Nasal tip complications and optional operative fixes

Complications in Rhinoplasty-Daniel G. Becker.  Ch.49 facial plastic and reconstructive surgery by Ira D. Papel

In the nasal tip;  

Over-reduction may violate critical tip support mechanisms (Table 49.1) which can lead to complications including tip ptosis and inadequate tip projection. Alternatively, overresection of the caudal septum can result in overrotation of the nasal tip with excessive shortening of the nose. Overresection may also contribute to other complication such as bossae, alar retraction, and alar collapse (external nasal valve collapse).

Under-reduction may be simply due to overcaution but is commonly due to a failure to correctly assess preoperatively the anatomical situation. For example, failure to recognize an overprojected nose, or to diagnose the steps required based on the patient's anatomy to adequately address this, can lead to a persistent overprojected state. Failure to adequately resect cartilaginous dorsum may result in a pollybeak deformity.

Asymmetries of the nasal tip may be due to unequal reduction of the lower lateral cartilages or to asymmetric application of dome-binding sutures. It may also be caused by unequal scarring that can occur during the natural healing process and may not be evident for months or even years after surgery. Also, assymmetry is often present preoperatively and should be recognized and pointed out to the patient prior to surgery.

Table 49.1 Tip-Support Mechanisms

Major tip-support mechanisms
1. Size, shape, and strength of lower lateral cartilages
2. Medial crural attachment to caudal septum
3. Attachment of caudal border of upper lateral cartilages to cephalic border of lower lateral cartilages
[the nasal septum is also considered a major support mechanism of the nose]

Minor tip-support mechanisms
1.Ligamentous sling spanning the domes of the lower lateral cartilages (i.e. interdomal ligament)
2.Cartilaginous dorsal septum
3.Sesamoid complex of lower lateral cartilages
4.Attachment of lower lateral cartilages to overlying skin-soft tissue envelope
5. Nasal spine
6. Membranous septum

Specific Complications:

Ptotic tip-loss of tip support may lead to a droopy tip (tip ptosis with an overly acute nasolabial angle (angle defined by columellar point to subnasale line intercepting with subnasale to labrale superious line) is 90 to 120 degrees.Within this range, a more obtuse angle is more favorable in females, a more acute angle in males. Loss of tip support can lead to a ptotic, underprojected drooping nose. Treatment of complications relating to a ptotic nose rely on restoration of tip support and tip projection.

Overrotated Tip-Conversely, one may face a patient with a nose that has been overrotated, with an overly obtuse angle. Overresection of the caudal septum is a common cause of overrotation of the tip. Overrotation of the nose creates an unsightly, overshortened appearance. Treatment rely on maneuvers that lengthen and counterrotate the nose.

Bossae- a bossae is a knuckling of the lower lateral cartilage at the nasal tip due to contractural healing forces acting on weakened cartilages. Patients with thin skin, strong cartilages, and nasal tip bifidity are especially at risk. Excessive resection of lateral crus and failure to eliminate excessive interdomal width may play some role in bossae formation. As an isolated deformity, bossae are typically treated through a small marginal incision with minimal undermining over the offending site followed by trimming or excising the offending cartilage. In some cases, the area is covered with a thin wafer of cartilage, fascia, or other material to further smooth and mask the area.

Alar retraction

Cephalic resection of the lateral crus of the lower lateral cartilages is commonly undertaken to effect refinement of the nasal tip. If inadequate cartilage is left, then the contractile forces of healing over time will cause the ala to retract. This is commonly seen squelae of overresection of the lateral crus. The surgical rule of thumb is to preserve at least 6 to 9mm of complete strip. From a study 20 percent of patients had a thin alar rim. These patients may require even more conservative approaches to avoid the risk of alar retraction and/or external nasal valve collapse. Also vestibular mucosa should be preserved, as excision of vestibular muscosa contributes to scar contracture with alar retraction. Alar retraction may be treated by cartilage grafts in more minor cases (1-2 mm). Auricular composite grafts are commonly used in more severe cases.

