Rhinoplasty Dubai

Anatomy and Aesthetics of the Tip of the Nose

Tip of the nose is a very important aesthetic subunit of the nose. The component of the tip of nose includes;

1. Skin- The skin of the tip is thick and immobile and in many people it is very sebaceous. The thickness of the skin masks the underlying architecture of the cartilages. In some people the skin is thin and cartilages are prominent, so the internal architecture is visible through the skin.
2. SMAS layer- this is a layer of fibrofatty tissue under the skin and thickness varies in different people.
3. Lower lateral cartilages (LLC)- These are specialized nasal cartilages that is arranged in butterfly shape.  The medial part of the LLC forms the columella of the nose and the lateral part supports the ala of the nose. The dome is the midsection of the LLC and gives shape to the tip of the nose.
4. Nasal Mucosa is the layer inside the nostril which lines the cartilage.

Nasal tip is one of the aesthetic subunits of the nose. The aesthetics of the tip is also defined by surrounding subunits of nose such as the ala and supratip area. The contour of the supratip area and the characteristics of ala add to the beauty of the tip of the nose.

An aesthetically balanced tip has a subtle dome projection which elevates above the supratip area. The lobule of the nose forms inferior part of the tip, and angle formed by columella and lobule is the key to an aesthetic nose tip.

Nose Tip-plasty

Tip-plasty is an artistic procedure to reshape the tip of the nose by harmoniously balancing with the rest of the nose.

Essential components of tip plasty

1. Tip reduction by defining the cartilaginous dome
2. Columellar and medial crural strengthening
3. Supra tip reduction of soft tissue and septal cartilage
4. Soft tissue and SMAS resection at key places to enhance tip- alar complex
5. Tip grafts and columellar strut grafts
6. Correction of tip angle and rotation
7. Correction of lobule and columellar proportion

Tip plasty is best accomplished by open tip approach and can be performed under local anaesthesia. Plane of dissection is either subSMAS or SupraSMAS depending upon the thickness of the skin. In very thin skin patient the dissection is close to the cartilage keeping the overlying perichondrium and SMAS intact to prevent postoperative unevenness.

In thick skin the dissection can be above the SMAS for adequate soft tissue resection.
Once the tip complex is adequately exposed, the anatomy is assessed.

A) Primary modification begins in the lower lateral cartilage (LLC). Assess the LLC for its contribution to the tip.

1. The cranial part of lateral crus of LLC  can be convex causing tip bulges
2. Lateral crus can be wide increasing the size of the tip
3. Dome position and interdomal distance contributes to broadening of tip ( boxy tip) and inadequate tip projection
4. Medial crural distance and strength causes bifurcation of tip and columella and dynamic tip drooping.

The Lower lateral cartilage (LLC) is reduced in size by resecting the cranial part leaving at-least 4-5 mm of lateral crus for alar support. Creating a dome by lateral crus stealing and interdomal sutures help defining the tip of the nose. Medial crus strengthening by using a columellar strut graft is very useful for supporting the tip. Additional tip graft is used for tip projection.

B) Upper lateral cartilage and caudal septum may also contribute to the tip of the nose.

1. Prominent and thick ULC makes the supra tip area wide
2. Cranial border of ULC and septum can cause supra tip fullness

Since ULC and septum plays a significant role in maintaining the integrity of internal nasal sphincter, a careful modification is performed in this area. Cranial edge of ULC can be trimmed down along with resection of caudal and cranial part of septum in the supra tip area.

C) SMAS and soft tissue also contributes to the thickness of tip and alar region. Careful resection of soft tissue in the tip, supra tip and alar area will help improve the contour of the tip. Excessive resection and breach of dermis can result in severe deformities of the tip.
Soft tissue removal will improve the contour of the supra tip area and alar groove that improves the aesthetics of the nose.

D) Secondary modification of the tip is performed to give a final shape as compared to the rest of the nose and lip- columellar complex.

Skin redraping is most important to drape the newly constructed tip complex. Few sutures can be placed in the supra tip area catching the subcutaneous part of the skin. This will prevent excessive edema and scar formation in supra tip region. Splinting with steritapes and thermoplastic splints for 5-6 days will also prevent excessive swelling.

Dr Sanjay Parashar
Rhinoplasty