeon has been the thick, heavy, and poorly defined nasal tip. In the Mediterranean, Anatolian, and Middle Eastern regions, rhinoplasty is the most frequently performed aesthetic procedure. In these regions, the ethnic characteristic of the nasal tip is mostly broad with thick skin, a poorly defined nasal tip, and weak lower lateral cartilages, which makes shaping the tip challenging. In this population, conventional rhinoplasty techniques may result in dissatisfied patients and surgeons.
The author presents his experience over the past 20 years with 3800 rhinoplasty patients with broad noses treated using his personal approach.
Using the Turkish delight type of cartilage graft (diced cartilage wrapped in Surgicel) for the tip region and the columellar strut improved the author's results considerably, giving the tip the desired form and eliminating the complications of late show seen in other types of tip grafts. In patients with very short columellae, insertion of a secondary strut was necessary after 1 year.
: This technique is safe, reliable, effective, simple, and easily applicable by plastic surgeons at all experience levels. Early and late results are very satisfactory, and there is no late show as is sometimes seen with other types of cartilage grafts such as crushed, oval, or rectangular grafts.
Therapeutic, IV.
Learning objectives:
After reading this article, the participant should be able to: 1. Discuss desired preoperative aesthetic and functional assessment of the postsurgical nose with rhinoplasty patients. 2. Identify factors that have the potential to affect procedural outcomes. 3. Develop an operative plan to address aesthetic goals while preserving/improving nasal airway function. 4. Recognize and manage complications following rhinoplasty.
Summary:
Rhinoplasty is one of the most commonly performed aesthetic surgical procedures in plastic surgery. Over the past 20 years, the trend has shifted away from ablative techniques involving reduction or division of the osseocartilaginous framework to conserving native anatomy with cartilage-sparing suture techniques and augmentation of deficient areas to correct contour deformities and restore structural support. Accurate preoperative systematic nasal analysis and evaluation of the nasal airway, along with identification of both the patient's expectations and the surgeon's goals, form the foundation for success. Intraoperatively, adequate anatomical exposure of the nasal deformity; preservation and restoration of the normal anatomy; correction of the deformity using incremental control, maintenance, and restoration of the nasal airway; and recognition of the dynamic interplays among the composite of maneuvers are required. During postoperative recovery, care and reassurance combined with an ability to recognize and manage complications lead to successful outcomes following rhinoplasty.
Herein, I describe lateral crural setback with cephalic turn-in flap as a new technique for management of the drooping nose. I report a technique for reinforcement of the alar cartilage after partial removal of its caudal portion used in 23 patients during open rhinoplasty. An objective assessment, which included measurement of nasal tip rotation and projection, was applied preoperatively and postoperatively. The average follow-up period was 11 months. Satisfactory results were achieved that resulted in an increase in the degree of nasal tip rotation. The mean increase of the nasolabial angle was 12°. This technique allows increasing the nasal tip rotation in an incremental fashion with preservation of nasal valve function and the strength and stability of the tip complex.
A novel technique for maintaining nasal tip support and external nasal valve integrity is proposed. The procedure involves mobilizing the lateral crus to a more cranial position after altering its shape from convexity to a more flat shape.
With the described technique, the lower lateral cartilage is dissected free from the skin in a retrograde fashion after an inter cartilaginous incision. The ligament between the lateral crus and the upper lateral cartilage is cut. The vestibular mucosa is not freed. With this maneuver,the lateral crus usually flattens sufficiently. When the convexity flattens, an extra millimeter of cartilage at the cephalic end is gained in the horizontal dimension. When the cut vestibular mucosa is sutured back to its place, the cephalic end of the lateral crus is advanced over the upper lateral cartilage. This technique allows durable support to maintain patency of the nasal valve. No bridges are burned because no cartilage is excised. The surgeon is left with the flexibility to modify the result on the operating table.
The technique was successfully used for 48 consecutive patients over a 3-year period. All the operations were primary rhinoplasties performed using a closed technique. The mean age of the patients was 32 years. For 72% of the patients, septoplasty also was performed. None of these patients had to undergo reoperation.
The authors emphasize the importance of the lateral crus in rhinoplasty and demonstrate that good results at the tip of the nose can be accomplished without cephalic trimming, averting related complications in selected cases.
