Preservation Rhinoplasty (Tip Plasty)

The Problem

A wide nasal tip occurs when the dome and lateral crura are wider than normal. The area between the nostrils and the lateral crura (i.e., the facet polygon) is usually narrow. The overgrowth of the dorsal cartilage and nasal bone leads to an aesthetically unappealing nose with a dorsal hump. The nose consists of mobile and immobile parts. The mobile tip is formed by the lower lateral cartilages, whereas the immobile part is formed by the septum, upper lateral cartilages, maxilla, and nasal bones ( Fig. 52.1 ).

The mobile nasal tip is connected to the septum and upper lateral cartilages by the Pitanguy and scroll ligaments. The nasal tip moves up and down on these ligaments. The scroll and Pitanguy ligaments are formed by the thickening of the superficial musculoaponeurotic system (SMAS) in the supratip region and they are functionally important as they are part of the SMAS. The preservation and repair of these ligaments are crucial for projection, mobility, and definition.

The Background

Rhinoplasty surgery started as nose reduction surgery with a closed approach. Controlled resection and reconstruction became more popular with open rhinoplasty techniques, and closed surgery without visualizing the tip cartilages by an intracartilaginous approach is losing its popularity. Young surgeons do not favor it because it is difficult to control. Open rhinoplasty became popular in recent years as it is easy to learn and perform; however, nose stiffness and numbness are bothersome side effects despite the surgeon having more control. Open rhinoplasty with a closed approach has started to be an alternative approach combining the control of open rhinoplasty techniques and the advantages of closed rhinoplasty surgery. The preservation of the columellar system and nasal tip ligaments enhances the outcomes of the surgery.

Dorsal aesthetic lines were originally defined as two light lines formed by the nasal dorsum. In Fig. 52.2A , these lines have been drawn as a simple arch (hourglass). However, when one looks more closely, it can be seen that the dorsal lines occur as parabolas. In Fig. 52.2B , the light density is low in sections 2 and 4, whereas sharper lighting appears in sections 1 and 3. reference 1 and 2

The nose can be divided into subunits called polygons ( Fig. 52.3 ). These polygons are:

• 1.

  Dome triangles

• 2.

  Interdomal polygon

• 3.

  Infralobular polygon

• 4.

  Columellar polygon

• 5.

  Facet polygons

• 6.

  Lateral crural polygons

• 7.

  Dorsal cartilage polygon

• 8.

  Upper lateral cartilage polygons

• 9.

  Dorsal bone polygon

• 10.

  Lateral bone polygons

• 11.

  Glabellar polygon

The Indications

Almost all nasal tip deformities can be handled with preservation tip plasty. The nasal tip deformities can usually be described as:

• Most patients who complain of a big nose have a history of nasal trauma. The cartilages and bones that make up the nasal skeleton are in close relationship. A big and deviated vomer is a common finding.

• The overgrowing septum pushes the upper lateral cartilages anteriorly and the medial crura caudally.

• The upper lateral cartilages pull the cephalic edge of the lateral crus anteriorly and distort the resting angle.

• The anterocaudally growing septal cartilage bends the middle crura and leads to more caudally situated domes. The overgrowing septum increases tip projection as well.

• The lobule appears short and the lateral crura long. As the lateral crura become dominant in the tip region, the tip widens.

• The convex lateral crura and abnormal lateral crural resting angle give rise to a wide and round tip.

The Patient

The visual examination is the most important, and the problems can be clearly verified with photographs. The nasal tip is usually wide; the lobule is usually short; and the lateral crura are usually convex, long, and wide. The cephalic edge of the lateral crus is anterior to the caudal edge, and the dorsal septum and nasal bones are hypertrophic. Because the nasal septum pushes the nasal tip anteriorly, the tip tends to become droopy when smiling.

Skin thickness directly affects the result of the surgery. Strong cartilages and a thin skin respond better to rhinoplasty. Information about soft tissues and cartilages can be obtained by touching the nasal skin and examining the mucosal side of the nasal tip with a light source. The frontal, basal, upper, lateral, and oblique view photographs are standard. Frontal and lateral photographs of the patient smiling give a hint about nasal tip dynamics.

The Surgery