COSMETIC SURGERY OF THE NASAL TIP OR “TIP-PLASTY

It has been said that “he who masters the tip, masters rhinoplasty”. To a large extent this is true. Creating a delicate, symmetric nasal tip that has the right projection, rotation and proportion to the other elements of the nose is a key factor in a successful rhinoplasty. It is the focal point that is initially noted and must be aesthetically pleasing for the overall appearance of the nose to look good. A great deal of experience and technical expertise is required to create a tip that is appropriate for the different skin types and anatomical variations that are encountered. Each rhinoplasty is different and, consequently, a “cookie cutter” approach is totally inappropriate. Some tips require manipulation of the cartilages already present in the area, whereas others may require either solid or crushed cartilage grafting. The cartilage necessary is usually obtained from the nasal septum or occasionally from an ear or rib. Synthetic material is not a good option, since it may extrude through the skin. Additionally, once the tip has been set, it is often necessary to adjust the surrounding tissues to produce a seamless result.

POST-OPERATIVE NASAL IRREGULARITIES

In rare instances, an irregularity will develop under the skin following a very successful rhinoplasty.  It usually becomes apparent days or weeks after the procedure as the swelling subsides. In some instances, it is bony in nature and may present as a spicule of bone, resulting from the irritated periosteum (lining over the bridge) or a larger area of bone, if there is a shifting or displacement of the reconstructed bony bridge. The treatment for this may be a simple procedure under local anesthesia in a treatment room or a more involved procedure in an operating room.  For a small spicule of bone, the area can be anesthetized locally and a tiny incision made in the club of the eyebrow. Through this incision a narrow chisel can be used to reduce the bony prominence…usually with one or two taps of the mallet. Unfortunately, if the bony irregularity is much larger in nature, a return to the operating room is usually necessary. In this case, rasping or even chiseling is needed and usually takes only a few minutes to accomplish.

If the irregularity noted under the skin is cartilaginous in nature from shifting of a graft or repositioning of the cartilaginous dorsum, an initial attempt at correction can be via a transcutaneous needle. In this case, the area is anesthetized and a small gauge needle is placed through the skin to fracture and progressively crush the cartilage. But, as with the larger bony deformity, if the cartilaginous deformity is large or unaffected by the transcutaneous approach, an intra-operative approach to trim it would be required.

CORRECTING THE BULBOUS NASAL TIP

By definition, a bulbous tip is one that resembles a “bulb” or appears as a rounded mass. And the two main components that establish this appearance are the structural tip cartilages and the overlying skin. One can have strong or flimsy cartilages as well as thick or thin skin. The most easily corrected combination is having strong cartilages, which allow for appropriate sculpting and repositioning, and thin overlying skin, which allows the cartilaginous contours to show through. The most challenging combination is having flimsy cartilages, which do little to express their shape externally, and thick skin, which masks the underlying structures. In this latter case, cartilage grafting is necessary to produce the appropriate contours. The grafts are usually taken from the nasal septum or ear or, rarely, a rib. Their shape and placement usually bear little resemblance to the normal anatomy in this area and is usually placed over it. The object is to create the external appearance of improved nasal aesthetics. In some cases, removing subcutaneous fat or scar from prior surgery may be necessary to help accomplish the desired result. Also, in many instances, the area is infiltrated with solutions such as steroids or fluorouracil to help prevent scar formation that may mask the final result.  Finally, it is sometimes necessary to do nightly taping or even periodic casting to direct the healing and create the desired shape.

I have two examples, which illustrate these extremes.


The first nose had strong tip cartilages with relatively thin skin. All that was necessary was to partially resect and then reconstruct and reposition the cartilages. In contrast, the second nose had flimsy cartilages, thick skin and scar tissue from prior surgeries.


In this case, soft tissue debulking was necessary along with cartilage grafting. The judicious use of injectable kenalog with fluorouracil and post-operative casting and then nightly taping was also employed.

NASAL IMPLANTS

Though many rhinoplasties are of the “reductive” variety, with the object being to make the nose smaller, occasionally an “augmentative” rhinoplasty is the procedure of choice. This may be necessary in certain ethnic groups, such as Asian and African, or for nasal revisions, if too much tissue has been removed during the initial surgery. The best material to use for this is the patient’s own cartilage. This is usually harvested from the nasal septum, the ear or from a rib. However, if cartilage is unavailable at these sites or if the patient refuses this additional surgery, then an implant may be necessary. Implants are synthetic materials that may or may not bond with the patient’s own tissue. The use of cadaver homograft cartilage is another option which I generally avoid because of its brittleness, lack of true incorporation at the recipient site and the possibility of resorption. Among the synthetic materials in use, we have silastic, Medpor (high-density porous polyethylene) and Gore-Tex (expanded-polytetrafluoroethyl ene). All have been used to augment the nasal bridge.

Silastic implants are usually pre-formed, though can be trimmed, and form a capsule of scar tissue around themselves. Because of this, they are never truly incorporated into the tissue. Consequently, you can move it side to side manually and, occasionally, it will break through the overlying tissue. I never use this implant material.

Medpor comes in various shapes and sizes, is somewhat firm, and can be carved or trimmed. It can be placed over the bridge or in areas to create lateral nasal support or even tip support, as long as there is soft tissue and cartilage covering it. There is a minimal amount of tissue ingrowth which tends to fix it in place.

Gore-Tex is a very popular implant, which also allows for a slight amount of tissue ingrowth enabling it to be fixed and stabilized. It comes in several thicknesses, is easily trimmed and is quite malleable. It makes for an excellent dorsal implant. However, as with any foreign material, there is a slight chance of infection. Also, Gore-Tex has to be fixed securely because it has a tendency to change shape or even allow for the formation of fluid under it.

NOSTRIL RE-SHAPING

One of the most difficult aspects of rhinoplasty is changing the shape of a nostril. Additionally, because there are two, it is important that they both match. The main deformities that we see are the following:

1. The nostril is too wide or flared, with the long axis in a horizontal rather than a vertical direction.

2. The nostril is too narrow.

3. There is a notch or retraction along the superior border.

4. There is an overhang of tissue along the superior border.

To correct a wide or flared nostril, we can remove tissue at the posterior aspect of the nostril before it attaches to the cheek or, at times, remove tissue from the nasal floor.

In less severe cases, a suture may be placed beneath the nose to cinch the nostrils closer to the midline. “Additionally, freeing the nostrils from their underlying bony attachments allows the nostrils to contract inward.”

To correct a narrow nostril, a straight cartilaginous strut can be placed along the margin of the nostril to widen the opening. In more severe cases, a flap of tissue located to the side of the nostril can be rotated in to expand the opening. This latter procedure is especially useful for patients with restricted airways to improve breathing.

When there is a notch or retraction along the superior border of the nostril, there are two methods that can be used to correct this. In mild cases, skin can be rotated downward and outward from within the nose, either with or without a cartilage graft for stability. In more severe cases, a composite graft of skin and cartilage, taken from the ear, can be placed within the nose to lower the rim.

Finally, in cases where there is excessive overhang along the superior border, this tissue can be pulled up internally and trimmed.