A New Extrasupported Tip Graft in the Treatment of Bulbous Nasal Tip

Treatment of bulbous nasal tip is difficult. In the presence of thick, inelastic skin, cartilaginous framework should be supported in special areas. Many tip grafting techniques have been described but the results usually are not satisfactory. We developed a new tip grafting technique to provide extra support and extra length to the nasal tip. The graft is prepared from the septal cartilage and has an extended ``A' appearance. The tip graft is supported with a columellar strut graft. Both grafts are inserted into small separate pockets through separate incisions. If necessary, the alar base is reduced with a modified Weir technique. Fifty-two patients were treated with this technique over the last 3 years. Results were satisfactory in all patients without any complications such as graft displacement, infection, or resorption. Extrasupported tip graft is an effective method in the treatment of bulbous nasal tip with thick skin.     

Tip graft from the cartilaginous dorsum in rhinoplasty

A cartilage graft from the cartilaginous hump can be used in primary rhinoplasty for nasal tip projection. This technique has now been used for two years without complications in 35 patients with similar nose deformities, which included an inadequately projected tip and a high dorsal line. These grafts have proved to be another easy way to get an adequate tip projection in primary rhinoplasty.Paper presented at The Annual Meeting of the American Society for Anesthetic Plastic Surgery, in Los Angeles, California, April, 1983     

A Simplified Use of Septal Extension Graft to Control Nasal Tip Location

Background For defining the shape and projection of the nasal tip, the bilateral and symmetric batten-type septal extension grafts proposed by Byrd and colleagues have drawbacks. The main problems are stiffness of the nasal tip and thickening of the septum in the nasal valve area. Methods Since 1998, unilateral single-batten grafts, and more frequently, bilateral asymmetric batten grafts as compared with Byrd’s bilateral symmetric application, have been used for 72 patients in our facility. Results At the 6-month postoperative follow-up assessment, tip projection was found to be satisfactory in 61 patients. Less than desired projection occurred in three cases and overprojection in two cases. Nasal lobule deviation was evident in one patient. The loss of the columellar break point was evident in five cases. Conclusion Unilateral or asymmetric bilateral batten grafts facilitate adjustment of the nasal tip intraoperatively. This technique results in a more pliable nasal tip in the horizontal plane. Construction of a three-layered cartilage in the nasal valve area is not needed, and the nasal airway is preserved. With this modification, a reliable and predictable nasal tip location is obtained with a minimum of graft usage.     

Nasal Tip Plasty Using Various Techniques in Rhinoplasty

Rhinoplasty is one of the most common aesthetic surgical procedures in Korea today. However, simple augmentation rhinoplasty results often failed to satisfy the high expectations of patients. As a result, many procedures have been developed to improve the appearance of the nasal tip and nasal projection. However, the characteristics of Korean nasal tips including the bulbous appearance (attributable to the thickness of the skin), flared nostrils, and restriction of the nasal tip attributable to an underdeveloped medical crus of the alar cartilage and a short columella have made such procedures difficult. Currently, most plastic surgeons perform rhinoplasty simultaneously with various nasal tip plasty techniques to improve the surgical results. An important part of an aesthetically pleasing result is to ensure an adequate nasal tip positioned slightly higher than the proper dorsum, with the two tip defining points in close proximity to each other, giving the nose a triangular shape from the caudal view. From June 2002 to November 2003, the authors performed rhinoplasty with simultaneous nasal tip plasty using various techniques according to the tip status of 55 patients (25 deviated noses, 9 broad noses, 15 low noses, and 6 secondary cleft lip and nose deformities). The surgery included realignment of alar cartilage by resection and suture, fibroareolar and subcutaneous tissue resection, tip graft, and columellar strut. The postoperative results over an average period of 10 months were entirely satisfactory. There were no patient complaints, nor complications resulting from the procedures. Good nasal tip projection, natural columellar appearance, and improvement of the nasolabial angle were achieved for most patients. In conclusion, rhinoplasty with simultaneous nasal tip plasty, achieved by a variety of techniques according to patients tip status, is an effective method for improving the appearance of the nose and satisfying the desires of the patients.     

