1. The nasal tip's support structures include bone, cartilage, and soft tissue attachments between these structures. 2. Modifying the nasal tip cartilages and related structures can alter the tip's projection, rotation, and definition. 3. Various surgical techniques can be used to increase or decrease tip projection and rotation, including modifying the lateral and medial crural attachments and using grafts. Precise suturing techniques are also important for shaping the tip.

1. Tip Plasty
Present by : Ali Darini MD

2. ANATOMY OF THE NASAL TIP SUPPORT
STRUCTURES
Support for the nasal tip is derived from a combination of bony,
cartilaginous, and soft tissue structures. Bone of the midface provides
the foundation for nasal support.
Medially, the maxillary crest serves as a buttress for the nasal
septum. The septum in return provides crucial support for the
external nose and nasal tip.
Soft tissue attachments from the dorsal and caudal septum to the
lower lateral cartilages have a direct inɻuence on tip support and
location. Laterally, soft tissue attachments connect the lower
lateral cartilage complex to the bony piriform aperture.

3. To rotate the nasal tip, the surgeon must identify and remove
anatomic structures resisting upward rotation.
Tip location is ultimately dependent on the position of the anterior
septum and lower lateral cartilages.

6. Lateral Crural Attachments to the Upper
Lateral Cartilages

7. The upper lateral cartilages are secured cephalically by their
connection to the nasal bones.
Medially, the upper lateral cartilages abut and connect to the dorsal
septum.
Caudally, the upper lateral cartilages exhibit a soft tissue
attachment to the cephalic border of the lateral crura at the scroll
area.
This connection provides support to the lateral crura and nasal tip.

8. Connective tissue ɹbers that attach the lateral crura to the upper
lateral cartilages allow movement between the two structures while
providing tip support.
Violating the soft tissue connection between these two structures with
an incision will obliterate this support as will cephalic trim of the lower
lateral crura.

9. The lateral crura attach laterally to the piriform aperture by means of
accessory cartilages.
The accessory cartilages share continuous perichondrium, allowing
them to function as a unit. Together the lateral crura, accessory
cartilages, and associated soft tissue connections to the piriform
aperture create the lateral crural complex.

10. Support of the lateral crural complex results from the suspensory
ligament of the tip resting on the anterior septal
angle

11. Medial Crural Attachments to the Caudal
Septum
The medial crura approximate the caudal septum and anterior nasal
spine with ɹbroelastic tissue attachments providing support but
allowing mobility.
Posterior movement of the medial crura is possible to some extent
Disruption of these soft tissue attachments, such as with a
transɹxion incision, allows greater posterior displacement of the medial
crura and decreased tip projection.

12. Suspensory Ligament of the Nasal Tip
Fibrous attachments of the lower lateral cartilages to the upper
lateral cartilages, piriform aperture, and
caudal septum are responsible for nasal tip support and position.
Surgical maneuvers including transfixion incision, intercartilaginous
incision, cephalic trim, and lower
lateral cartilage division will violate support structures and change the
position of these cartilages.

13. THE TRIPOD CONCEPT

14. The tripod concept proposed by Anderson remains a useful means of
understanding the relationship between tip rotation and projection.
The lateral crura represent two upper lateral legs, and the abutting
medial crura produce the central lower leg. The lower tripod leg is also
inɻuenced by the caudal septum.
Shortening the medial crura or violating the related soft tissue support,
as mentioned previously, leads to a decrease in nasal tip projection
and rotation.
Shortening of the upper legs or violation of associated soft tissue leads
to decreased projection and increased rotation.
Augmentation with grafts or struts that alter tripod leg length will also
inɻuence tip position.

15. Shortening (or violating support) of the lower leg
leads to decreased projection and rotation.

16. Shortening of the upper tripod legs will result in
decreased projection and increased rotation.

17. Shortening of all three tripod legs will result in
decreased projection, with minimal inɻuence on
tip rotation.

18. Lengthening the lower tripod leg should
result in increased tip projection and rotation

19. Lengthening the upper tripod legs and shortening
the lower leg should accentuate upward tip
rotation

20. Modiɹed tip cartilages are commonly used for the
following purposes:
• 1. To alter tip projection
• 2. To alter tip rotation
• 3. To improve tip deɹnition
• 4. To reduce tip fullness
• 5. To create a supratip break
• 6. To improve the alar-columellar relationship

