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.