Augmentation of the Columella-Labial Angle to Prevent the ``Smiling Deformity' in Rhinoplasty

Aesthetic diagnosis of the smiling deformity, which is functional rather than anatomical, is essential to provide the best treatment in rhinoplasty. The nasal tip tends to rotate inferiorly during smiling, and the central upper lip moves superiorly. A posteriorly sloping upper lip with a retrodisplaced columella–labial junction gives an unaesthetic appearance. Downward movement of the tip and a sharper nasolabial angle are usually aesthetically unpleasant. In 28 nasal surgeries, augmentation of the columella–labial angle with cartilage strip grafts has been performed. The augmentation of the angle and additionally cutting of the depressor septi muscle created a wider nasolabial complex, and this angle looks full and more pleasant. This procedure has mainly been used as an additional procedure to standard reduction rhinoplasty in order to improve smiling deformity. Strip cartilage grafts were inserted subcutaneously into the upper lip extending half way to the columella and secured with a transcutaneous suture under the columella–labial angle to prevent misslocation. Augmentation by the cartilage graft together with cutting the depressor septi muscle prevented elevation and shortening of the upper lip, and also drooping of the nasal tip. This procedure provided an aesthetically pleasant appearance both at rest and during smiling.     

Effect of Nasal Tip Surgery on Asian Noses Using the Transdomal Suture Technique

The past two decades have ushered in a new era of nasal tip surgery. The new philosophy focuses on preserving and reorienting nasal tip structures. Modern suture techniques can give predictable results because of more precise suture placement. Only a few reports, however, have objectively evaluated the suture techniques for Asians. Accordingly, the authors aimed to assess the efficacy of the tip suture technique through projection and rotation analysis. We focused on transdomal sutures because they involve one of the most popular suture techniques. Preoperative and postoperative photographs of 85 patients who underwent rhinoplasty at Inha University Hospital between June 2002 and June 2004 were analyzed. The patients were categorized into four groups according to the techniques used. Tip projection was measured by the modified Heuzinger’s method and tip rotation by the nasolabial angle. The pre- and postoperative indexes were compared within each group and among the four groups. Paired and unpaired t tests were used for statistical analysis. When the pre- and postoperative indexes were compared within each group, only the combined technique (transdomal suture with onlay graft) showed significant tip projection improvement. All tip surgeries resulted in insignificant tip rotation increase. Comparison among the four groups showed no significant difference based on the type of tip surgery performed. The suture technique has many advantages, although it has some limitations with Asian noses, especially if used alone. Therefore, we recommend using the suture technique in combination with other tip surgical procedures, such as onlay grafts, to achieve significant tip projection.     

Management of the Long Nose: Review of Techniques for Nasal Tip Supporting Structures

The long nose with a “plunging” tip is a deformity that involves an inferiorly rotated nasal tip, leading to an increase in the length of the nose. The anatomic basis of the long nose with a plunging tip may be divided into two types. Type 1 presents a normal alar–cartilage complex inferiorly displaced by a long nasal septum and long upper lateral cartilages. Type 2 is caused by a dislocation of the alar cartilages downward from the aponeurotic attachments to the septal angle. During the study period, the authors identified 60 patients with long noses and plunging tips. For 22 patients with type 1 long noses, the high septal incision technique was used in 12 cases and the step technique in 10 cases. The invagination procedure alone was used for 22 of 38 patients with type 2 plunging noses. Also, an extension graft with the invagination procedure was used for 6 patients, and a columellar strut graft was used for 10 patients. A high septal incision increased tip rotation without significantly changing the amount of tip projection. However, the step procedure, the invagination technique alone, septal extension graft with the invagination technique, and columellar strut grafts increased nasal tip rotation and projection. During the study period, 38 patients were identified as having a smiling deformity, which was improved using the authors’ modification procedure. On the basis of the results, the authors recommend that the appropriate treatment for each patient with a long nose and a plunging tip must be determined by preoperative and intraoperative examination findings with the patient at rest and while smiling.     

Use of umbrella graft for nasal tip projection

An adequate nasal tip projection is of the utmost importance for good nasal aesthetics. Conventional rhinoplasty procedures are not adequate for achieving nasal tip projection in tips with inadequate projection (TIP). This article describes our technique of using an umbrella-shaped cartilage graft to the tip. The graft is carved from caudal septal and alar cartilages. The results and advantages of the technique are discussed.     

Allogenous Cartilage Graft Versus Autogenous Cartilage Graft in Augmentation Rhinoplasty: A Decade of Clinical Experience

Cartilage grafts have great value in augmentation rhinoplasty. For most surgeons, an autogenous cartilage graft is the first choice in rhinoplasty because of its resistance to infection and resorption. On the other hand, an allogenous cartilage graft might be preferred over an autogenous graft to avoid additional morbidity and lengthened operating time. Allogenous cartilage grafts not only have the advantage of averting donor site morbidity but also are resistant to infection, resembling autogenous cartilage grafts. The authors present their experience with 41 patients who underwent augmentation rhinoplasty using 22 autogenous and 19 allogenous cartilage grafts between June 1994 and August 2004. For evaluation of adequate augmentation rates, photographic analyses were performed on preoperative, early postoperative, and late postoperative photographs from all the patients. To assess patient satisfaction, the Facial Appearance Sorting Test (FAST) was applied preoperatively and late postoperatively in both groups. These results were compared, and it was concluded that in terms of resorption, there was no difference in the early and late postoperative follow-up data between allogenous and autogenous cartilage grafts. Evaluation of the preoperative and early postoperative photographic outcomes showed statistically significant differences with respect to adequate augmentation rates between the two groups. The FAST scores showed statistically significant differences between preoperative and late postoperative outcomes. There were no infections in the two groups of patients. Commentary to DOI: .     

