Views of double-dome unit (top),
single-dome mattress sutures (bottom left), and double-dome mattress sutures
View of the high septal transfixation
Alar cartilages supported by Metzenbaum
Separation of the vestibular skin
from the undersurface of the domal cartilage.
Placement of a single-dome mattress
suture using 5-0 absorbable synthetic polyglycolic acid (Dexon).
Beveling the cephalic portion
of the single-dome unit.
Tying the double-dome mattress
stitch with the alar cartilages replaced.
Preoperative (A-C) and postoperative
(D-F) views of a patient whose trapezoidal tip was reconstructed.
Preoperative (A and B) and postoperative
(C and D) views of a patient whose bifid tip was reconstructed.
Preoperative (A and B) and postoperative
(C and D) views of a patient whose bulbous tip was reconstructed.
Preoperative (A and B) use of
dome completed truncation and double-dome suture for asymmetrical and overprojected
nose and postoperative (C and D) result.
Perkins SW, Hamilton MM, McDonald K. A Successful 15-Year Experience in Double-Dome Tip Surgery via Endonasal ApproachNuances and Pitfalls. Arch Facial Plast Surg. 2001;3(3):157-164. doi:
From the Department of Otolaryngology–Head and Neck Surgery,
Indiana University School of Medicine (Drs Perkins and Hamilton), Indianapolis.
Drs Perkins, Hamilton, and Ms McDonald are also in private practice in Indianapolis.
Background Endonasal double-dome techniques provide a reliable method to approach
the nasal tip.
Objectives To review one surgeon's 15-year experience using a graduated method
of endonasal double-dome tip surgery including patient selection, intraoperative
techniques, and postoperative complications and to emphasize the nuances to
achieve symmetry and consistent results.
Patients and Methods Three hundred eighty-six patients who had adequate follow-up after undergoing
endonasal double-dome tip rhinoplasty.
Results Results at 1 year showed high rates of supratip (94%), dome (96%), and
nostril (88%) symmetry. There was a high rate of patient satisfaction with
a low rate of revision (7%).
Conclusion Endonasal double-dome tip surgery provides the surgeon the ability to
achieve consistent results with high patient satisfaction and a low rate of
THE MOST challenging part of rhinoplasty is the nasal tip. Endonasal
delivery techniques have an extensive and successful history. Since its introduction,
open structure rhinoplasty has gained increased recognition as reportedly
a more reliable technique. In this article we will demonstrate the simplicity
of endonasal double-dome tip surgery and show how in one surgeon's (S.W.P.)
hands it has proven reliability with consistent results and a low rate of
Achieving tip definition has evolved since cosmetic rhinoplasty began
with Joseph in the late 1800s. Tebbetts1 describes
this evolution. Initially, nasal tip-shaping techniques were destructive,
consisting of mostly incising and resecting cartilage. This resulted in consistent
loss of nasal tip support and increased the risk of secondary deformities.
Then came the era of open structure rhinoplasty with the routine use of tip
grafts. This increased the number of variables in a surgery in which the normal
anatomical structures could produce the same or better results. Now we have
evolved into an era of nondestructive tip-shaping techniques. These methods
allow achievement of the desired aesthetic appearance while maintaining functional
support. This assures excellent results, not just at 1 month, but also at
1 year, 5 years, 10 years and more.
Our approach is based on the creation of the double-dome unit as described
by McCollough and English.2 In addition, individual
treatment of each dome to create the correct contour is further refined. If
traditional techniques of morselization and scoring are unsuccessful, a suture
can be used to achieve the "ideal" single dome prior to double-dome reconstitution
These techniques are not for all patients. Tardy et al3
list the ideal patient characteristics for suture techniques. The ideal patient
has a bifid, broad, or even trapezoidal nasal tip. Thin skin and sparse subcutaneous
tissue are more appropriate for these refined techniques. The alar cartilage
itself must be firm and strong. Finally, the alar sidewalls should be thin
and delicate. Patients do not necessarily need to have any or all of these
characteristics. By using the endonasal approach and a progressive method
with each tip, an aesthetic result can still be achieved with more aggressive
A total of 1282 medical records of patients who had nasal surgery by
one of us (S.W.P.) between April 1, 1983, and April 1, 1997, were retrospectively
reviewed. Of these patients, 822 had tip-altering procedures as part of their
nasal surgery. Of these, we selected those patients who had endonasal double-dome
tip rhinoplasty and at least 1-year follow-up. A total of 386 patients qualified
for this study.