Alar-Columellar Disproportions (protruding or hanging columella)

The range of normal columellar show is generally considered to be 2 to 4 mm. The surgeon should avoid excessive resection of the caudal septum and should avoid resection of the nasal spine. Treatment of a protruding or hanging columella may include resecting full thickness tissue from the membranous columella, including skin, soft tissue, and perhaps a portion of the caudal end of the septum itself. If the medial crura is excessively wide, excision may include a conservative excision of the caudal margin of the medial crura. Retracted columella may be improved with plumping grafts inserted at the base of the columella to address an acute nasolabial angle; columellar struts may also be helpful for minor deformities. A cartilage graft may be used to lengthen the overshortened nose. The use of composite grafts have also been described.

Pollybeak- A pollybeak refers to postoperative fullness of the supratip region, with an abnormal tip-supratip relationship This may have several causes, including failure to maintain adequate tip support (postoperative loss of tip projection), inadequate cartilaginous hump (anterior septal angle) removal, and/or supratip dead space/scar formation. Management of the pollybeak deformity depends on the anatomical cause. If the cartilaginous hump was underre­sected, then the surgeon should resect additional dorsal sep­tum. Adequate tip support must be ensured; maneuvers such as placement of a columellar strut may be of benefit. If the bony hump was overresected, a graft to augment the bony dorsum may be beneficial. If pollybeak is the result of exces­sive scar formation, Kenalog injection or skin taping in the early postoperative period should be undertaken prior to any consideration of surgical revision.

Operative Maneuvers:

 Increase Rotation: Lateral crural steal, Transdomal suture that recruits lateral crura medially, Base-up resection of caudal septum (variable effect), Cephalic resection (variable effect), Lateral crural overlay, Columellar struct(variable effect), Plumping grafts (variable effect) Illusions of rotation: increase double break, plumping grafts (blunting nasolabial angle)

Decrease Rotation (Counter-rotate) Full -transfixion incision, Double-layer tip graft, Shorten medial crura, Caudal extension graft, Reconstruct L strut as in rib graft reconstruction (integrated dorsal graft/columellar strut) of saddle nose.

Increase Projection: Lateral crural steal (increased projection, increased rotation), Tip graft, Plumping grafts, Premaxillary graft, Septocolumellar sutures (buried) Columellar strut (variable effect), Caudal extension graft,

Decrease Projection: High-partial or full transfixion- incision, Lateral crural overlay (decreased projection, increased rotation), Nasal spine reduction, Vertical dome division with excision of excess medial crura with suture reattachment

Increase Length: Caudal extension graft, Radix graft, Double-layer tip graft, reconstruct L strut

Decrease Length: See "increase Rotation, Deepen nasofrontal angle

Secondary External Rhinoplasty
David W.Kim, Benjamin A. Bassichis, and Dean M. Toriumi,  Chapter 31; Revision Surgery in Otolaryngology. By David R. Edelstein.

Persistently Wide or Bulbous Tip

A persistently wide tip after primary rhinoplasty may be due to the failure of the surgeon to account for a thick, inelastic SSTE (soft-skin tissue envelope) when modifying the dome region. In these patients, performing dome-binding sutures alone may improve the shape of the alar cartilages themselves, but this change will not necessarily  transmit through the thick SSTE. Failure to project the tip into the skin envelope and effectively stretch it to conform to the underlying tip shape will lead to this problem. Study of the overall projection and rotation of the tip, the nasolabial angle, and nasal length should be performed to determine how best to project the tip and restore optimal tip shape. A shield-shaped tip graft may be sutured to the intermediate and medial crura to provide the desired augmentation to the infratip lobule and tip. Although the nasal base remains unchanged, the leading edge of the shield graft may project the domes by as much as 8mm. A buttress or cap graft may be placed cephalad to the leading edge of the graft to support the graft and camouflage the transition to the supratip. Lateral crural grafts are placed on the existing lateral edge of the shield graft when the tip graft projects > 3mm above the existing domes. These also provide additional support and camouflage to the shield graft. Lateral crural grafts also bolster lateral alar support in cases in which the native lateral crura have been weakened or removed.

