Asymmetric nasal tip

Asymmetry of the nasal tip is a common finding in the setting of primary and revision rhinoplasty. Careful preoperative analysis is imperative to identify the anatomic etiology of the asymmetry to develop an appropriate surgical plan to correct it. This article describes the anatomic structures that affect the overall appearance of the nasal tip, explains how intrinsic asymmetries can alter nasal tip appearance, and offers a menu of surgical techniques that can be used to correct these asymmetries.     

Grafting the projecting nasal tip

Cartilage grafting in some projecting nasal tips can enhance the result obtainable by modifying the alar cartilages alone: where there is a sizeable discrepancy between skin sleeve and skeletal volumes, or where a small tip requires a change in configuration. These principles are defined and illustrated in primary rhinoplasty.     

自体肋软骨移植构建鼻尖软骨复合体在鼻整形中的临床应用

目的：通过应用自体肋软骨重塑鼻尖软骨支架结构,形成稳定的鼻尖软骨复合体,来达到完美、立体的鼻尖外形,同时应用膨体聚四氟乙烯或硅胶假体支架抬高鼻背,从而达到理想的鼻部整形美容效果。方法：以鼻小柱基底部＂几＂字形切口和鼻孔内鼻翼软骨外侧缘切口,彻底分离皮肤达鼻翼基底部,对鼻尖短小朝天者可松解到达梨状孔边缘,显露两侧鼻翼软骨及侧鼻软骨,同时暴露鼻中隔软骨游离端;雕刻自体肋软骨,移植、固定到鼻中隔软骨上,贯穿缝合鼻翼软骨、移植的软骨,形成鼻尖软骨支架结构,构建鼻尖软骨复合体。雕刻膨体聚四氟乙烯或硅胶假体支架放置到鼻背鼻骨骨膜下抬高鼻背。结果：本组96例手术者均采用自体肋软骨移植构建鼻尖软骨复合体行鼻整形,术后7天拆线,切口Ⅰ/甲愈合。随诊6～12个月,95例术后鼻尖表现点明显,鼻形立体、挺拔,自然美观,鼻尖活动度好,效果满意。1例术者感觉鼻小柱下垂,通过修复移植软骨,达到满意效果。结论：应用自体肋软骨重塑鼻尖软骨支架结构,构建鼻尖软骨复合体,同时应用膨体聚四氟乙烯或硅胶假体支架抬高鼻背,可以达到理想的鼻部整形美容效果。     

Functional support of the nasal tip

Surgery of the nasal tip is among the most challenging aspects of rhinoplasty. Abnormalities of the nasal tip, whether primary or iatrogenic, have both functional and aesthetic consequences. This review focuses on the functional support of the nasal tip, surgical techniques commonly used to improve nasal tip support and function, and the effects of these techniques on the appearance of the nose.     

Metastatic tumours of the nasal tip

Two cases of metastatic tumour at the nasal tip are described. Both originated from a primary tumour of the bronchus. In each case the lesion was the first sign of an otherwise silent neoplasm.     

Correction of the secondary nasal tip

A technique used concomitantly with Rethi's incision to reach and treat the secondary nasal tip is described. The technique involves removing the cartilage remnants of both domes and placing a shaped cartilage autograft that is immobilized by sutures. No hypertrophic scarring has been observed in the 546 patients treated.     

Suture contouring of the nasal tip

Scoring, morselizing, and resecting the alar cartilages in an attempt to modify the position and shape of the nasal tip may lead to postoperative distortions of the lobule. Contour grafts have the disadvantage of asymmetries, visible irregularities, and absorption. For these reasons, surgeons have adopted suture techniques as the primary method of recontouring the alar cartilages. My philosophy in dealing with mild to moderate tip deformities consists of the following principles: (1) limited or no resection of cartilages; (2) no scoring or morselization of alar cartilages, which produces irreversible change and unpredictable results; (3) use of support grafts in the form of columellar struts and lateral crural battens to supplement structure and correct intrinsic alar cartilage weaknesses; (4) reliance primarily on the use of sutures to recontour and position the tip; and (5) limited use of contour grafts for situations that cannot be corrected with sutures and support grafts. Arch Facial Plast Surg. 2000;2:34-42     

Revision of painful distal tip amputations

From 1968 to 1987, 22 patients were diagnosed with dysfunctioning digits after complete distal digital amputations. Each patient had the proximal portion of the partially amputated phalanx left within the injured digit. On average, 21 months after the initial injury, each patient underwent an excision of the remnant portion of the phalanx which averaged 6 mm (range 1 to 17 mm). All 22 patients reported excellent postoperative results of full function and no residual pain with an average follow up of 9 months. We theorized that localized synovitis produces joint pain related to: 1) nontolerated joint stress loading due to a change in the lever arm length of the amputated phalanx, or 2) inadequate cartilage nutrition owing to lack of stress applied to this joint. Maintaining digital length must be rethought with emphasis placed on painless function. Considering the losses to these patients in terms of time, employment, and money, a distal remnant measuring 4 mm or less should be excised, regardless of the digit, at the time of the injury.     