Supratip, tip, and nostril symmetry were evaluated from slides taken
at the 1-year point. All evaluations were done by one of us (M.M.H.). Judgment
was made as to whether symmetry had been achieved.
Final results from the patients' most recent visit were evaluated in
a similar manner as done at the 1-year point. If supratip, tip, and nostril
symmetry had been achieved, the patient was judged to have had a satisfactory
surgical result. In addition, office notes from this most recent visit were
reviewed to determine patient satisfaction. Length of postoperative time (in
months) from the initial surgery was also recorded.
Revision rates were determined to further judge consistency. A determination
was made from operative reports as to whether the patient had tip, dorsum,
or septal revision work.
The delivery approach is begun by first making either a complete transfixion
incision or a high septal transfixion depending on tip projection (Figure 2). Curved sharp scissors are then
used to dissect up over the anterosuperior septal angle and expose the upper
lateral cartilages. Next intercartilaginous and marginal incisions are made
in a standard fashion. Thin Metzenbaum scissors are then used to separate
the overlying skin from the underlying lower lateral cartilages. Finally,
the alar domes are delivered with a single hook and supported with the Metzenbaum
scissors.4 In this fashion each dome is assessed
and recontoured individually (Figure 3).
The first step to achieving improved definition is removal of the fibrofatty
tissue between the domes. This allows greater approximation of the 2 alae.
An intact or complete strip is performed next by excising the cephalic portion
of the lateral crura. This achieves both volume reduction and improved supratip
definition. It is essential to preserve at least a 7- to 9-mm width of cartilage.
The cartilages can be repositioned in situ. In a few select cases, this may
be all that is required. Most often, however, satisfactory tip symmetry and
definition have not been achieved, and further refinement and stabilization
If the contours of the domes need refinement, either suture techniques
or morselization may be used. The goal with morselization is to lightly crush
the cartilage enough that a more acute angle is created at the domal junction.
This technique of "pinch" morselization is reserved for very strong wide domes.
A great deal of finesse is required to achieve the desired contour without
breaking the cartilage. Because of this, suture techniques are favored.
The ideal alar configuration has been described as when the domal segment
is convex, the adjacent lateral crura is concave, and the overlying soft tissue
is thin.5 The safest method of achieving ideal
domal configuration is with suturing. This allows preservation of cartilage
strength and resiliency. Prior to placing the suture, the vestibular skin
is separated from the undersurface of the domal cartilage (Figure 4). A 5-0 absorable synthetic polyglycolic acid (Dexon) mattress
suture is placed at the junction of the lateral and medial crura (Figure 5). This is where the individual tip-defining
point is refined.6 The knot is tightened to
the point where the proper amount of domal definition is achieved.
If tip asymmetry exists or supratip definition requires more refinement,
the stronger dome can be trimmed. This is typically done by "beveling" the
cephalic portion of the dome to match the opposite dome (Figure 6).
With achievement of symmetrical, aesthetically pleasing individual domes,
the entire tip is reevaluated. By using the endonasal approach, this continual
critiquing can occur. A double-dome stitch or transdomal mattress suture is
next used to bring the individually defined domes together and to stabilize
these into 1 unit. Stabilization is the key for long-term predictability of
symmetry and maintenance of long-term results. The suture is placed horizontally
through the lateral and medial crura of both domes. A 5-0 clear polypropylene
(Prolene) suture is typically used. Varying the tension on the suture can
alter the amount of lobule narrowing desired. By replacing the domes, the
amount of narrowing achieved can actually be visualized as one ties the knot
(Figure 7). It is essential to avoid
cinching the suture down to avoid creating a unitip appearance.
