Rhinoplasty Dr Bashar Bizrah Article on: Principles of Tip Surgery Part 1: Principles of Tip Surgery

It is to be understood that tip surgery is the base stone and the key for a successful rhinoplasty. Master rhinoplasty surgeons are those who deal confidently with the tip. The classic endonasal Joseph rhinoplasty has ended with many unpleasant results of dropped tip, pollybeak, hanging columella and wider nostrils. The reason is that tip supportive means were not considered, in order to compensate for the loss of tip support, that is caused by our incisions and excisions. These divide the anatomical factors maintaining the tip support.

The first attempts to improve tip projection were made by Irving Goldman. The Goldman’s tip was based on cutting the angle between the medial and lateral crura and suturing the medial crura together. Safian (Joseph student) had vertically cut the dome, but Goldman’s concept was that the more lateral cut would augment the medial crura and thus improve tip projection. Although Goldman’s tip was a creative technique, in time, surgeons realized its problems of pinching, notching, retraction, asymmetry and pointed tip. The concept of Goldman’s tip has been, over the years modified and developed further by master rhinoplasty surgeons of the past twenty years (Sheen, Simon, McCollough, M.E. Tardy and Peck) who developed the technique of new dome creation, scoring, suture fixation, columellar strut and tip graft. This approach preserved the lateral crus and established a strong tripod structure of conjoined lateral to medial crura supported by columella and dome grafts. Our objective is to obtain a clearly defined and properly projecting tip that appears symmetrical, triangular on basal view and that flows and blends well with the rest of the nose. In the author’s series of over 3,000 rhinoplasties performed on people from the Middle East, Europeans, Indians, Chinese and Africans, it has been found that the manoeuvres of new dome creation, scoring, suture fixation, columellar and tip grafts are the key to a successful rhinoplasty. These manoeuvres achieve adequate tip projection, elevation, definition, rotation and symmetry with the least and most easily managed postoperative problems. The author has also developed a new technique which is largely based on the Goldman’s Tip and I-beam of medial crura but without delivery of the lateral crus. This is in order to keep an intact rim and avoid any problems along the alar rim such as notching, retraction, collapse or asymmetry and dimpling of the alar side wall. The author has been applying this method for the last two years. In his opinion this technique is proving to be safe and useful in achieving tip projection, definition, rotation and refinement in selective situations. The new concept of rhinoplasty is balanced manoeuvres of reduction and augmentation. Therefore, rhinoplasty is transforming from an exercise in reduction to an operation of reorientation and preservation of structure.

Fig. 8 - 2. Patient presented w ith long nose, mild hump and underprojected tip. This type of nasal deformity is common in our region. The patient was managed by endonasal approach, hump reduction, medial and lateral osteotomies, conservative trimming of the caudal septum and caudal ends of the upper lateral cartilages. Tip projection, definition and rotation is achieved by the technique of modified vertical dome division without delivery of the lateral crus (Bizrah Modification).

Types of nasal tip deformities: (Figs. 8 – 32 to 82)

1. Broad nasal tip: bulbous, boxy, trapezoid, wide and/ or thick skinned.
2. Underprojected, dropped, drooping, under-rotated, short columella.
3. Overprojecting.
4. Hanging columella.
5. Retracted columella.
6. Tip asymmetry.

Key Technical Steps of Closed Tip plasty

The author uses a closed approach of intercartilagenous, transfixion and marginal incisions in over 90% of his septorhinoplasties. The external approach of transcolumellar incision is reserved only for difficult revisions. (Fig. 17 – 5)

Step A. Intercartilagenous incision

The intercartilagenous incision is made at the mucosal-vestibular skin junction between upper and lower cartilages from the most lateral point and carried out medially around the superior septal angle and down along the caudal septal margin in a hemitransfixion incision. (Figs. 5 -1,2)

Step B. Septa! graft or septoplasty

If septoplasty is needed, it is performed at this stage. Septal graft is also obtained at this stage for later augmentations. (Fig. 17 – 9)

Step C. Marginal incision

It follows the inferior margin of the lower lateral cartilage from about midcolumella to mid-alar rim on each side. It may as indicated extend from the medial crural foot plate to pyriform aperture. The skin incision at the columella is made one mm behind the caudal edge of the medial crura, but the incision must stay close to the cartilage caudal edge at the intermediate and lateral crura to prevent postoperative scarring and alar margin retraction. (Fig. 5 – 3)

Step D. Delivery of alar cartilage as bipedical chondrocutaneous flap:

Start first with a sharp scissors at the columella to identify the right plane and the caudal margin of the medial crura and follow dissection along the caudal margin up to the intermediate and lateral crura using blunt scissors to avoid skin damage. Once the alar has been delivered as bipedical chondrocutaneous

Fig. 8 - 3. Leave at least eight to ten mm of vertical lateral crus, the lateral most portion of lateral crus is preserved in order to avoid alar sidewall collapse. (Fig. 17 - 12)

Fig. 8 - 4. New dome creation and scoring. The manoeuvre will lengthen the medial crura and shorten the lateral crura which is essential for tip projection, elevation, definition and symmetry.

flap, deliver the other side and remove any fat or scar tissue on the surface of the cartilage and between the two alars (interdomal soft tissue), keeping the cartilage clear. (Fig. 17 – 12)

Step E. Trimming of the lower lateral cartilage:

Horizontal excision of the appropriate amount of the cephalic lateral crus with portion of the intermediate crus is performed reserving the vestibular skin and leaving at least eight to ten mm of a wide intact segment of vertical lateral crus behind. The lateral most portion of the lateral crura is preserved to avoid alar collapse. (Fig. 8 – 3)

Step F. New dome creation
Modifying the dome angle
Vertical dome division or scoring
Suture Fixation

1. New dome creation
   Tissue forceps is pushed under the bilateral flaps and the bilateral flaps are elevated in order to achieve symmetry and create a new more acute domal junction between the medial and lateral crus (apex of the dome). This manoeuvre will lengthen the medial crus and shorten slightly the lateral crus, which is essential for tip projection, elevation, definition and symmetry. To avoid dimpling and pinching, we suggest not to borrow more than two to three mm of lateral crura. The angle of the dome is defined as the angle between the long access of the medial and intermediate crura and the long access of the lateral crura. (Fig. 8 – 4 and Fig. 17 -13)
2. Vertical new dome scoring:
   The newly created dome at the apex is now scored vertically on each side with preservation of the vestibular skin and mucosa. The principle of vertical dome division is to divide medial and lateral crura into two separate units which is bound by suture fixation. These units can be realigned in such a way as to alter and improve tip dimension, in order to obtain tip projection, elevation, definition and symmetry. (Figs. 17 -13,14)
3. Suture fixation:
   A 4/ 0 PDS interdomal buried suture is passed through the intermediate

Fig. 8 - 5. A 4/0 Dexon interdomal buried suture is passed through the intermediate and lateral crura just one mm below the scored area. In order to achieve a more acute domal angle for tip definition, a laterally based cephalic triangle is excised

Fig. 8 - 6. Mattress suture will convert converse lateral crura to a concave lateral crura reducing the supratip fullness.

and lateral crura just one mm below the scored area in a simple or mattress suture in order to create a more acute domal angle and preserve a stable tripod structure of conjoined lateral and medial crura. The mattress suture fixation will convert convex lateral crura to a concave lateral crura reducing the supra-alar fullness. (Figs. 8 – 5,6 and Fig. 17 -14)

4. Trimming of cephalic based triangle:
In order to achieve a more acute domal angle to tip definition, a lateral crus cephalic based triangle is excised from the domal region to lower the lateral crus cephalic margin and ensure that the caudal margin of the lateral crus is tilted anterior or higher (more projecting) than the cephalic margin. This manoeuvre is usually performed after conservative cephalic trimming of the lateral crura to allow reorientation of the supra-alar region. Excision of a cephalically based triangular of the cartilage will lower the cephalic margin of the lateral crus below the caudal margin. This trick will decrease the vertical component in tip bulbosity allowing the surgeon to preserve greater vertical lateral crus. (Fig. 8 – 5)

Advantages of New Dome Creation/Scorin[Y’Suture Fixation

1. Creation of a more acute domal angle between lateral and medial crura resulting in a more defined triangular tip. (Fig. 8 – 7)
2. Achieve tip definition and refinement.
3. Narrow the tip and domal arch.
4. Reduce supra-alar fullness and convert a convex lateral crura to a concave crura.
5. Achieve minimal projection.

Indications of Dome Creation/ Scorin[Y’ Suture Fixation:

1. Tip projection, definition and elevation.
2. Domal arch narrowing.
3. Correction of short, hanging and buckled columella and drooping tip.
4. Correction of tip asymmetry.