The nose is one of the most operated organs in the body and its anatomy has been well defined by plastic and ENT surgeons. Although rhinoplasty is the most commonly performed operation in plastic surgery, some unexpected results and complications may be related to unknown or unclarified anatomical structures in the nose. We aimed to evaluate the interdomal region in four fresh cadavers and 24 patients who underwent open rhinoplasty, since the nasal tip area is the most difficult part of the rhinoplasty. Detailed cartilage and soft tissue interactions were studied in fresh cadavers. The existence of the interdomal fat pad as a separate anatomical structure was proven in necropsy specimens from cadavers using various histochemical dyes. Nasal tip ultrasonography was performed preoperatively in patients who underwent rhinoplasty. All patients had a fat pad in the interdomal space, of varying sizes, but fatty (bulbous) noses had larger fat pads. Interdomal fat pad tissue, which occupies the interdomal space, was demonstrated by ultrasonography. The size of the fat pads varied from 1.2 mm x 2.4 mm to 3.6 mm x 5.2 mm. Anatomical observation and biopsies were performed during surgery. Finally, surgical and radiological anatomy of the interdomal fat pad was demonstrated in all cadavers and patients. We speculate that the interdomal fat pad is an important anatomical structure and may contribute to unexpected postoperative results in rhinoplasty. This newly defined fat pad can be assessed by ultrasonography, a safe and inexpensive technique. The surgical approach to the interdomal fat pad is solely through open rhinoplasty technique. Thus, a consideration of the interdomal fat pad and detection of its size preoperatively may play a key role in choice of technique and success of rhinoplasty.
To the plastic surgeon, the nose is one of the most interesting and challenging facial structures and its anatomy is well defined. From the point of view of aesthetic surgery, the nasal tip area is an especially important structural unit, and the most difficult to address in rhinoplasty. The objective of this study was to demonstrate the existence of the nasal interdomal fat pad as a distinct anatomical structure that occupies the interdomal space and is apart from subcutaneous fat. In our study we proved the existence of the interdomal fat pad by histochemical studies and anatomical observations in 88 patients who underwent primary external rhinoplasty and three fresh cadavers. All specimens were examined by hemotoxylen-eosin, Sudan black, and oil red staining, as well as S100 protein immunoreactivity staining. The mass of the interdomal fat pad was greater in patients with bulbous noses and/or divergent alar cartilage than in patients with thin skin. We speculated that the interdomal fat pad may be the major anatomic structure contributing to unexpected results in difficult cases, such as those involving bulbous noses. According to our study, the existence of the interdomal fat pad should be kept in mind during the preoperative planning of rhinoplasty.
The authors stress that conservative correction should be the main goal in aesthetic and functional rhinoplasty. The surgeon controls the operative event and must be skilled at manipulating and controlling the dynamics of postoperative healing to achieve long-term functional and aesthetic results.
A bulky nose is a challenging issue to manage, and surgeons have not found the ultimate solution to this problem in the evolution of rhinoplastic surgery. Because of the multiplicity of techniques and controversies published in the literature, it has become confusing for the operating surgeon to find the most appropriate and effective way of solving this frustrating dilemma. The subcutaneous fat is the thickest in the supratip area, and the soft tissue thickness over the tip of the nose varies considerably from patient to patient. The focus of this study was to find a method for reducing the overlying soft tissue of the tip for better re-draping of skin over the nasal skeleton. The hallmark of this technique is to undermine the nasal skin in two layers. We believe that soft tissue trimming in biplane dissection can minimize the thickness of the tip skin in a relatively safe and homogeneous way. With this report we introduce a new method of dissection of nasal soft tissue and of trimming it in different areas of the nose for different purposes. In the authors' opinion, this approach is one of the most effective ways of handling unpliable, thick nasal skin.
Resection of the cephalic or middle portion of lateral crura of alar cartilages is a method for correcting bulbous nose in which the resected cartilages usually are discarded, resulting in a waste of autologous tissues. A silastic implant usually is used to correct saddle nose in Asian countries, but implant extrusion, a severe complication, sometimes occurs. Cartilage flaps were first reported by José to increase the projection of the nasal tip. In this study, the authors used cartilaginous flaps of the lateral crura to wrap the tip of the nasal implant for patients with bulbous and saddle noses. This study aimed to investigate the application of cartilaginous flaps of lateral crura.
A flap was created from the cephalic portion of the lateral crus of the alar cartilage, leaving the caudal portion intact. The cartilage flap remained attached at the level of the original domal segment of the middle crura. It was rotated over to wrap the tip of the silastic implant, then sutured to the other side flap.
From March 2003, 19 patients were treated with this technique. The results were satisfactory without implant extrusion or any other complications except for nonobvious scars.
The cartilage flap can reduce the incidence of implant extrusion and help to reduce the size of the bulbous tip.
