Nasal tip surgery: how the shape of the tip is created

What determines the shape of the nasal tip?

The nasal tip is the part of the nose that projects farthest forward ^[1]. Its outward shape is described as being determined by the curvature and contour of the lower lateral cartilages and by how these cartilages fit together with the surrounding tissue ^[1]. There are reference standards for the ideal shape and shading of the nasal tip, but the actual goal is set with the harmony of the whole face in mind ^{[1, 3]}.

Rhinoplasty is still a difficult operation, but it is regarded as having become somewhat more systematic as understanding has grown of the structures that support the nasal tip and how to adjust them ^[2]. Controlling the nasal tip is described as the key to an attractive result that preserves the function of the nose ^[2].

Why a nasal tip can look low or bulbous

A lack of support in the nasal tip can be present from birth or can result from previous nose surgery ^[6]. When the inner parts of the tip cartilages (medial crura) are underdeveloped, the tip often does not project far enough and looks poorly defined ^[6].

When the outer parts of the cartilages (lateral crura) are weak or out of position, the rims of the nostrils can be pulled upward and the side walls of the nose can weaken ^[6]. In these cases, structural cartilage grafts are used to strengthen the framework of the tip, reinforce collapsed support structures, and adjust the position of the tip ^[6]. In revision surgery, the goal is described as anatomically rebuilding weakened or divided cartilage to restore stable support for the nasal tip ^[6].

Sutures, cartilage grafts, and a stepwise approach

One review described a structural approach that removes very little tissue and strengthens the support of the nose with sutures and cartilage grafts ^[3]. For the nasal tip, it presented a stepwise method that starts with simple, predictable techniques and moves on to more complex, less predictable ones only when needed ^[3]. This review was written in a setting with many patients of mixed ethnic backgrounds, so there are limits to applying it directly to East Asian patients ^[3].

When tip sutures alone are not enough, cartilage grafts are described as a versatile and effective way to change the shape of the nasal tip ^[1]. The tip grafts most commonly used in rhinoplasty are listed below ^[1].

• A graft placed on top of the tip (tip onlay graft)
• A strut graft that supports the columella, the strip of tissue between the nostrils (columellar strut graft)
• An extension graft that lengthens the end of the septum (caudal septal extension graft)
• A shield-shaped graft that refines the front of the tip (shield graft)
• A graft that supports the lateral crura (lateral crural strut graft)
• A graft that reinforces the rim of the nostril (alar rim graft)

Septal extension and the East Asian nose

A septal extension graft is a method that can adjust how far the nasal tip projects, its shape, and how much it is rotated up or down ^[4]. Septal extension and synthetic implants along the bridge have been widely used in East Asian rhinoplasty, and it has been pointed out that this has led to surgery-related (iatrogenic) complications, such as deformities in which the nose becomes shorter and damage to the remaining septum ^[4].

The same review described a method for East Asian patients with relatively small noses that uses an extension graft for the L-shaped septal support (L-strut) to reinforce the lower part of the nose forward and downward ^[4]. This method is described as being used in first surgeries where the bony part of the bridge is fine but the cartilage part is underdeveloped, and in revision surgeries for noses that have become shorter because of synthetic implants ^[4]. Not everyone needs septal extension, and the decision should be made carefully, taking into account the condition of the remaining septum.

Nasal tip surgery and nasal function

The end of the septum that supports the nasal tip (caudal septum) is important for both function and appearance ^[5]. If this part is bent, it can block the nasal passage or narrow the internal nasal valve, causing a stuffy nose, and outwardly it can make the tip look twisted, change its height and angle, and upset the balance between the nostrils and the columella ^[5].

There are recent reports that techniques that preserve and reshape cartilage are effective, and it is summarized that the approach should be stepwise, based on an accurate diagnosis, ranging from simple sutures to the use of grafts ^[5]. It is stressed that there is no single surgical technique that suits every case ^[5].

What to ask during your consultation

The results of nasal tip surgery vary from person to person depending on the size and strength of the cartilage, skin thickness, the condition of the septum, and any previous surgery. It is stressed that the surgical plan should be based on the anatomical findings and the look the patient wants ^[3].

• Whether a low or bulbous tip is caused by the cartilage, the skin, or the septum
• Whether sutures alone are enough or a cartilage graft is needed
• Where the cartilage would come from, and whether septal extension is needed
• Whether there are also functional problems, such as a stuffy nose
• Possible risks, such as the nose becoming shorter or the tip becoming twisted