Background: The tip of the nose is the most common area that is changed in many rhinoplasty surgeries. It is an anatomically complex structure of the nose due to the merging of the paired lower alar cartilages and the midline septum. This cartilage confluence is frequently referred to as a tripod concept from an architectural support standpoint and is a good way to envision how to change its shape.
The most common tip shape change, seen in many female rhinoplasties, is to rotate the tip of the nose upward, known as increasing tip rotation. (more open nasolabial angle) This is done by a combination of cartilage removal and suturing techniques. While it can be seen as a lessening of the support of the nose, it is better to think of it as changing how the tripod structures of the nasal tip is arranged/shaped. The most significant concerns when increasing tip rotation is that it ends up being overdone and a ‘pig nose’ results with too much nostril show.
Conversely derotating the tip of the nose (decreasing the nasolabial angle) poses a different set of challenges. Anatomically bringing the tip of the nose means adding support since that is the only way to do so. The only question is where that support by cartilage grafting should be placed either behind the tripod or in front of it.
Case Study: This male desired to have the tip of his nose brought down and narrowed. He had no prior rhinoplasty surgery.
Under general anesthesia and through an open rhinoplasty approach the tip cartilages were exposed. The tip cartilages were long and broad.
A large septal cartilage was harvested and a 1 cm septal extension graft was placed between the caudal septum and medial footplates of the lower alar cartilages. Onlay septal grafts were placed on top of the infratip area to further help with the derotation. Tiop narrowing was done by double dome suturing.
The immediate intraop changes was the skin was pulled back over the tip and closed can be seen in profile.
Key Points:
1) Derotation of the tip of the nose is more challenging to achieve than rotating the tip upward.
2) Derotation requires adding structural support to the tripod of the tip with cartilages grafting.
3) Cartilage grafting can be done by septal extension, infratip only for both to drive down the tip of the nose.
Dr. Barry Eppley
World-Renowned Plastic Surgeon