Reductive Rhinoplasty

The Problem

Reductive techniques have become a mainstay in aesthetic rhinoplasty. Most commonly, reduction techniques are applied to the bony and cartilaginous dorsum, septum, and lower lateral cartilages. In this chapter we will discuss specifically reductive techniques to assist with tip rotation and refinement. The appropriate cephalic position and rotation are generally associated with an aesthetic nose and a youthful appearance. Nasal tip underrotation or ptosis is a common complaint from people seeking aesthetic nasal surgery. This is often accompanied by nasal tip shape deformities such as bulbous, boxy, amorphous, or asymmetric lower lateral cartilages, which can be corrected in conjunction with cephalic rotation of the nasal tip complex. Nasal tip position is the complex result of many contributors to include tip projection, tip morphology, the columellar–lobular angle, and the nasolabial angle. This chapter will discuss four reductive rhinoplasty techniques that can directly or indirectly rotate the nasal tip without complex grating or suturing.

The Background

The appropriate position of the nasal tip is described with some variation in the literature, but in general can determined by the nasolabial angle, which is measured at the intersection of the line of the nasal columella and the line of the upper lip. The ideal nasolabial angle has ranged in literature from 90 to 125 degrees and may be subjective to the surgeon within that range. A study by Armijo et al. has shown that the ideal is 93.4 to 98.5 degrees for men and 95.5 to 100.1 degrees for women. The cephalic position of the nasal tip, which has its most projected points at the domes of the lower lateral cartilages, is influenced specifically by the lateral and medial crura (size, position, and length of each), the length of the upper lateral cartilages, the columellar–labial angle, the columellar–lobular angle, the anterior septal angle, and the caudal septum. Surgical manipulation of these components can influence tip rotation. Specifically, four reductive techniques can be employed to increase tip rotation:

• 1.

  Cephalic trim of lower lateral cartilages

• 2.

  Caudal trim of upper lateral cartilages

• 3.

  Lateral crural shortening

• 4.

  Caudal septal trim

The Indications

An acute nasolabial angle, underrotated nasal tip, and the app­earance of a ptotic or drooping tip are indications for surgical cephalic rotation of the nasal tip complex. This condition may be accompanied by a dorsal hump or pseudohump, other nasal tip deformities, nasal tip malposition, or columellar abnormalities that can be corrected in conjunction with tip rotation maneuvers and are discussed elsewhere in this text.