21. Many techniques to achieve such goals have
been described, including the following:
• Cephalic trim of the lateral crura
• Suture reshaping of the cartilages
• Suture repositioning of the cartilages
• Vertical transection and overlapping of the lateral crura
• Vertical transection and overlapping of the medial crura
• Excision of the medial crura caudal margins
• Resection of the caudal septum
• Placement of tip graft(s)
• Placement of a columellar strut graft
• Placement of lateral crural strut grafts
• Placement of alar spreader graft(s)
• Placement of extended alar contour graft(s)

22. Increasing Tip Projection
Increasing projection of the nasal tip can prove quite challenging.

23. When there is moderate ɻaring of the medial crura as they transcend
the dome area, suturing the medial aspect of the domes together can
provide a slight increase in tip projection.
Thus suturing straightens the ɻare of the anterior medial and middle
crura

24. Placement of a columellar strut graft may provide some
increase in nasal tip projection.
This is particularly true when using a ɹxed strut and less so
when using a ɻoating strut.
The increase in projection is relative to strutsize and is
inɻuenced by skin envelope characteristics

25. Following elevation of the nasal skin envelope, a pocket is created
between the feet of the medial crura. Again, a soft tissue
layer is preserved on the premaxilla to avoid having the strut seated
directly on nasal spine bone.
The columellar strut can be placed in an invisible position by
dissecting the pocket closer to the caudal septum superiorly. If
changes in the shape of the columella, alteration of the alar-
columellar relationship, and/or columellar-labial
transition are desired, this pocket can be dissected closer to the
columellar skin.

27. The columellar strut is placed into the pocket with Brown-Adson
forceps and pushed toward the anterior nasal spine to ensure that it
is resting in the bottom of the pocket.
Double-pronged skin hooks secured in each vestibular
apex are used to maintain the tip in the desired position during
placement of the medial crural-columellar strut
sutures.
A 30-gauge needle can be used to align the strut during suturing by
placing it through the medial crus and
columellar strut, then through the opposite medial crus.

28. If additional tip projection is required, the lateral crura may be
advanced medially. This maneuver is termed the
lateral crural steal and is performed with horizontal mattress sutures,
resulting in the creation of new tip-deɹning points on each lateral
crus. Suture placement is performed so that the medial vertical
segment of the suture lies on
the same vertical plane as the original tip-deɹning point. The lateral
vertical segment of the suture then lies 3 to 4
mm lateral to the tip-deɹning point. The suture knot lies medially.

29. The suture is tightened and tied to secure the position of
the manipulated cartilage. Suturing of the medial surfaces to the
columellar strut stabilizes the tip.
Lateral crural steal is easier when the convexity of the domes is a
gentle curve and is not more acutely angulated.

30. If additional projection is needed, a shield-shaped tip graft is
used. The original Sheen description used a ɻat shield-shaped graft
from septal cartilage with one end notched in the center.
The blunted cartilage remained 6 to 8 mm apart to create the two
tip-deɹning points. Graft length varied, depending on the projection
needed, but on average was 10 to 12 mm.

32. Over time the tip graft can become visible, with thinning of the
overlying skin, distortion of the graft, or displacement of the graft.
Visibility is primarily a problem when graft edges are appreciated
through the skin. To circumvent such outcomes, using blended tip
grafts such as anatomic cap grafts from the cartilage removed during
cephalic trim or morselized septal cartilage can alter tip shape
while having imperceptible edges.

33. A graduated approach to increasing tip projection includes
placement of a columellar strut graft, followed
by lateral crural steal with fixation to the strut, and if necessary,
tip grafting may also be used to achieve
greater tip projection.
Septal extension grafts may also be used to increase tip
projection.

35. When the increase in tip projection exceeds 4 mm, autologous rib
is used for strut fabrication. Rib cartilage is
inherently rigid and can be harvested to any required length. Initially,
columellar struts were carved with a notch
on one end. This end was then placed so that the notch seated directly
on the anterior nasal spine. Tip projection of
6 to 7 mm could be gained with this method, but the strut placed in
this plane led to signiɹcant widening of the
columella and was subject to warping forces.