  Another common error of omission leading to a persistently wide tip is the failure to straighten convex lateral crura. Domal narrowing will not result in a defined triangular tip appearance if the lateral walls of the triangle are curving outward. Unless the curvature is straightened with suture technique or lateral crural struts, persistent tip width will be present. These problems may be detected through the study of the base view of the nose. If lateral crural struts will be needed, strong segments of cartilage are required to overcome the curvature of the existing alar cartilage. These grafts are placed between the undersurface of the lateral crura and the vestibular skin that should be carefully elevated. The caudal attachment of the lateral crus and skin should remain intact to prevent caudal migration of the graft. The graft should extend from just lateral to the domes to the lateral aspect of the lateral crura. The lateral crural strut graft may be stabilized with a full thickness chromic suture, but it should be finally secured to the lower lateral crura with a 5-0 clear nylon suture.


Nasal Tip Management Utilizing the Open Approach. Russell W.H. Kridel and Peyman Soliemanzadeh  Ch.69 Rhinology and facial plastic surgery by Fred J. Stucker
Prior to contouring the nasal tip, the surgeon must stabilize the base of the nose. If tip support is found to be lacking, a sutured in place columellar strut can effectively stabilize the base. This graft is placed into a pocket dissected between the medial crura. When it is necessary to alter tip projection, the alar columellar relationship, and the nasolabial angle the Tongue-in-groove technique can be utilized to stabilize the base. Specifically, if the patient has a hanging columella and prominent caudal septum that would otherwise require trimming, the surgeon can set the medial crura back on the midline caudal septum. Bilateral membranous septum excision is almost always necessary to remove excess tissue which results from the TIG technique. The TIG can also be varied in order to enhance rotation and or to increase projection.

 Tip deprojection can be accomplished by removing an equal amount of lateral crura and medial crura in a technique called dome truncation (DT). 

 http://archfaci.ama-assn.org/content/7/6/374.full

 http://www.drphilipmiller.com/Assets/Structuralapproach.pdf 

Who's the best revision nose surgeon?

The most common question, asked, researched, googled, by people seeking revision nose surgery (and for very legitimate reason's) is "who's the best revision nose surgeon". Obviously, your primary or revision nose surgery didn't go as planned or wished for. You might not like the aesthetic appearance of your nose for various reasons, or you have functional issue's which weren't resolved or are new, or combination of those issue's. It's very frustrating to have to go through another surgery, especially one which is labeled "elective" surgery, meaning you have to pay out of pocket for and may include the stress and cost of air travel. I put in quotes "elective" because many unhappy with the results of their operated nose would disagree with that term, since they feel it's a "necessity" now for reasons i already explained above. It's also about regaining trust. How can you trust that the next surgeon will do what he/she promises, since you already were told by your last surgeon, that you would receive what you desired, but didn't. [Note: I'm not simply blaming the surgeon here, because there may of been an issue of miscommunication] That's a major step to take and the most challenging for you the prospective secondary/revision patient and the secondary/revision surgeon. This of course occurs in every profession and business. You have to make it clear to your surgeon what your expectations are from the surgery, and your surgeon needs to make clear to you what you can realistically expect. Of course there's a lot more to it then that as I have already written about on my other posts regarding questions to be asked, and doing your research ="due diligence".Even after seeing a few surgeons that your happy with you may be apprehensive,which is normal but at some point given long thought out consideration, you need to take a leap of faith or decide your not really ready for another surgery. Maybe you just need to see a few more surgeons before being sure you found the right one.

*Note; you should never feel pressured or rushed into elective surgery!!! Not by the surgeon or by someone else, including yourself!!! If the surgeon seems hesitant that he/she can help you but is still willing to try, then DON"T do it!!! [Even if you've already paid for airfare and put down a deposit]. That's what happen to me with my last surgeon in 2005. If you've been reading my posts, then you already know the dangerous consequences of a bad outcome (neuropathy, empty nose syndrome) from nose surgery.  I can't emphasize this enough... do not ever take nose surgery lightly!!!

So I assume most of you seeking revision nose surgery have seen different lists of "who are the best nose revision surgeons" recommended online and have noted which surgeons appear repeatedly, and you have searched forums and other sites to see what others have to say about each of them.Which is all good. But now that you have your own "A" list, narrowed down to let's say a half dozen, your having difficulty deciding which two or three to consult with for various reasons. You may of just read a bad review about the surgeon you were so keen to seeing in person, called their office and realized that surgeon's prices are way out of your price range, or spoke to that surgeon by phone or in person and didn't like the way you were treated or something or other.

