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The nose can have a wide variety of shapes due to its complex interdigitating anatomy. The nasal bones, septum, upper and lateral alar cartilages create a diverse group of external nasal shapes. Where the greatest variability in anatomic shapes exists is in the nasal tip where the confluence of the lower alar cartilages and septum come together. The differences in the size and shape of these three structures combined with the thickness of the overlying skin makes each person’s nasal tip almost like a unique ‘fingerprint’ for their face.

Despite the uniqueness of each person’s nose, the tip can be grouped into several categories based on its overall shape. One type of tip shape is the bulbous nose. As the name implies the nasal tip has the shape of a ball. In the most simplistic understanding it can be due to abnormal anatomy of the lower alar cartilages, thick skin or a combination of both. But there are other contributing factors such as the tip appearing larger because of a lower nasal bridge or surrounding narrow alar base. (narrow nostrils)

Some bulbous tips can be done alone (tip rhinoplasty) but often are done as part of an overall or complete rhinoplasty. In either case an open approach is usually best to maximize the maneuvers needed to make the tip less wide. One of the most basic maneuvers in its correction is the well known cephalic trim of the lower alar cartilages but it must be avoided in being overdone. If too much of the cartilage is resected it will become weak causing collapse….creating the exact opposite effect. While less width of the lower alar cartilage is needed it must be stout/supportive to help create a well defined central ‘tentpole’ to push out on the central nasal tip skin…while the side skin can fall in more inward. This is where a columellar strip of cartilage is helpful as well.

Alar cartilage resection must be balanced with the use of lateral crural spanning sutures whose use lessens the need for dramatic cephalic cartilage trims.  It also contributes to midline tip support while significantly decreasing supratip fullness. Tip grafting may also be useful to help create some top definition through the usual thick nasal tip skin. Defatting the tip skin will help ant tip grafts to potentially have a more visible effect.

The bulbous nose always responds to these intraoperative maneuvers for reduction in the size of the ball with a better tip shape. Because of the typical thicker skin one should expect some prolonged tip swelling in which it will take at least six months to reach a maximal reduction outcome. With this swelling, steroid, 5FU or combinations thereof are frequently used early on to help with this prolonged swelling process in thicker nasal skin.

Dr. Barry Eppley

Indianapolis, Indiana

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