36. Decreasing Tip Projection
Decreasing nasal tip projection is accomplished by weakening or
eliminating the elements that support the tip.
Several of these supports are violated with routinely used surgical
incisions. A complete transɹxion incision violates the ɹbroelastic
connections between the medial crura and caudal septum.
This allows greater posterior migration of the medial crural footplates
toward the anterior nasal spine.

37. Placement of an intercartilaginous incision, release of the lateral
crura from the upper lateral cartilages at the scroll area, or
cephalic trim of the lower lateral cartilage violates the ɹbrous
attachments suspending the lateral crura from the
upper lateral cartilages and decreases tip support.
Additionally, division of the suspensory ligament that spans the
domes will weaken tip support.

38. A lateral crural complex that is strong and ɹrmly adherent to the
piriform aperture resists posterior movement of the tip.
Resistance may be reduced or eliminated by undermining the
vestibular skin from the deep surface of the lateral crural complex and
vertically transecting the cartilages to allow
overlapping and posterior movement. Suture ɹxation is used to secure the
region of overlap and reestablish support
of the lateral alar wall.
In some cases, a lateral crural strut graft may be required for adequate
support after transection and overlap of the
lateral crus

40. Altering Tip Rotation
The tripod concept also applies to altering of tip rotation. Moreover,
understanding the anatomic structures that
support the nasal tip is important as such structures may limit tip rotation.
Factors that resist upward rotation of the nasal tip include the following:
• Fibrous attachments connecting the lateral crura to upper lateral cartilage
• A cephalic abutment of the lateral crural complex against the piriform aperture
• A prominent caudal septum
• Lengthy upper lateral cartilages
• High septal angle
• Skin adherence to the lateral crura, upper lateral cartilages, and nasal bones

41. Increasing rotation of the nasal tip requires evaluation of each factor
that may limit upward rotation. The result of such assessment guides
surgical decisionmaking.

42. Either placement of an intercartilaginous incision or resection of the
cephalic lateral crura eliminates resistance
from the ɹbrous attachments connecting the lateral crura to upper
lateral cartilages. If rotation is desired, a portion
of the cephalic margin of the lateral crura is resected. Following
resection, the lateral crura are typically free to be
moved upward.

43. If the lateral crural complex abuts the piriform in a more cephalic
direction, it will prevent upward tip rotation.
Elimination of this force is as previously described, with vertical
transection of the cartilage and overlap with
suture ɹxation. Placement of a columellar strut is occasionally needed
to maintain tip rotation and avoid posterior
movement of the medial crura

45. If rotation of the tip is still limited after these maneuvers, the caudal
septum should be assessed as it may interfere with upward movement
of the medial crura.
Loose connective tissue between the medial crura feet and
caudal septum typically allow rotational movement.
When greater rotation is needed these connections may cause
tethering and need to be released usually with caudal septal
resection.

46. Determining which portion of the septum
should be resected depends on the
columellar-labial angle.

47. If the angle is normal then resection should be isolated to the
anterior portion of the caudal septum.
When the angle is displaced down and out, more cartilage is resected
from the posterior caudal septum and adjacent to the
anterior nasal spine. Resection to any signiɹcant degree of the caudal
septum is typically accompanied by similar
resection of membranous septum.

49. Improving Tip Definition
Decreasing the width between tip-defining points can be best
accomplished with interdomal suture placement to closer
approximate the domes.
An additional method to accomplish this task is through cephalic trim
of the lateral and middle crura of the domes.
Typically, as the lower lateral cartilages transition from dome to
columella, they flare so that the caudal margins are separated.
Resection of the cephalic margins improves alignment and allows the
tip-defining points to shift
medially.

52. Advanced Suture Techniques
Transdomal Suture
A 5-0 PDS horizontal mattress suture on P-3 needle is applied to the
dome starting at the caudal end so that the knot is not in the
supratip region. If the dome is diɽcult to identify, the tip cartilages
are gently squeezed with forceps, which causes the dome to become
more apparent.
The suture is not tied too tight, but to the appropriate width. After
that is done, the domes take on an axis, and the separation between
thoses axes is usually about 90 degrees. Some improvement to the
lateral crus convexity also occurs.

54. Hemitransdomal Suture
When eversion of the lateral crus is desired, a hemitransdomal suture is
useful and often replaces the transdomal suture.
While the dome is held with a forceps, a 5-0 PDS simple suture is applied
to the cephalic side of the dome.
This squeezes only the cephalic side, causing the lateral crus to evert and
even straighten slightly.
The hemitransdomal suture narrows the dome and everts it.