The technique of new dome creation/ scoring/ suture fixation was modified and described by Dr. Simon of Miami who originally modified the Goldman technique. The Goldman technique was based on excision of vertical lateral crura, (the segments just lateral to the dome area, the cartilage and

Fig. 8 - 7. Advantages of new dome creation I scoring/ suture fixation: 1 - Creation of a more acute domal angle 2 - narrows the tip and domal arch 3 - reduces supra-alar fullness 4 - achieves minimal projection and definition 5 - reduces alar flare.

underlying mucous and vestibular skin are excised). This classic Goldman procedure resulted in many problems such as: pinching and notching of the alar, alar retraction and collapse, poor tip definition and asymmetry, unwanted creases, nasal bossae and pointed tip (tent pole).

The vertical dome scoring is a conservative technique that preserves the integrity of the lateral crura, leaving at least eight to ten mm of vertical lateral crura, keeping the caudal rim of the lateral crura intact, together with a strong tripod of medial crura and lateral crura and dome apex mattress sutures, constituting a strong and natural tip. The author has been applying this technique for the last seven years. The author learned this technique from Robert Simon of Miami and Gaylon McCollough of Birmingham, Alabama. He did not find the need to use the external approach and always uses the endonasal approach of intercartilagenous transfixion and marginal incisions. The author believes that it is a very reliable and predictable way to deal with the nasal tip and it is a key to successful rhinoplasty.

Tip projection, definition, refinement, minimal elevation and narrowing are achieved by increasing the length of medial crura and shortening the lateral crura (new dome creation). Scoring or division of vertical dome creates a more acute domal angle for tip definition. Suture fixation of medial crura to lateral crura at the dome creates a more acute domal angle and establishes a totally new dome. It provides additional tip definition, refinement, narrowing and minimal degree of tip projection. Excision of cephalic based triangle at the dome and suture fixation will achieve more tip narrowing and supra-alar definition.

The aim is to preserve the integrity, continuity of the anatomical natural tripod structures of the medial and lateral crura bound together by simple or mattress sutures at the newly created dome to achieve more favourable acute domal angle for pleasant tip definition and refinement.

Step G. Suture-in place columellar strut:

A precise pocket is dissected between the two medial crura. This pocket should extend to a depth approximately two mm above the nasal spine. Mattress sutures are used to fix the strut that lies between the two medial crura. The first mattress

Fig. 8 - 8. Suture-in place columellar strut.

Fig. 8 - 9. Suture-in place tip graft. 

suture is placed near the junction between the medial and intermediate crura to preserve the normal divergence of the intermediate crura, in order to obtain a natural double break. (Fig. 8 – 8 and Figs. 17 -14,15)

Indications for columellar strut:

1. Tip projection, definition, and refinement.
2. Preservation of tip projection.
3. Correction of hanging columella.
4. Correction of buckle medial crura.
5. Correction of retracted columella.
6. Correction of tip asymmetry.
7. Strengthening weak medial crura.
8. Stable site for tip grafting.
9. Correction of bifid columella.

The columellar graft is usually about two cm long and two mm in width. The graft should not extend into the nasal spine in order to avoid clicking of the graft with smiling. If the graft is displaced to one side of the spine, the result is deviated columella, tip and nares asymmetry. The graft should be one mm below the dome angle.

In the thin skinned patient particularly Caucasians with normal tip dimensions and adequate tip projection, tip support may be sufficiently obtained by 20mm x 2mm columellar strut. This is inserted into a pocket between the medial crura, through a small columellar marginal incision. The upper limit of the dissecting pocket should not exceed beyond the level of the external soft triangle. This in order to avoid the later demarcation of the strut at the dome.

Step H. Suture-in place tip graft:

The tip graft is thicker and wider at the leading edge and thinnest at the base. The width of the graft can vary from eight to twelve mm at the leading edge and the length can vary from six to fifteen mm. The graft is cut wider at the leading edge. The leading edge of the graft is rounded and bevelled to avoid sharp edges and demarcation of the skin. (Fig. 8 – 9 and Fig. 17 – 16)

In thin skinned patients, in order to prevent the tip graft showing through the skin, the graft is crushed or softened with Rubin morselizer, or the edges are bevelled and shaved with a 11-blade. (Fig. 17 -17)

Fig. 8 - IO - Long tip graft is indicated in order to achieve more elevation, rotation, and augment the nasolabial angle.
- Medium or small grafts are indicated to achieve more projection, definition and elevation.
- The edges of the graft are bevelled or shaved to avoid lines of demarcations. 

Fig. 8 - I I. If the tip graft is stiff and thick, the graft should be scored horizontally in order to achieve natural infratip double break. In thin skinned patient, the graft is crushed.

