Nasal Tip Surgery and Its Deformities

Nasal Tip Surgery

Nasal tip surgery is the major beneficiary of the open approach since it exposes the tip's structural components in their natural, undisturbed position. This allows unparalleled diagnosis of the various deformities and asymmetries, precise surgical manipulation of the tip cartilages, and suture fixation of grafts. 

It allows the visualization and correction of minor asymmetries, thus adding extra surgical finesse. Modeling the alar cartilages alters the tip projection and rotation based on the ‘tripod’ theory.  This theory states that the nasal tip's structural framework is based on the two lateral crura and the conjoined medial crura, each forming one leg of the tripod. 

This allows an understanding of the effect of altering the size and position of the medial or lateral crura on the tip position. For instance, if the medial and lateral crura are reduced in length, the tip is deprojected; if they are augmented, projection is achieved.

Superior rotation is achieved by shortening the lateral crura or lengthening the medial crura, causing rotation at the ‘hinge’ region. Problems encountered may be conveniently thought of as being due to under- or over-rotation, under- or over-projection, width problems, or intrinsic tip deformities. 

Manipulation of any part of the tripod model normally leads to predictable changes in the projection and rotation of the nasal tip. The external approach allows for a more controlled and high degree of symmetry in all aspects of tip surgery. 

Deformities of nose

Rotation Deformities

Various maneuvers based on the tripod theory can affect the correction of the under-rotated tip. Lateral crural steal techniques, using the pull of the lateral crura medially and domal suturing, create tip projection and rotation. Conversely, resection and overlay of the lateral crura (lateral crural flap/overlay technique) produce rotation with deprojection. Such a technique is generally used to shorten the nose as well when over-projections are problematic. 

Plumping grafts and columellar struts are also used to create an illusion of rotation. Correcting an overly rotated nasal tip is often challenging, particularly when it results from prior surgery. 

The mainstay of management is the placement of a caudal septal extension graft to effectively lengthen the nose. Extended spreader grafts are then used to stabilize the septal complex, and the lower lateral cartilages are extended downwards and fixed to the extension graft. 

Again, using the tripod theory, division and overlap of the medial crura will create counter-rotation, although this also deprojects the tip. Finally, graft in the tip/infratip area will give the illusion of counter-rotation and increased length of the nose and is best employed in addition to, rather than instead of, the other listed procedures when required. This is best avoided, however, in thin-skinned individuals where grafts in the tip region are potentially easily visible. 

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Projection Deformities

Projection of the nasal tip is often desirable in rhinoplasty surgery.  Both external and endonasal rhinoplasty approaches can create post-operative ptosis, so attempts to maintain adequate projection are important. Dome suturing often defines the nasal tip by increasing triangularity and narrowing. When the projection of the tip is required, the lateral crural steal is a workhorse technique that can also rotate the tip. 

It is important not to overtighten sutures as this can create a pinching effect. A further option is the ‘tongue-in-groove’ technique of septocolumellar suturing, which usefully allows the setting of the projection and rotation of the nasal tip. 

A disadvantage of this method is its rigidity and lack of mobility. Although such a procedure imparts to the tip, it is generally well tolerated by most patients.

This technique can cause a degree of columellar retraction and over-rotation of the tip if the distance between the medial crura and the caudal septum is excessive. Columellar struts may help strengthen inherently weak medial crura, thereby creating projection. 

Frequently Asked Questions:

Q: What is the use of Nasal Tip Surgery?

Answer: Nasal Tip Surgery allows unparalleled diagnosis of the various deformities and asymmetries, precise surgical manipulation of the tip cartilages, and suture fixation of grafts. 

Q: What technique is used for septocolumella suturing?

Answer: Tongue-in-groove technique.

Q:What compromises the tripod complex?

Answer: The conjoint medial crura comprise one leg of the tripod, while the lateral crura comprise the other two legs.

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