Rhinoplasty :

Correction of the tip

Dept. of Oral and Maxillofacial
Surgery
S.C.Ahn

Anatomy
Bony compartment
Cartilaginous
compartment
Connective tissue

Anatomy
Bony pyramid (upper 1 / 3)
1) Nasal bone
2) Frontal process
of maxilla
3) Nasal process
of frontal bone

Anatomy
cartilaginous vault - lower 2 / 3
1) Upper lateral cartilage
2) Lower lateral cartilage
= alar cartilage (major)
(1) lateral crus
(2) medial crus
3) Lesser alar
= minor alar cartilage

Anatomy
4) sesamoid cartilage
= accessory cartilage
5) septal cartilage
= quadrangular cartilage

Anatomy
Blood supply
1) Facial artery
and its branches
2) Dorsal nasal artery
from ophthalmic artery
3) Angular vein

Anatomy
Thrombophlebitis arising from a
furuncle of the upper lip or the nose can
spread via the ophthalmic vein to the
cavernous sinus to cause a cavernous
sinus thrombosis(or thrombophlebitis)
Danger area of face : Triangle made of
lines from glabella to both mouth
corners

Anatomy
Sensory nerve
1) ophthalmic nerve
a. nasociliary
b. external nasal
c. infratrochlear
2) maxillary nerve
3)infraorbital nerve

Anatomy
Muscles
1) procerus
2) nasalis (transverse + alar parts)
3) levator labii superioris alaeque
nasi
4) depressor septi
5) dilator naris (anterior + posterior)

Landmarks
1. infratip lobule
2. columella
3. alar sidewall
4. facet, or soft-tissue
triangle
5. nostril
6. columella-labial angle
or junction
7. alar-facial groove or junction
8. tip defining points
9. Medial crural footplate

Orientation

anterior(dorsal)
posterior(ventral)
cephalic
caudal

Tip support mechanism

Major tip supports
1) The thickness, size, shape, contour of
the alar cartilages
2) The connective tissue relationship
between the caudal margin of the upper
lateral cartilage and the cephalic margin of
the alar cartilage
3) The medial crural footplate attachment
to the caudal quadrangular cartilage

Tip support mechanism

Minor tip supports
1) The nasal tip interdomal ligaments
2) The cartilaginous dorsum
3) The nasal spine
4) The strength, length, resilience of the medial
and intermediate crura
5) The thickness of the tip skin-subcuta
neous tissue complex
6) The supportive strength of the alar sidewalls

Procedure
Incisions : methods to gain access to
nasal tip structures
Approaches : divided into delivery
and nondelivery categories
Techniques : those sculpturing
modifications carried out on the alar
cartilages

Incision
Does the incision
1)Provide reasonably unencumbered visualization and access to the alar cartilages?
2)Preserve whenever possible the important tip support
mechanisms?
3)Avoid interference with other incisions contemplated in
the same area?
4)Lend itself well to healing without contraction or undue
scarring?

Incision
Alar cartilage incisions
Intercartilaginous incision
Transcartilaginous incision
Marginal incision

Incision
Septal

incisions(transfixion

incisions)
CompletePartial(limited)HemiHigh Columella incisions

Approach
Nondelivery approach to the lower
lateral cartilage
(1) Transcartilaginous approach
(2) Retrograde or eversion approach
Delivery of the lower lateral cartilage
(1) Bipedicle chondrocutaneous flap
approach
(2) External or open approach

Transcartilaginous approach

Retrograde or eversion
approach

Bipedicle chondrocutaneous
flap approach

External or open approach

Advantages
Adequately
expose
deformities,
abnormalities and asymmetries.
Accurately
diagnose
deformities,
abnormalities and asymmetries
Binocular vision and bimanual surgical
dissection
Microcautery for exacting hemostasis

External or open approach

Disadvantages
Transcolumellar external scar
Interruption to the ideal structures in no
need of change
Prolonged tip edema

External or open approach

Potential excess trauma by manipulation
and retraction
Increased operative time
More traumatic
Demanding suture fixation of any grafts
positioned to contour or support the
nasal bone

External or open approach

External or open approach

Sculpturing of cartilage
Principles
1) Almost all tip techniques share the principle
of volume reduction of alar cartilage
2) The more alar cartilage left undisturbed
consistent with adequate esthetic tip
correction, the more predictable is the
healing process
3) The laterocephalic portion of the lateral crus
should be left intact and not resected.

Sculpturing of cartilage
4) Identifying and preserving the tip
defining point of the alar cartilage
dome is mandatory for optimum tip
definition and projection.
5) A shape and attitude change may be
induced in the residual caudal strip
with
suture
techniques
without
resorting to a vertical incisional
interruption of the complete strip

Sculpturing of cartilage
6) The overlying skin canopy must be of
sufficient thickness to camouflage any
irregularities or offsets that would
otherwise become palpable and/or
visible in the long-term post-op period

Sculpturing of cartilage
Volume reduction
1)

Cephalic cartilage volume reduction with

preservation of an intact complete caudal
cartilage strip
2) Cephalic cartilage volume reduction with caudal
complete strip preservation with a shape change
induced by sutures or by cartilage attenuation
procedures
3)Cephalic cartilage volume reduction with vertical
division of the dome and/or lateral crus, medially
or laterally

Sculpturing of cartilage
Complete strip

Sculpturing of cartilage
Weakened complete strip

Sculpturing of cartilage
Incomplete(Interrupted) strip

Nasal tip augmentation

1)

Alar cartilage suturing

Interdomal suture
Transdomal suture
Domal creation
suture

Sheens method

Nasal tip augmentation

Pecks method

Flowers method

Unfavorable nasal tip

Projectingnasaltip
1) McCarthy-Wood-Smith method
2) Sheens method
Pointednasaltip
1) Aufrichts method
2) Rotation of tip
3) Nasal tip graft

Unfavorable nasal tip

BroadorBulbousnasaltip
1) Alar cartilage suture
2) Rotation of tip
3) Partial resection of alar cartilage
or skin resection .
Bifidnasaltip
Deviatednasaltip
Plungingnasaltip
Type I, II, III

Smilingormobilenasaltip

Correction of plunging tip(type I)

Correction of plunging tip(type II)

Correction of smiling tip