The tip graft is positioned so that it projects one to two mm above the dome. Usually four sutures (4/0 Dexon) are used, the tip graft is sutured to the caudal margin of the medial crura. The tip graft should be sutured carefully, cartilage to cartilage, symmetrically and not displaced to one side. (Fig. 8 – 10)

If the tip graft from the septal cartilage is stiff and thick, the graft should be scored horizontally in order to achieve a natural curvature contour to the infratip lobule, the edge of the graft should be shaved and bevelled to avoid demarcation of the grafts, particularly in a thin skinned patient (Fig. 8 – 11). However, the crushed tip graft is important in these thin skinned patients in order to avoid pointed tip and sharp domal edges.

Indications of tip graft:

1. Tip definition, projection, refinement, contouring. (Fig. 8 -14)
2. Create well-defined double break.
3. Create well-defined supratip break.
4. A nicely contoured infratip lobule.
5. Long graft, narrow the tip and increase tip projection.
6. Correct dome asymmetry.
7. Correct tip bifidity.

Long tip graft is used to:

1. Narrow the tip in a patient with thick skin. The graft should project two to three mm above the dome. (Fig. 8 -10 and Fig. 17 -16)
2. Increase rotation of the dome and the tip.
3. Support the columella in retracted columella, weak medial crura, hanging columella and bifid columella.
4. Augment the acute nasolabial angle.
5. Correct nasal tip and columella bifidity.

Double and triple grafts are used to:

1. Achieve more tip projection, definition and refinement in a thick skinned patient. (Fig. 17 -16)
2. Increase the length of the over-rotated nose by increasing the distance from the nasal starting point (the nasion) to the tip defining points (infra tip lobule).

Asymmetry of the tip graft and dome may result from:

1. Mal positioning of the columellar strut which may be too long.

Fig. 8 - 12. Batten graft is used to support weak and short lateral crura.

Fig. 8 - 13. Cab graft is placed on the cartilagenous dome behind the tip graft in order to prevent over-rotation of the tip graft.

2. Suturing the tip graft in an asymmetrical manner.
3. Scoring of the newly created dome in an asymmetrical manner.
4. Weak or short lateral crura: Batten graft shaped like lateral crura is placed over the weakened lateral crura and fixed by mattress suture. (Fig. 8 – 12)

Indications for Batten graft:

1. Reconstruction of lateral crura in revision surgery.
2. Support weak and short lateral crura.

Cab graft can be placed between the leading edge of the tip graft and the existing dome to prevent over-rotation of the tip graft. (Fig. 8 – 13)

Judgement and experience are necessary and essential during every step of tip surgery. The shape, direction, length and number of the grafts to be used in the tip are all judged and thought out carefully and positioned according to the deformity to be corrected. Special care and extra time is required to position these grafts. Any surgeon unwilling to work with precision, using careful judgement and taking the extra time needed to achieve balanced and symmetrical tip grafting, trimming, scoring and suturing, should not attempt this technique. Outstanding surgical skills are required in order to utilize this approach.

Pinching of the alar sidewalls:

Prevention:

1. Conservative cephalic trimming of lower lateral cartilage leaving at least
   eight mm vertical height of lateral crura.
2. In patients with narrow tip, avoid mattress sutures at the dome, use simple
   sutures.
3. In patients with narrow long noses leave the cephalic end of lower lateral
   cartilage intact.
4. Conservative trimming of the caudal distal end of upper lateral cartilage.
5. Scoring of the dome in a symmetrical manner.

Step I. The reoriented dome ( complex structure of alar cartilage and grafts) is pushed back inside the nose into a normal position. Careful assessment is made for fine refinement for the level of the tip projection to the dorsum. Usually, the tip

Fig. 8 - 14. Advantages of new dome creation, scoring, suture fixation, columellar strut and tip graft:
1 . Achieve adequate tip definition, projection, elevation
and symmetry
2. Narrow the tip and create a more acute domal angle
3. Reduce supra-alar fullness
4. Correct tip asymmetry
5. Correction of hanging, retracted and short columella
6. Stretch the alar sidewalls and reduce alar flare 

Fig. 8 - 15. Septocolumellar suture: To preseNe the already achieved tip projection or increase tip projection in underprojected nose because too much grafting may cause tension on the tip skin.

is made to project two mm above the dorsum in order to achieve favourable supratip break and to avoid pollybeak nose. The level of tip projection at the end of surgery should be within normal dimensions and not overprojected. This technique achieves a strong tripod of medial lateral crura, columellar strut and tip grafts, the projection is not dependant on septocolumellar sutures.