55. The two sutures (transdomal and hemitransdomal) can be compared
side by side. This small amount of eversion is
important if it is to minimize a pinching of the domes and a resultant
rim concavity.

56. Interdomal Suture
Opening the nose, splitting the tip cartilages slightly to gain access to the
anterior septal angle of the septum (to elevate mucoperichondrium and
release upper lateral cartilages) are all necessary maneuvers but do result in
some splaying of the domes and loss of strength and symmetry. The
interdomal suture restores symmetry and corrects splaying.
A 5-0 PDS suture is approximate the middle crura (on the cephalic side) at a
level that is approximately 3 to 4 mm below (posterior to) the domes. The
domes themselves are not sutured together because there is normally a
small separation of a few mm between the cephalic end of the domes. If a
columellar strut is planned, this suture is usually placed after the strut is put
in place because strut placement can often be disrupting.

58. Lateral Crus Suture
Any convexity of the lateral crus can be improved or reversed with a
horizontal mattress suture of 5-0 PDS. While holding the most convex
portion of the convex lateral crus, the suture needle is placed on one
side of the forceps, perpendicular to the direction of the lateral crus
trying to take as small a bite as possible.
The second bite is taken on the other side of the forceps so that the
distance between should be approximately 6 mm.

60. Intercrural Suture
On occasion the caudal aspect of the middle crura tends to ɻare causing
what would be a wide columella. At the anterior end of the middle
crura such ɻaring can actually cause an unwanted broad infratip lobule.
An intercrural suture narrows the width of the middle crura in this
region.
It is simply a 5-0 horizontal mattress suture not tightened too much
but just enough to give the proper width to the columella.
The intercrural suture narrows the medial crura (columella).

62. Cephalic Trim

63. Only when the domes are bulbous or boxy, causing paradomal fullness,
is a cephalic trim indicated. It is important to realize that cephalic trim
intrinsically decreases tip support by disrupting attachments of the
upper and lower lateral cartilages at the scroll area.
The cephalic portion of the middle and lateral crura is detached from
the underlying mucosa and excised leaving at
least a 6 mm alar rim strip.

64. Lower Lateral Crural Turnover Flap

65. As opposed to cephalic trim of the lower lateral crura, the lower lateral
crural turnover ɻap can be used to preserve this cartilage and use it to
correct concavities/convexities of the lower lateral crus, strengthen the
external valve, and oppose pinching of the tip caused by tip
suturing.
This exploits intrinsic concavities or convexities of the lateral crus
and repositions these forces into opposition resulting in correction
of the deformity. This ɻap is particularly useful when the lower
lateral cartilages appear weak and will help to reduce tip fullness while
making use of the intrinsic strength of the lower lateral cartilages.

66. Medial Crural Septal Suture

67. Medial crural septal sutures can be placed after all other tip-
suturing techniques are performed, or concomitant with medial
crural suturing when signiɹcant tip rotation and repositioning is
anticipated preoperatively.
Medial crural septal sutures secure the middle crura to the caudal
septum and can be used to reduce or increase nasal tip projection,
depending on the placement. If the medial crura are anchored to a
more anterior position on the caudal septum, the tip will rotate in a
cephalad direction and tip projection will increase.
Conversely, if the medial crura are ɹxed to the more posterior
portion of the caudal septum, tip projection will decrease.

68. Invisible Tip Grafts

69. Invisible tip grafts, including the anatomic cap graft and morselized
cartilage onlay grafts, are used if a small degree of tip contouring or
volume augmentation is desired after tip suturing is completed. Cartilage
resulting from the cephalic trim of the lower lateral cartilage can be used to
fashion an anatomic cap graft.
This cartilage graft is typically thin and pliable so it contours over the
tip very well and it does not have any distinct edges, so palpability
and/or visibility of the graft is not a problem. If the tip requires minimal
augmentation or improvement of mild irregularities, morselized cartilage
onlay grafts can be placed. The cartilage is morselized in a cartilage
crusher and can range from being slightly bruised (to make it less rigid and
more conforming without sharp edges) to crushed into a thin sheet (which
can act as scaʃolding for tissue ingrowth)..