Tip surgery, the most important part of the rhinoplasty procedure, has entered a new era in the past few decades. Various treatment protocols have been attempted. To date, however, opinions on the management of the Asian tip have not been solidified. To generalize and provide appropriate guidelines for the treatment of typical Asian tips, an English literature search from 1977 to March 2007 was conducted. Finally, a total of 26 papers were selected for review. The full text of each paper was read carefully, and data were extracted. Then all extracted information was imported into Microsoft Excel. Nine articles treating 11 groups of patients described the suitable techniques for Asian nasal tips, with 81.8% of the groups advocating that the protocol include a grafting technique, 64% reporting use of the grafting technique alone, and 9% applying cartilage reduction and a suturing technique. Of the 11 (18%) groups, 2 attempted more than one technique. Because of the Asian nasal tip's innate qualities, success with nasal tip plasty for Asians depends on the combined application of appropriate suturing, grafting, and defatting, with grafting techniques contributing the most.
Bulbous nose is a ball-like nasal deformity, frequently seen in postoperative cleft lip patients, that is hard to prevent despite numerous techniques available for nasal tip plasty. Here we describe a new method for correcting bulbous nose in cleft lip patients by creating an ideal alar groove.
A subcutaneous flap with the pedicle of the overlying skin connected circumferentially is made just beneath the position for the ideal alar groove. The subcutaneous flap is fixed to the septum cartilage to create the alar groove depression on the nasal tip. This method is generally performed in conjunction with other rhinoplasty using the open nasal approach.
Three postoperative cleft lip and nose patients underwent alar groove plasty combined with rhinoplasty. All retained good contour after the operation.
Alar groove plasty using the subcutaneous flap technique improves bulbous nose deformities of cleft lip patients and can retain good postoperative contour.
Design and placement of autogenous vomer or cartilage grafts in the nasal tip are reported. Mobility of the nasal tip, quality of the graft material and the effect of the contour of the nasal tip are discussed.
This retrospective study was undertaken to investigate the soft-tissue response rate to the skeletal and soft-tissue alterations following a rhinoplasty. Ninety-eight patients, 80 females and 18 males, with a mean follow-up of 13 months, were included in this study. The tracings of the outline of preoperative cephaloxerograms and life-size photographs were superimposed on the postoperative ones, and the differences were measured and confirmed with measurements of intraoperative resected segments. The soft-tissue response to skeletal alterations was measured in seven different zones. Zone 1 (nasion) and zone 7 (nasal spine area) had the lowest mean response rate of approximately 25 percent. Zone 2 (proximal bridge) and zone 3 (midbridge) had a 60 percent response rate. Zone 4 (supratip area) had a 43 percent response, zone 5 had a 41 percent response, and zone 6 had a 40 percent response rate. There were statistically significant differences among the response rates of thick, medium, and thin noses. Age was an important factor in zones 1, 4, 5, 6, and 7. The patient's sex did not influence the soft-tissue response rate to skeletal alterations. The soft-tissue response in relation to the alar base narrowing was about 52 percent. This study reveals a predictable soft-tissue response to skeletal alterations on all zones except zone 7 (nasal spine area).
Conflicting guidelines for excisions about the alar base led us to develop calibrated alar base excision, a modification of Weir's approach. In approximately 20% of 1500 rhinoplasties this technique was utilized as a final step. Of these patients, 95% had lateral wall excess ("tall nostrils"), 2% had nostril floor excess ("wide nostrils"), 2% had a combination of these ("tall-wide nostrils"), and 1% had thick nostril rims. Lateral wall excess length is corrected by a truncated crescent excision of the lateral wall above the alar crease. Nasal floor excess is improved by an excision of the nasal sill. Combination noses (e.g., tall-wide) are approached with a combination alar base excision. Finally, noses with thick rims are improved with diamond excision. Closure of the excision is accomplished with fine simple external sutures. Electrocautery is unnecessary and deep sutures are utilized only in wide noses. Few complications were noted. Benefits of this approach include straightforward surgical guidelines, a natural-appearing correction, avoidance of notching or obvious scarring, and it is quick and simple.
Two hundred and forty patients who underwent a corrective rhinoplasty have been presented. Of these, 224 patients (93.3 percent) had a cartilage repositioning procedure in which the alar cartilages were only undermined and repositioned, and 16 patients (6.7 percent) had a cartilage resection procedure. The techniques and indications for both procedures are described and discussed. The results obtained in this series of patients indicate that cartilage repositioning is an effective and reliable procedure to refine and reshape the nasal tip. Cartilage resection is less reliable and should be reserved for a few selected patients with specific indications. Indiscriminate resection of the lower alar cartilage is neither warranted nor wise.