The droopy nasal tip

Nasal tip drooping following primary rhinoplasty often results secondary to disruption of nasal tip support. Predictable correction of this problem requires restoration of support within the destabilized nasal tip. This article highlights the use of structural augmentation and precise suture stabilization methods via the open rhinoplasty approach for repairing the postrhinoplasty droopy nasal tip.     

The crooked nasal tip

Successful treatment of the crooked nasal tip includes proper analysis and assessment, employment of the proper techniques, reaching ideal tip dynamics, and close follow-up. Both the caudal septum and the nasal tip cartilages must be addressed. When executed properly, satisfaction should be high for both the patient and the surgeon.     

The prominent nasal tip

The authors associate the projection of the nasal tip to hypertrophy of the alar cartilages and, more specifically, of their medial branches. The heavy, blobby, or bulbous nose is caused by an increase of the columellar-alar angle of the alar cartilages, and bears no relationship to the cephalometric nasal index. Moreover, the bulbous nose usually has excess fatty tissue present in the tip of the nose. The projecting tip may be corrected by excising a rectangular or quadrangular segment from the medial branches of the alar cartilages, or by resecting the cupula of the alar cartilages, including a small or large segment of its medial branch, in order to obtain the desired effect, namely, to lower the tip and decrease the columellar-alar angle. The nasal index remains unchanged. If in addition, the tip of the nose is bulbous, the fatty tissue should be removed at the same time.     

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.     

鼻背皮瓣修复鼻尖缺损的探讨

目的 探讨应用鼻背皮瓣修复鼻尖区组织缺损的方法和效果.方法 根据患者鼻缺损的部位及范围设计鼻背皮瓣,旋转前徙覆盖创面再造鼻尖,修复过程中注意保护各美学单元的完整性,利用天然皱褶掩盖瘢痕.结果 本组4例患者鼻背皮瓣均完全成活,术后随访1～4年,鼻外形良好,效果满意.结论 鼻背皮瓣对于鼻尖1.5～2.5cm的缺损能够提供色泽、质地匹配的修复.     

Geometric sculpturing of the thick nasal tip

Historically, one of the most persistent challenges to the rhinoplastic surgeon has been the thick, heavy, and poorly defined nasal tip. This type of tip is frequently seen in a wide variety of ethnic backgrounds, particularly in Blacks, Hispanics, and Orientals. Attempting improvement through conventional techniques has often resulted in dissatisfied patients and surgeons. Improved definition can be achieved by creating the illusion of a thinner nose rather than actually decreasing the overall size. This article discusses how this is accomplished by a combination of advanced reduction and augmentation techniques including geometric tip defatting, alar cartilage and base reduction, and the use of an ultrasupportive, peapod-shaped tip graft.     

Graduated sculpture refinement of the nasal tip

Because of the complexity and variety of tip deformities encountered by the rhinoplasty surgeon,no single stylized approach or technique will suffice to satisfactorily correct the myriad anatomic configurations that present [21]. Thus, a graduated anatomic approach to nasal tip surgery is recommended, which equips the surgeon to correct more modest deformities with conservative approaches and techniques,reserving more aggressive approaches and techniques for more profoundly abnormal tip deformities. Pre-serving an undivided, complete residual strip in the majority of patients is entirely possible and eminently desirable for the control of long-term healing.Mastering a wide variety of tip sculpture techniques,employed as dictated by the presenting anatomy [22],equips the surgeon with the tools to correct the astonishing variety of nasal tip deformities encountered.     

Revision of severe nasal trauma

Facial trauma commonly includes injury to the nose and perinasal area. In this review, we will focus on the sequelae of severe nasal trauma and provide examples of correction of the severely deviated nose, the severely collapsed nose, and revision of a traumatic deformity after prior rhinoplasty. We will then discuss coexistent deformities of perinasal regions in addition to functional and posttraumatic nasal correction, including posttraumatic periorbital deformities.     

Revision of the functionally devastated nasal airway

Functional rhinoplasty can be especially challenging in a patient who has had previous surgery, trauma, anatomic abnormalities, or systemic disease affecting the nasal mucosa. A thorough analysis of the type and location of the obstruction is critical, and only after identifying the precise anatomic cause of the problem can surgical planning begin. Scarring, altered anatomy, and disrupted tissue planes all complicate this process. Structural support and nasal mucosa often require augmentation with autogenous grafts from the ear, rib, or other portions of the nasal cavity. Attention to nasal support mechanisms, the internal and external nasal valves, and internal lining during primary surgery may help to avoid future complications. Through careful analysis and planning, proper function may be restored to a functionally devastated nasal airway.