So the point I want to make is, rather then driving yourself obsessively crazy by limiting your quest with "who's the best revision nose surgeon in the world or USA or Europe" It would be wise to ask   "What surgeons or type of surgeons should I be avoiding" so I don't make the same mistake again of choosing a similar type of surgeon. Note: I don't mean to blame the patient, because sometimes we can take all the right steps and yet not get the results we were hoping for or were promised! STEP 1. [make a list of things you didn't like about your last surgeon(s)]. This should help you towards finding a surgeon who you feel understands you (on the same page), cares about his/her patients, and has the expertise and proven experience of  getting  the job done.  STEP 2.[make a list of things your looking for in your next surgeon].ie. You will want to find out what percentage of his/her practice is devoted to Rhinoplasty and Revision Rhinoplasty in conjunction with their experience in performing the type of surgery you require.  If you have had a lot of reductive nose surgery therefore requiring a lot of reconstruction surgery, then you will need an experienced revision nose surgeon who has performed many major types of reconstructive nose surgery's.  STEP 3. After researching [information websites like this blog, using internet forums, rating sites, realself.com where some surgeon's  recommend or speak highly of other surgeon's, etc..] and seeing a few surgeons who you had at the top of your list, decide which one you have the most confidence in and feel comfortable with. Your decision may come down to liking one surgeon's methods better then another's. i.e.) maybe you prefer your own cartilage rather then synthetic material in your nose, or prefer closed approach over open, or like some other technique one surgeon use's that other's don't. You need to discover what the surgeon's exact plans are for your nose surgery and be comfortable with it.

This I feel should help direct your focus in the right direction and alleviate some of your understandable fears and obsessions with  finding out or limiting yourself to, who's Numero Uno. It's really a process, a process of elimination to finding the right surgeon(s) for your specific case  (which there may be more then one, two or three surgeons) which therefore suggests there is no best revision nose surgeon for all cases. Hope that's of some help!

Note: Your list can include things you didn't like about the surgeons surgical center, after care offered, etc... 

Top 12 list of questions relating to the revision surgery planned for your nose

 So you've been told by the revision nose surgeon that you need more support in your nose. Your last surgeon did too much reductive surgery and you need to have your nose built back up for either cosmetic and/or breathing issues. Here is a list of pertinent questions relating specifically to the surgery, which you need to ask.

1. Will the surgeon be using autografts (harvested from your own body) allografts (from cadavers) or alloplasts(synthetic material).

2. Assuming autografts will be used, where is the surgeon going to harvest the grafts from.Cranium, Rib, Ear, or Septum. If allografts, are they from an accredited tissue bank(which one?) and how have they been processed and stored. ie) irradiated, freeze dried, etc. If alloplasts whats the name of the material ie)medpore, gore-tex, etc..

3. What soft tissue material does surgeon use as filler or to wrap the grafts. ie) Deep temporal fascia, Perichondrium, alloderm. Will crushed or diced cartilage be used to fill out some area's..

4. What are the particular names of the grafts planned out for surgery. ie) alar batten grafts, rim grafts, spreader grafts, lateral crural grafts, butterfly graft, columella strut grafts, caudal extension graft, dorsal graft,.composite grafts.etc...

5. What steps does surgeon take to reduce the warping of rib grafts.

6. Will the surgery improve the function (internal valve &/or external valve) &/or cosmetic appearance (tip, bridge,asymmetrical issues) of the nose.

7. Will the surgeon be using sheets of soft tissue or skin tissue and from what source?  forehead flap, alloderm, enduragen, etc because you have damaged or thin skin

8. How long will surgery take and is it a closed or open approach.

9.  How many procedures has surgeon done similar to yours in a year or since in practice

10.  Is there an agreement form outlining that the surgeon will redo any necessary minor changes needed after surgery and is that an extra cost or is it included in the price of the original surgery.

11.  Is the surgeon planning to do anything to the turbinates (inferior or middle) ie)outfracture, resectioning, cauterize, etc...

12.  How long will the sutures remain inside the nose after surgery. Are they dissolvable.temporary sutures or meant to be the permanent type.

Remember you should find out before the surgery what the specific plan is for your surgery.  If you're not sure after you initial consult, call the surgeon's office and ask for a copy of the surgical plan proposal and doctors notes pertaining to your consult visit.