Correction of the bulbous nasal tip is difficult. Numerous techniques for tip rhinoplasty have been described, but many differ in their treatment of the wide intercrural angle and the flared lateral crus, which are characteristics of the bulbous tip. The technique described in this article has been used successfully on 44 patients over the last two years. The technique is as follows: if the skin is thick and there is adequate projection of the tip, the rim should be transected just lateral to the genu. If there is too much projection, a piece of the rim should be removed. If the skin is thick and there is adequate projection of the nose but a bulbous appearance because of the flared arch, a portion of the arch should be resected without removal of the lining. If there is unilateral or asymmetrical deformity, the individual segments can be resected.
This paper presents a new, comprehensive, and systematic approach to analysis, planning, and techniques of primary nasal tip rhinoplasty, emphasizing techniques that limit uncontrollable variables before proceeding to techniques which increase uncontrollable variables and risk secondary deformity, including (1) maintenance of structural integrity of the alar rim strips, limiting use of scoring or morselization techniques which reduce support and introduce potential secondary deformities, (2) shaping and positioning the lateral and medial crura in a reversible, nondestructive manner using permanent suture and nonvisible control graft techniques, (3) minimizing uncontrollable postoperative variables by decreasing the need for visible grafts to shape the tip complex in primary rhinoplasty, achieving the same results with existing alar structural elements, (4) integrating these concepts with specific sequences of surgical techniques--bilateral alar arch components individually positioned, then shaped and unified for symmetry, and finally positioned for rotation and projection--and (5) introducing an integrated set of surgical techniques and sequencing of tip surgery to achieve the objectives listed above in most primary and some secondary rhinoplasties. The concepts and techniques of this approach are based on the principle that preservation of structural integrity of alar complex elements (medial and lateral crural arch elements) preserves support and reduces the incidence of secondary deformities (kinking, buckling, discontinuity) that can result from shaping techniques which disrupt that integrity. If shaping and positioning of the tip can be achieved with reversible, nondestructive techniques, the need for placement of visible grafts (with their additional variables) is greatly reduced. Shaping and positioning can be performed incrementally and reversibly without jeopardizing structural integrity and support in the surgical process. Ten fresh cadaver dissections were utilized in the development of the surgical techniques. A total of 233 rhinoplasties (220 primary and 13 secondary) with 1 to 9 years of follow-up have been performed using this approach. Only two secondary procedures for tip deformity have been performed.
External shaving is an accepted technique in the treatment of rhinophyma. The application of external shaving to aesthetic rhinoplasty is also valuable in the treatment of a thick, sebaceous nasal tip that does not respond to standard reduction rhinoplasty. External shaving will reduce the thickness of the nasal tip skin and enhance tip definition. Fifty consecutive patients undergoing external shaving were followed over a 5-year period. The majority of the cases were secondary rhinoplasties. The results reveal a very high success rate, with one significant complication, a hypertrophic scar, and two minor complications. Proper diagnosis, patient selection, and surgical technique produce predictable and favorable aesthetic results.
The lateral crural strut graft is a new, versatile technique for reshaping, repositioning, or reconstructing the lateral crura. These grafts are strips of autogenous cartilage that are sutured to the deep surface of the lateral crura. Lateral crural struts are useful in the correction of the boxy nasal tip, malpositioned lateral crura, alar rim retraction, alar rim collapse, and concave lateral crura. We describe the surgical technique and demonstrate representative results of our experience with these grafts in 118 patients.
Inadequate nasal tip projection is the most common problem of primary and secondary rhinoplasty. Inadequate nasal tip projection with inadequate septal support requires an umbrella graft. The umbrella graft consists of a vertical cartilaginous strut between the medial crura and a horizontal onlay graft overlying the alar domes. The umbrella graft supports the nasal tip pyramid and reestablishes nasal tip projection. The statistics included in this report involve 1252 cases from 1986 to 1996, and it was discovered that 22 percent of the patients required an umbrella graft. Most of these patients had secondary rhinoplasties. The revision rate was 5 percent; the most common complication was cartilaginous show. Cartilage graft loss or significant absorption was not observed. A closed rhinoplasty approach with autologous tissue to reconstruct nasal tip projection was used. The umbrella graft technique is time proven, successful, and reproducible.
At the center of the tip, the tip points (TPs) are the single most defining feature of a nose. In a random survey (N = 146; females, 76; males, 70), TPs were 8.9 +/- 1.6 mm apart. TP quality was graded into four categories based on the criteria of presence, interdomal crease, base width, and distinction. The distributions of TPs according to TPG were as follows: I, 12%; II, 50%; III, 30%; and IV, 8%. The TPG system was applied to a collection of photographs of female Caucasian magazine models, which had a distribution similar to that of the Caucasian females in the study population, demonstrating the effectiveness of grading. Surgical guidelines for the preservation and generation of TPs are presented, especially the geometric consequence of various surgical maneuvers, e.g., dome division and tip graft.