Rhinoplasty Dr Bashar Bizrah Article on: Principles of Tip Surgery Part 3: Broad Nasal Tip

In treating a patient with a broad nasal tip, a surgeon must understand the aetiology and extent of the problem, and decide if the broad nasal tip was caused by an increased bulk of cartilage and or thick skin. (Fig. 8 -22 and Figs. 8 – 32 to 78)

I. Broad nasal tip due to an increased bulk of cartilage:

1. Standard operation plan

• Closed approach rhinoplasty.
• Intercartilagenous, transfixion and marginal incision.
• Alar delivery.
• Trimming of caudal end of upper lateral cartilage for curvature, remnants or scroll. Fatty and connective tissue removed from the surface of the cartilage.
• Trimming of cephalic strip of lateral crura leaving eight to ten mm of vertical lateral crura with preservation of the distal horizontal lateral crura. If lateral crura is weak, leave at least ten mm of vertical lateral crura.
  Interdomal fatty connective tissue removed. Columellar strut is inserted in between the two medial crura and sutured
  in place. It will correct and narrow bifid columella and bifid tip. New dome creation/ scoring/ suture fixation/ columellar strut/ tip graft
  unit: This will achieve tip definition, projection, refinement and elevation. Double or triple tip grafts may be needed to achieve more definition. (Fig. 17 – 16)

2. Additional surgical steps:

1. Lateral crura overlay technique:
   If following the above measures there is still a wide tip due to fullness of the supra-alar region caused by flared, convex or long lateral crura, the author would go for the lateral crura overlay technique, in which the volume of the lateral crura is conservatively reduced without the need for excessive cartilage excision. In the author’s opinion it achieves quite satisfactory results and solves the problem. (Figs. 8 -16,17)
2. Transdomal suture repair:
   If following all above mentioned steps, the tip is still wide at the dome, the transdomal suture will help to narrow and achieve more refinement of the infratip lobule. It is quite useful when we have a bifid lower lateral cartilage, thin skin and minimal subcutaneous tissue, firm cartilages and delicate alar sidewalls. This tip refinement technique of transdomal suture is useful with thin skinned patients when we are not in favour of tip grafts to avoid showing through the skin.

II. Broad nasal tip due to thick skin and subcutaneous fat:

1. Excessive subcutaneous fatty tissue can be trimmed by using blunt fully curved scissors. Care should be taken not to cause injury to the epidermis as this will cause tip necrosis.
2. A patient with thick, heavy skin poses a problem, since this type of skin will not favourably contract around the newly created dome. Double or triple umbrella grafts may be needed for tip projection and narrowing. The patient should be informed about realistic expectations.
3. Special inter-lateral crus suture (p. 142).
4. Rhinophyma
   When the skin is too thick, the skin may be shaved by dermabrasion or by CO2 laser. The patient should be informed about complications of shaving such as dyschromias, scarring and that sebaceous pores may be more visible.