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.