At this point the tip is reevaluated. Minor asymmetries can first be
addressed by removing or replacing the double-dome mattress suture. It is
possible to adjust one dome to the other by alterations in placement of the
double-dome stitch. Next, excising or recontouring cartilage above the sutures
can be used for more minor asymmetries.
Following achievement of a symmetrical and well-defined tip, attention
is then turned to the septum, the dorsum, and osteotomies. A columellar strut
fashioned from septal cartilage is placed between the medial crura and anterior
to the nasal spine prior to osteotomies. Intranasal incisions are closed with
5-0 catgut. In closing marginal incisions it is important to avoid the lateral
crura when suturing. Retraction of the lateral crura could lead to possible
alar collapse and a more pinched tip or nostril asymmetries.
A small rolled piece of absorable oxidized regenerated cellulose (Surgicel)
is placed inside the nose within the vestibule of each newly constructed dome
to add stability and prevent hematoma. Tan surgical tape (Micropore) along
with an alloy metal splint is used for the external dressing that is removed
at 1 week.
A total of 386 patients (297 females and 89 males) underwent endonasal
double-dome tip rhinoplasty and had adequate (1-year) follow-up. Average follow-up
was 17 months.
Dome symmetry was present in 371 patients (96%) at 1 year. Supratip
symmetry was found in 362 patients (94%) and nostril symmetry in 335 patients
(88%). There were a total of 47 revisions. In 27 of these revisions, tip work
was performed. Twenty-two revisions involved work on the dorsum and 2 involved
work on the septum. Overall the percentage of patients required revision tip
surgery was 7%.
Final results were determined from the most recent follow-up (following
any revision). Patients were judged to have a satisfactory result if tip,
supratip, and nostril symmetry had been achieved. Also, patient satisfaction
was determined from the most recent office note. A satisfactory aesthetic
result as well as patient satisfaction were obtained in 357 patients (92%).
In 13 patients (3%) an unsatisfactory aesthetic result persisted, but the
patient remained satisfied. In 11 patients (3%) it was believed that a satisfactory
aesthetic result was achieved, but the patient remained dissatisfied. Finally,
in 5 patients (1%), a less than completely satisfactory result was obtained
and the patients were satisfied. These results were seen across a variety
of nasal tip deformities (Figure 8, Figure 9, Figure 10, and Figure 11).
Nasal tip surgery has evolved into a philosophy of preservation of normal
anatomy. Endonasal double-dome techniques offer methods that follow this principle.
The merits of these techniques are many. By using the endonasal approach,
results of individual steps can continuously be reevaluated. Normal anatomy
is used instead of newly created grafts that increase the possibility of secondary
deformities. The procedure is performed in incremental steps, most of which
The success using these techniques is demonstrated here. In a large
series of 386 patients with long-term follow-up, excellent results were consistently
achieved. Supratip, tip, and nostril symmetry were achieved 96%, 94%, and
88% of the time, respectively. Nasal tip revisions (7%) were infrequently
needed in a study in which only patients with long-term follow-up were included.
Finally, patient satisfaction remained high (95%) even years after the surgery.
The disadvantages of these techniques include the need for greater surgical
finesse in delivering and suturing the alar cartilages. Also these techniques
are not as effective in those with thick skin or with thin, frail alar cartilages.
Nevertheless, for most cosmetic tip rhinoplasties, endonasal double-dome techniques
provide consistent results and few complications.
Accepted for publication March 14, 2001.
Presented in part at the Seventh International Symposium on Facial Aesthetic
Surgery of the American Academy of Facial Plastic and Reconstructive Surgery,
Orlando, Fla, June 16, 1998.
Corresponding author and reprints: Mark M. Hamilton, MD, Meridian
Plastic Surgery Center, 170 W 106th St, Indianapolis, IN 46290 (e-mail: firstname.lastname@example.org).