Nasal Tip Rhinoplasty by: Arian Mowlavi M.D.

Figure 19b

(Figure 19)

Following nasal hump reduction, the second more frequent nasal contouring procedure sought involves improving the look of the nasal tip. When trying to access the nasal tip it is important for ;your surgeon to visualize the shape of your lower lateral cartilages; each of these cartilages looks like an umbrella or a modified boomerang as described above which then meet together at the tip of the nose to provide what you see as the shape of your tip.

Patients seeking to improve their tip may feel that their tip is too wide or rounded in appearance which has been described by by a variety of descriptions such as a "bulbous" or "platypus" tip (Figure 19). This appearance is caused by several factors including: 1) an obtuse middle crura bend or curvature; 2) poor approximation of the two middle crura at the tip area, and/or 3) extraneous fat under the nasal skin.

Thus treatment of a wide top should require correcting of one or all of the above deformities:

1) A stitch can be placed to make the middle crural bend more acute called an intra-crural stitch; 2) a stitch can be placed between the two middle crura more closely approximating the bend structures and thus setting the dome/tip width and is called an inter crural stitch; and/or 3) defat the fat from the underlying soft tissue tip; this maneuver must be performed cautiously as to not compromise blood flow to the nasal tip cover.

Figure 20(Figure 20)

In addition to narrowing and/or refining the nasal tip shape, it is paramount to set its position or height. There are certain proportions that must be kept in mind when altering the nasal tip structures and these include keeping the nasal tip as the lead point of the nasal dorsum. This means that the nasal tip must be slightly higher than the nasal dorsum. For females, this nasal tip projection can be slightly more pronounced as depicted by a supratip break; in contrast males should have a subtle tip lead (Figure 20).

Figure 21(Figure 21)

Tip positioning is an extremely important consideration especially following open rhinoplasty, in which the tip must be appropriately supported as it will be pulled down during tissue healing that takes place along the columellar incision. Your surgeon may use a variety of methods to reinforce the tip structure including: tip set back on the anterior caudal septum, a floating columellar strut graph is ideal for male patients whose nasal length does not require adjusting and and who only require an minimal tip lead on the nasal dorsum. Finally, the septal extension graph is ideal for female patients who have appropriate nasal length and desire a strong nasal tip lead.

The use of these maneuvers is also influences by the naso-labial angle determined by the angle created by the vectors extending from the nasal base to the tip and the nasal base to the upper lip as seen on the lateral or profile view. In females this angle should be more generous and approximate 100 to 105 degrees, in males this angle is more closed and approximately 90 to 95 degrees (Figure 21).

Figure 22(Figure 22)

The nasal tip reinforcement techniques described above will affect the nasolabial angle and must be chosen approximately. Additionally, the reinforcing techniques used above will further affect the nasal length to nasal projection ratios which should be maintained at a 3:1 length ratio (Figure 22).

Nasal Tip Anatomy by: Arian Mowlavi M.D.

Figure 9(Figure 9)

The nasal tip shape is created by the intimate contact of two boomerang shaped cartilages called the lower lateral cartilages with each other and their underlying central structural pillar cartilage called the septum. The lower lateral cartilage has been divided into three segments called the lateral, middle, and the medial crura. The medial crura act as accessory support beams as they converge together within the columella, the name of the central, lowest part of the nose. The medial crura compromise the bend portion of the boomerang and define the dome, i.e. tip of the nose. The nasal tip shape is determined by not only the middle crural bend but also by how the two middle crura of each side of the nose come together, the confluence of the two middle crura and the angle created by them translates into the dome and tip shape. The tip shape can be blunted if the middle crural angles are obtuse or in patients who have excessive fat overlying the underlying cartilagenous infrastructure. Finally, the lateral crura extend laterally from the middle crura to the medial aspect of the cheek along the alar rims. The lateral crura help support the alar rims thereby keeping the nares, or nasal entry ways open.

Figure 10(Figure 10)

When looking up at the nose (termed the worm´s eye view), an equilateral triangle should be appreciated. This triangle is formed by the nasal base and toe slanted lines outlining the alar rims converging at the tip. This triangle is bisected by the central structure called the Columella (Figure 9). The columella houses the the converging medial crura that create the lowest component of the central pillar. On the lateral view the nasal alar rims should be just behind the columella (central) structure described above. A gentle ellipse should be able to be drawn between the offset of the alar rims from the columella. When the ellipse is wide, this is an indication of either retracted ala or prominent columella, when the ellipse is narrowed then this is an indication of droopy or overhanging alar rims or retracted columella. (Figure 10) Finally, on the front view, the alar rims should lie within a vertical line dropping from the medial canthi. (Figure 11) Then the alar rims extend lateral to this line, then consideration for alar rim reduction should be considered.

Figure 11(Figure 11)

Knowledge of the nasal tip infrast ructure and current aesthetic standards will help you better convey the changes you are desiring to your surgeon. Conversely, this knowledge will help your surgeon communicate to you the maneuvers that he will be performing to refine your nasal tip shape.

How our patients feel about us:

As stress free as possible... Dr. Mowlavi and his staff did everything they could to make my experience as stress free as possible. The care that was provided prior, during and after surgery was exceptional. Both James and Dr. Mowlavi were available to answer my concerns and questions. I am very happy with the results.

Joyce J. Dana Point, CA

My nose looks amazing! I went to Dr. Mowlavi two months ago, trying to decide on undergoing rhinoplasty. His staff was very professional and so was he they made me feel at home and a month later I had the surgery with no complications and my nose looks amazing! They have been amazing with answering any questions I had. Thank you Dr. Mowlavi I would definitely recommend him!

Gabby Laguna Beach, CA

He sincerely cares for each of his patients... I first went to Dr. Arian Mowlavi a couple years ago for my septoplasty and rhinoplasty (amazing results on both by the way), and then on and off for botox for the past couple years. I finally made the decision to have a breast augmentation in July 2015 and have to say that Dr. Mowlavi and his staff made something that normally would have been a very nerve racking experience into a very comfortable and easy one. Dr. Mowlavi is a caring doctor that really wants the best for everyone he treats. He took his time to listen to what I wanted and suggested what would be the best for me. I find him to be a very empathic human being that sincerely cares for each of his patients...

Marie N. San Clemente, CA

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