At this stage, if the tip is overprojected, deliver the dome out again and trim the leading edge of the tip graft. If the tip is slightly underprojected add more tip grafts and suture it to the apex of the dome.

Make sure that the nares and supra-alar regions are symmetrical and there is no bulging or pinching of the supra-alar region (pinching may be managed by Batten grafts, bulging by lateral crura overlay technique which will be discussed later). Make sure there is no deviation of the columella or tip asymmetry, if so, deliver again and consider repositioning of the columellar strut three mm above the nasal spine and ensure accurate suturing of the tip graft.

Step J. Close the marginal incision with 4/0 Dexon:

The trick is to obliquely position the sutures of the marginal lateral crus incision, low on the lateral crus skin and high on the rim skin. This will pull up the lateral crus and approximate accurately the marginal incision in order to avoid healing problems such as alar notching, retraction, pinching, collapse and nares asymmetry. (Fig. 5 – 3)

Step K. Close the transfixion incision with 4/0 Dexon:

The transfixion incision is closed with buried suture of 4/ 0 Dexon or PDS. The suture is positioned obliquely in order to pull up the medial crura complex.

Step L. Septocolumellar suture:

Septocolumellar sutures are used to fix the medial crura/ columellar strut complex to the caudal septum. A 5-0 Proxy or nylon suture is placed high on the caudal septum and low on the medial crura columellar strut complex to fix and support the tip. If septocolumellar suture is ignored, the medial crura/ columellar tip complex will drop down resulting in long or drooped shape nose, with redundant mucovestibular junction. (Fig. 8 – 15)

Fig. 8 - 16. Lateral crura overlay technique is indicated in tip overprojection, drooping tip and to reduce alar flare. A vertical incision is made at the mid portion of the lateral crus ten mm away from the dome with preservation of vestibular skin. This manoeuvre shortens and superiorly rotates the lateral crura in drooped tip. (Fig. 17 - 17)

Fig. 8 - 17. A mattress suture will firmly lock the tip into the desired position. If rotation is required, a triangular cartilage is trimmed to achieve a straight alar margin.

Indications:

1. To preserve tip projection and not necessarily to increase it when transfixion incision is used.
2. To increase tip projection in underprojected noses because too much grafting on the tip may cause tension on the skin, so the septocolumellar suture will help to increase tip projection by elevating the entire medial crura, columellar strut, dome grafts complex.

Step M. Steri-strips around the tip and at the nasal dorsum are used to support and to reduce oedema on the tip and supratip. Plaster is applied. (Fig. 17 – 26)

LATERAL CRURA OVERLAY TECHNIQUE

This technique is preserved for more difficult tips such as overprojected, drooping, broad and an asymmetrical tip. It produces a more natural appearing nose without excessive cartilage excision. It was described by Rees and explained more fully by Webster in 1975.

Indications:

1. Tip overprojection:
   Shorten long lateral crura.
2. Drooping tip:
   Rotate and shorten lateral crura.
3. Broad tip:
   Narrow, shorten and reduce the flared bulbous and convex lateral crura.
4. Correct bilateral supra-alar fullness:
   Correction of bulging or flaring lateral crura.
5. Correct unilateral supra-alar fullness or asymmetry:
   This can be caused by:
   1. Preoperative:
   Crooked nose – congenital alar asymmetry – cleft lip.
   2. Operative:
   Asymmetric new dome creation/ scoring.
   The lateral crura overlay technique in these situations releases the tension of
   the tip by shortening the flared protruded lateral crura.

Technique:

1. Closed technique of alar delivery. (Fig. 17 -17)
2. Conservative cephalic trimming of the lateral crura.
3. New dome creation – scoring – suture fixation – columellar strut – tip graft unit.
4. Lateral crura is inspected and a straight vertical incision made at the mid-portion of the lateral crura, at least ten mm away from the dome. The incision is located midway between the dome and free posterior margin of the lateral crus with preservation of the skin vestibule (Fig. 8 – 16). The cartilage is then undermined above the vestibular skin towards the dome for two to five mm, according to the required correction of shortening or rotation. The free undermined crura segment will overlay the posterior segment, resulting in shortening of the lateral crura with preservation of the lateral crus cartilage. After the optimal tip position is determined, a vertical mattress suture is placed on the overlayed cartilage; this suture firmly locks the tip into the desired position (Fig. 8 – 17). If rotation is required, a triangular cartilage develops along the caudal crural margin. This should be trimmed in order to achieve a straight alar rim. Marginal incision sutured with 4/ 0 Dexon.