Nasal tip refinement in primary rhinoplasty: The cephalic trim cap graft

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.)     

New concepts in nasal tip contouring

Control of nasal tip contour has always been a key component of a successful rhinoplasty. Typically, this procedure is performed with an emphasis on narrowing the nasal tip structure. Creating a natural-appearing nasal tip contour is a complex task and requires a 3-dimensional approach. In an effort to identify the characteristics that make an ideal nasal tip, I evaluated numerous aesthetically pleasing nasal tips. After extensive study, I created a series of images to demonstrate how specific contours create highlights and shadows that will help guide the surgeon in creating a natural-appearing nasal tip contour. Many commonly used nasal tip techniques can pinch the tip structures if an overemphasis is placed on narrowing. These changes isolate the dome region of the nasal tip and can create an undesirable shadow between the tip lobule and alar lobule. Prior to contouring the nasal tip, the surgeon must stabilize the base of the nose with a columellar strut, suturing the medial crura to a long caudal septum, caudal extension graft, or an extended columellar strut graft. Stabilizing the nasal base will ensure that tip projection is maintained postoperatively. To contour the nasal tip, dome sutures are frequently used to flatten the lateral crura and eliminate tip bulbosity. Placement of dome sutures can deform the lateral crura and displace the caudal margin of the lateral crura well below the cephalic margin. This can result in a pinched nasal tip with the characteristic demarcation between the tip and the alar lobule. Alar rim grafts can be used to support the alar margin and create a defined ridge that extends from the tip lobule to the alar lobule. This form of restructuring can create a natural-appearing nasal tip contour with a horizontal tip orientation continuing out to the alar lobule. When dome sutures alone are inadequate, lateral crural strut grafts are used to eliminate convexity and prevent deformity of the lateral crura. Shield tip grafts can be used in patients with thick skin and an underprojected nasal tip. Whenever a shield tip graft is used, it must be appropriately camouflaged to avoid undesirable visualization of the graft as the postoperative edema subsides. When contouring the nasal tip, the surgeon should focus more on creating favorable shadows and highlights and less on narrowing. Nasal tips contoured in this manner will look more natural and will better withstand the forces of scar contracture that can negatively affect rhinoplasty outcomes.     

The comma-shaped tip cartilage graft

Conventional onlay grafts of cartilage to the tip, columella, and alar margin provide valuable techniques for the refinement of minor deformities in both primary and secondary rhinoplasty. However, they cannot produce a full restoration of the dynamic anatomy of the lower lateral cartilages, which give forward thrust and arch support to the tip and nostril margins. For these grosser problems another graft design has been devised by the author. A report is given of the successful use of a comma-shaped septal graft used for over five years in selected cases of secondary rhinoplasty. The graft replaces the deficient lateral crus and alar dome and is sculpted and then sprung into position so that it restores function and gives the desired aesthetic effect.     

Bone Chips and Diced Cartilage: An Anatomically Adopted Graft for the Nasal Dorsum

Since 1996, cranial bone chips or septal bone chips harvested during septal deviation surgery and small chips of ear or septal cartilage have been used in 67 patients for dorsal nasal augmentation or for smoothing dorsal nasal irregularities. In this study, 59 overresections of ostecartilaginous nose structures during previous aesthetic nose surgeries and 8 primary rhinoplasties occasioned the use of bone or cartilage grafts. For 57 patients both bone and ear cartilage grafts were used for the reconstruction. Bone grafts were used for seven cases and cartilage grafts for three cases.The results from 7 years, of experience with this method of nasal dorsum reconstruction were satisfactory and durable. The most important advantage of this method is that the bony side of the nose is reconstructed with bone and the cartilage side with cartilage. Another advantage is that the bone chips are incorporated with both nasal bones, building a strong dorsal nasal bony monoblack.This technique also is useful for augmenting mild saddle nose deformity and dorsal nasal projection deficiency on the bony part, cartilage part, or both parts.Presented at 16th Congress of ISAPS, Istanbul, Turkey, 26–29 May 2002 and 24th National Meeting of the Turkish Plastic Reconstructive Aesthetic Surgery Society, Ankara, Turkey, 18–20 October 2002.     

