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Category: Nasal Tip

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.

Open versus Closed Rhinoplasty

The difference between an “open” versus a “closed” rhinoplasty is a small (transcolumellar) incision between the nostrils. This incision, when connected to the traditional intranasal incisions within each nostril, allows the skin to be elevated off the underlying framework. This “opens” up the surgical field which has certain benefits, especially when operating on a nose that has been injured or operated on previously. In both of these cases, dissection through scar tissue is easier, evaluating causes of asymmetry is easier, placement of grafts is easier and performing certain suture techniques is easier. I have not seen an increase in swelling or post-operative recovery time with the open technique. And the resultant transcolumellar scar is generally imperceptible over time. On the other hand, unless special care is taken to avoid disrupting the attachments of the tip to the septum, nasal tip support has to be re-instated which lengthens operative time. Additionally, there are special cases where an open rhinoplasty is also useful. These involve procedures where the tip has to be significantly reconstructed or repositioned. Though many of these manipulations can  be accomplished  using the “closed” technique by an experienced surgeon, they are more easily and more predictably performed  using an “open” approach. Furthermore, in the “closed” technique all of the access routes to the bone and cartilage are through intranasal incisions. Because of this, placement of any synthetic implant could be problematic due to the risk of extrusion.

Though I’ve outlined many advantages of the “open” versus “closed” technique, I should state that in a fairly straightforward, primary rhinoplasty, the closed technique is perfectly satisfasctory, predictable and probably most often employed.

Common Misconceptions regarding Nasal Surgery

Nasal Surgery

One of the biggest misconceptions is that just about any nose that you desire can be accomplished with the right surgeon. While it is true that experience, technical expertise and aesthetic judgment  vary among surgeons, there are certain limiting factors that no surgeon can overcome. Chief among these is thickness and quality of the skin. The thicker the skin, the less likely it is that it will re-drape  to a smaller, more angular framework. Various techniques such as cross-hatching the dermis, injecting with steroids and other medications such as 5-FU, prolonged casting or nightly taping and the use of Accutane to diminish the oil glands in the skin have been used with variable success. Additionally, as one ages there is a loss of elasticity in the skin making it harder to shrink-wrap down onto a reshaped  bony-cartilaginous framework. Since the skin over the upper one half of the nose is thinner with less oil glands, it is more capable of conforming than the skin over the lower half. Additionally, since the lower half skin will shrink to the smallest volume for its surface area, which is a sphere, we tend to see a rounded lower half of the nose if too much bone and cartilage has been removed for the skin to adapt. This is called the “pollybeak” deformity.

Another misconception is that breaking the nose makes the operation more painful with a longer recovery period. In actuality, nasal surgery is usually painless or minimally painful in the post-operative period, whether or not breaking of the bones was necessary. And it’s been my experience that recovery time is unchanged in either case. Furthermore, I have seen people bruise without bone breaking and no bruising in some patients who required it. It seems more related to capillary fragility, hormonal balance and/or medications or herbal products that they were taking.

Another misconception is that there are some things that can’t be corrected on the nose, such as nostril asymmetries and their  facial attachments . Since wide variation exists between surgeons regarding experience and abilities, it is wise to go to several surgeons if you are told that something can’t be done. It might just mean that this particular surgeon can’t do it!

Another misconception is that you will have no idea what your nose will look like until six to twelve months have passed. While it is true that swelling and settling can take weeks or months to resolve, it has been my experience that you should have a rough idea of what your nose will look like in the immediate post-operative period.  Obviously, there are many variables that play into this, such as skin thickness, techniques used, post-operative care, etc.

Another misconception is that  very “difficult” noses require two operations. While it is true that minor revisions or “tweaking” a result may be warranted in 5%-10% of the time, most of the time all that is needed can be accomplished in one operation.

A final misconception is that a surgeon who performs rhinoplasty can also perform revision rhinoplasty or reconstructive rhinoplasty. In actuality, it’s usually just the reverse. In revision rhinoplasty, the surgeon is trying to establish an aesthetic result in a nose that was operated on with a poor outcome. Like the first  surgeon, he is trying to achieve a nose that is better than it was initially…that is, taking a normal nose and making it “better than normal”. However, in this case there is additional internal scarring, misplaced or absent tissue, shrinkage of internal lining and maybe external scarring as well. In reconstructive rhinoplasty, the surgeon is trying to establish a normal appearing nose from one that is less than normal, from a cancer procedure or trauma. The techniques used may require skin flaps or grafts as well as cartilage or bone from several sources. The internal arrangement of these components may have no resemblance to what normal nasal anatomy is. However, the goal is to establish a nose that looks relatively normal and functions well.


Increasing Nasal Tip Projection

The ideal nasal profile has a tip that is slightly higher than the rest of the bridge. In many instances, this requires raising the tip to this level. To accomplish this, there are several techniques that can be employed. The first involves narrowing each of the two tip cartilages and then sewing them together. Because each cartilage forms an arch under the tip skin, narrowing them with sutures causes them to elongate upwards (Fig. A).  Another popular way of increasing tip projection involves placing a cartilage tip graft over the underlying tip cartilages (Fig. B). This has the added benefit of creating more angularity to the nasal tip, which is especially useful with thick skin. Finally, the third most common way of increasing tip projection is by placing a fixed strut of cartilage anchored to the septum to which the tip cartilages can be sutured in a more projected fashion (Fig. C). Though each of these techniques work to accomplish an increase in tip projection, the choice of which one to use depends on many factors such as the need to improve tip definition or the desire to improve the proportional relationship between the length of the nostril to the length of the tissue in front of it (the lobule).