Tip Grafting

The Problem

Work on the nasal tip is done to improve rotation, projection, and definition. This can be done with sutures and or grafts. In this chapter, we will focus on contemporary grafting techniques for the nasal tip.

The lower third of the nose is formed by a tripod structure that is composed by both alar cartilages. The conjoined medial crura forms the central portion of the tripod, and the two lateral portions are formed by the lateral crural. This tripod rests on an underlying pedestal, which is the caudal end of the septum. This tripod–pedestal structure is covered by the overlying skin–soft tissue envelope (S-STE) resulting in the final shape of the nasal tip.

The tip has three important support mechanisms: the thickness, strength, size of the alar cartilages; the attachments of the caudal edge of the alar cartilage with the cephalic margin of the upper lateral cartilage (scroll area); and the relationship of the medial crural footplates to the caudal edge of the nasal septum. The relationship of the tripod with the pedestal is maintained by ligamentous structures that help keep the feet of the medial crura close to the posterior septal angle and nasal spine, and the domal area near the anterior septal angle.

Grafts can be used to reinforce and give additional strength to support structures of the nose while creating shape and definition.

The Background

Grafting material for rhinoplasty is not unlimited. The ideal grafts for the nasal tip are autogenous cartilage grafts and when needed perichondrium or temporalis fascia. The possible sites for grafting are the nasal septum, conchal ear cartilage, and rib cartilage.

In primary rhinoplasty patients, the first option for a graft is the nasal septum; however, care must be taken to leave an inverted L-strip of cartilage of at least 10 to 15 mm dorsally and caudally. Auricular cartilage is harvested when septal cartilage is not available or is insufficient, or when patients refuse harvesting of rib cartilage. Auricular cartilage is more malleable and is curved, so it is not the ideal option when structural grafts are needed. Rib cartilage is an excellent option when strong structural grafts are needed, or when big quantities of cartilage are needed and septum is not available. The main downside to harvesting rib cartilage is the additional surgical time, donor site pain, and the possible complications of rib cartilage harvesting like pneumothorax, bleeding, visible scars, and infection. Rib cartilage is harder to carve and is less malleable than septal or conchal cartilage.

Grafts in the nasal tip have evolved over the years with more emphasis being placed on reinforcing the pedestal before performing any tip work. Nasal tip grafts today are geared toward strengthening the lateral alar sidewalls, correcting any alar malposition, and aligning alar cartilages in the proper anatomical plane. Grafts are also used for increasing definition in the nasal tip area and for camouflage.