Use of costal cartilage cantilever grafts in negroid rhinoplasties

Dorsal augmentation and nasal tip refinement are important objectives in Negroid rhinoplasty. Use of a costal cartilage cantilever graft will achieve these objectives. We report on our experience in 19 patients. The technique offers an excellent solution to supplying the large amount of material often required to adequately augment the dorsum in these patients. The graft is also versatile enough to allow nasal tip refinement. There are additional aesthetic benefits as the cantilever causes a lengthening in the nasal columella, a reduction in the flare of the nostrils, and increases the columellar-labial angle. The procedure is relatively simple to perform. The problem of warping is minimized by symmetrical carving and the use of large grafts with a substantial cross-section.     

耳软骨在二次隆鼻术及鼻尖成形术中的应用

目的：探索二次隆鼻术及鼻尖成形术的方法。方法：采用鼻小柱“飞鸟”形切口加鼻翼软骨缘切口,切开分离皮肤、皮下组织,显露假体并取出,分离两侧鼻翼软骨及侧鼻软骨等,将取下的耳软骨缝合固定于新雕刻假体的顶部及短壁上,插入鼻背固定,缝合双侧穹窿部鼻翼软骨,缝合切口。结果：自2010年6月～2013年6月对46例不满意隆鼻术行二次隆鼻及鼻尖成形术,获得满意的手术效果。术后鼻尖形态自然、鼻长度延长、高度增加、歪鼻也得到矫正等。结论：用自体耳软骨及硅胶假体行二次隆鼻术及鼻尖整形术,能解决鼻尖不良形态,矫正鼻偏斜、鼻孔外露、增加鼻长度,获得鼻部整体形态自然协调的效果,是一种理想的手术方法。     

隆鼻术中鼻尖整复的体会

目的：为使鼻尖低平或鼻小柱下垂者在隆鼻术中达到更好的效果。方法：对65例患者在隆鼻术的同时利用自体的鼻翼软骨进行界尖抬高,通过切除部分中隔软骨进鼻算小柱下垂的繁复。结果：经随访一周至半年,效果满意。结论：本文所述方法简单易行,并发症少,患者容易接受,术后外形自然。     

A Technical Refinement to Prevent Supratip Deformity in Aesthetic Rhinoplasty: “The Trapezoid Peak”

Background The relationship between appropriate caudal dorsum resection and supratip deformity or inadequate tip projection currently is clear. Correct quadrangular cartilage management seems to have a basic role in the final tip aspect after aesthetic rhinoplasty. Methods Primary aesthetic rhinoplasty was performed for 38 Caucasian patients. A septal refinement was used for patients requiring extra tip support and not requiring grafts. Results The minimum follow-up period was 1 year. No supratip deformity was noted after surgery. The tip and midvault had adequate projection. Conclusions The described maneuver sustains the alar cartilage without sutures, preventing supratip deformity, sustaining soft tissues, and avoiding loss of tip projection. Presented at the 51st National Italian Congress of Plastic Surgery, SICPRE, Verona, Italy, 19–21 September 2002, and at the 9th International Congress of Italian and American Plastic Surgeons; New Orleans, 20 September 2004     

Versatile grafting at the nasal tip

Placing cartilage graft at the nasal tip is the most frequent technique to achieve proper tip projection and a well-balanced nose. The graft functions to support the nasal tip though reconstruction of the tripod concept legs and add greater definition to the tip. Tip grafts can be broadly classified into two categories: those that are used as mechanical nasal tip support, and those that are used for contouring or enchantment of nasal tip projection. This classification offers guidance to select the type of tip graft needed of overcome the present anatomy deformity.     

Autologous Cartilage Graft Rhinoplasties

Background: The authors report their experience with autologous graft rhinoplasties. Methods: Data were collected retrospectively, with selection of only autologous grafts from 2,000 rhinoplasties performed at the Plastic and Reconstructive Department of the University of Rome Tor Vergata. Results: A total of 62 patients from January 1995 to January 2005 were selected. Most of the patients were treated with the “open tip” technique, whereas 9.7% had a classic endonasal approach. Follow-up evaluation was performed with outpatient visits at 2 and 6 weeks, then at 3, 6, and 12 months. Good aesthetic results were obtained for 93.5% of the patients, and 83.7% had complete satisfaction. Conclusion: Autologuos cartilage graft rhinoplasty is an affordable technique easy to learn that widens possibilities of interventions for nasal pyramid reconstruction.