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Abstracts: Commentary
September 2005

The Pursuit of Excellence in Nasal Tip Planning

Arch Facial Plast Surg. 2005;7(5):353-354. doi:10.1001/archfaci.7.5.353

Plastic and Reconstructive Surgery

The Two Essential Elements for Planning Tip Surgery and Primary and Secondary Rhinoplasty:
 Observations Based on Review of One Hundred Consecutive Patients

Mark B. Constantian, MD

Nasal tip surgery has become significantly more complex since the introduction of tip grafting and the many suture designs that followed the resurgence of open rhinoplasty. Independent of the surgeon's technical approach, however, is the need to identify the critical anatomical characteristics that will make nasal tip surgery successful. It is the author's contention that only two such features require mandatory preoperative identification: (1) whether the tip is adequately projecting and (2) whether the alar cartilage lateral crura are orthotopic or cephalically rotated (“malpositioned”). Data were generated from a review of 100 consecutive primary rhinoplasty patients on whom the author had operated. The results indicate that only 33% of the entire group had adequate preoperative tip projection and only 54% had orthotopic lateral crura (axes toward the lateral canthi). Forty-six percent of the patients had lateral crura that were cephalically rotated (axes toward the medial canthi). Both inadequate tip projection and convex lateral crura were more common among patients with malpositioned lateral crura (78% and 61%) than in patients with orthotopic lateral crura (57% and 20%, respectively). Tip projection can be reliably assessed by the relationship of the tip lobule to the septal angle. Malposition is characterized by abnormal lateral crural axes, long alar creases that extend to the nostril rims, alar wall hollows, frequent nostril deformities, and associated external valvular incompetence. The data suggest that the surgeon treating the average spectrum of primary rhinoplasty patients will see a majority (61%) who need increased tip support and a significant number (46%) with an anatomical variant (alar cartilage malposition) that places these patients at special risk for postoperative functional impairment. Correction of external valvular incompetence doubles nasal airflow in most patients. As few as 23% of primary rhinoplasty patients (the number with orthotopic, projecting alar cartilages in this series) may be proper candidates for reduction-only tip procedures. When tip projection and lateral crural orientation are accurately determined before surgery, nasal tip surgery can proceed successfully and secondary deformities can be avoided. (Plast Reconstr Surg. 2004:114;1571-1585)

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