An excessively projecting nose can be corrected through tip refinement techniques. Symmetrical nasal crura and narrow alar rims should be ensured.
Tip augmentation can also be accomplished using cartilage-grafting techniques such as shield and cap grafts; however, these may increase the visibility of the graft when applied in patients with thin soft tissue envelopes. Rhytidectomy or facelift may also be combined with nasal refinement surgery to optimize results in the setting of facial aging.
1. Cephalic Trimming
One of the most frequently performed nose tip reshaping maneuvers is trimming of lower lateral cartilage. This technique can help reduce full or bulbous noses while improving tip definition; however, too aggressive an approach could result in postoperative problems such as alar rim retraction or upward rotation of the nose.
An alternative approach is the use of a lateral turn-in flap, which maintains the strength of a lateral crural underlay and also avoids unfavorable rotational effects.
To assess the long-term impacts of cephalic trim, we used a finite element model to simulate internal forces and nose tip depression (palpation). Both conservative and aggressive resections produced some degree of alar rim displacement and tip rotation; however, with increasing volume resectioned the tip reaction force was marginally decreased.
2. Intercartilaginous Incisions
An ideal nose size must complement the proportions of a person’s facial features for aesthetic balance. In some patients, however, their nasal tip may be excessively large and require correction to enhance its definition.
In this technique, we utilize a closed approach to achieve the desired reshaping. A medial osteotome and rasp are used to reduce the nasal hump while simultaneously narrowing the bony bridge and nasal base areas.
An intercartilaginous incision involves dividing the fibroareolar tissue close to the surface of domes and creating discrete scar contraction. This encourages discrete scar contraction that pulls domes together and defines lobules. Paired with marginal incisions along caudal margins of lower lateral cartilages, this method provides ample exposure for more extensive nasal tip modifications under direct visualization.
3. Transdomal Incisions
Suture techniques or grafts may provide relief to patients suffering from nasal tip underprojection. Lateral crural steal and tip augmentation with extended spreader or batten grafts may achieve modest increases in projection; however, their use may be limited due to issues of asymmetry and visibility.
The hemitransdomal suture is an effective method of narrowing domal width while avoiding an inversion of lateral crus. To be effective, however, it requires careful examination of skin and lateral inferior lower lateral cartilage as well as the precise entry point of suture placement – usually placed just superior to divergence of medial crura divergence – with spreader or batten graft fixations at two interdomain points providing increased control and creating concavity on either side of nose crural concavity; plus it must also maintain adequate width to support nasal valve and alar rims properly.
4. Hemidomal Incisions
Refining the nasal tip may be difficult without cartilage grafts, yet is still achievable with proper proportions matching those of the face. Achieving natural-looking results requires matching up the length and width of your eyes while maintaining an anterior-to-medial width ratio that approximates one-third of your facial width between nostrils and the end of the nose.
Closure of hemidial incisions may be accomplished using either interrupted permanent or fast-absorbing sutures (5-0). A septal splint may also be utilized in certain instances to help minimize dead space, edema, and hematoma formation.
Non-delivery approaches minimize surgical exposure and are ideal for patients who display minimal bulbosity and triangularity on base view. This technique can be divided into two subcategories: cartilage-splitting techniques and retrograde approaches.
5. Cranial Tip Suture
Though anatomically distinct from each other, nasal valves and tip cartilage often need surgery simultaneously to achieve maximum improvement in structure and function. Therefore, any techniques targeting nasal domes should strive to simultaneously address both issues.
One common method is dome binding suture (DBS). This involves using horizontal mattress sutures on either side of where a new tip defining point should be located; this technique may lead to pinched nostrils or buckled lower lateral cartilages, potentially altering their original form.
Our approach to nasal tip refinement combines interdomain and hematoma incisions with the vertical division of upper lateral cartilages for a natural look. A P-3 needle, equipped with 5-0 Prolene suture thread is used to enter inferior to the dome and pass it horizontally across a medial portion of the intermediate crus. A second bite enters 3mm laterally 3 mm ipsilateral from this initial bite before exiting inferiorly one millimeter away from the cephalic margin of LLC cephalic margin for six to seven tight knots to secure this suture. Nasal refinement is completed with a craniotomy suture, securing a more circular soft-tissue shape of the tip, ultimately creating a more attractive nose and improved airflow.
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