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The shape of the nose varies greatly amongst people and its uniqueness is very much like a fingerprint for the face. No two noses are ever exactly alike. (unless one is a twin) But there are distinct types of shapes, particularly at the tip of the nose, which can be classified by their underling cartilaginous anatomy. The tip has the greatest amount of variability of the nose due to the confluence of the lower alar cartilages and the septum at the central tip region.

One of the very well known types of end of the nose deformities is that of the bifid tip. Also known as a cleft or ‘butt’ nose this is where a visible vertical groove or indentation occurs at the center of the nasal tip down into the columellar area below it. In essence the nasal tip looks split. It can occur in varying degrees from slight to a very profound groove.

The anatomic basis for the presence of bifid nasal tip is exactly how the underlying cartilages are shaped. The major shape of the tip of the nose is highly influenced by the size, shape and convergence of the lower alar cartilages as they come together in the midline. In most noses the paired alar cartilages come together and/or meet…or at least come close enough to create a unifed shape or single appearing tip. There is always some separation or flare of the caudal edges of the alar cartilages over the dome, enough to give a two point light reflex, but not typically enough to create a bifid or split nasal appearance.

But in the bifid nasal tip, the alar cartilages are further apart and/or have very flared caudal edges which allows the overlying skin to fall down in between their edges. The degree of alar cartilage separation or flare, and how much it extends along their vertical length determines how visible the tip bifidity is.

The treatment of the bifid nasal tip tis to either sew the caudal edges of the dome and infra tip areas together or to place a columellar strut cartilage graft between the split cartilages and see across it. (essentially filling in the midline defect. Which approach is best depends on what else is being done in the rhinoplasty procedure. Since many bifid tips are just one component of a rhinoplasty procedure the columellar strut is often used for its tip support benefits.

Dr. Barry Eppley

Indianapolis, Indiana

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