Nasal Tip Rhinoplasty and Light and Shadows
Hi this is Dr David Kim and this is another rhinoplasty video blog. Today we are going to talk about the nasal tip. We have talked before about how a triangular nasal tip will be one that shadows the best and looks most natural and aesthetic, especially in the frontal view. We have talked previously about the cartilages along the sides of the nose, between the tip and the base, needing to be relatively straight in order to create this triangularity. When this cartilage is bulged out in a convex manner it creates a wide, full or bulbous tip. When the cartilage is pinched inward on both sides, creating narrowness at the alar margin or the nostril margin we start to see harsh shadows in that area. Both of these situations can be treated with a technique that allows for triangularity of the nasal tip.
The presentation that I am about to show was a lecture that I gave at a recent rhinoplasty meeting. I am going to pick out selected slides from this presentation to help bring home my point. “A Graduated Approach to creating tip Triangularity – Aesthetic Lights and Shadows”.
In general a tip should have the right shape; the right position (in term of how far it sticks out from the nose and how high it angles) and it should result in an airway or nasal passages that are open. As far as aesthetic concerns; smooth, unbroken curvatures tend to look the best. This results in smooth light reflections and gradual transitions into shadow. Whenever there is irregularity or abrupt interruptions of contour. we start to see harsh light reflections and noticeable, distinguishable shadows. This of course is affected by lighting, skin type and angle. Rhinoplasty should result in a smooth shape to avoid these harsh lights and angles. The sphere is the ultimate smooth shape and you can see the surface is very even with a continuous ark. The picture on the right is a photographer’s artistic portrayal of a bed sheet with lighting from the side. You can see all these ups and downs, these lights and shadows. Although it looks neat in a photograph it is not what you want to be displayed on surface of the face or the nose. This is what we want. We would like to see a nose with a smooth transition between the tip and the base. Lights and shadow blending smoothly and in balance. When we start with so many origins of anatomy and we try to create this smooth triangular shape it can be very challenging. It can be particularly difficult when we have thin skin. You can see in this artist’s rendition that thin skin envelope covering a sculpture reveals everything about the structure beneath the skin. In a nose if the skin is very thin all the changes that we make underneath are going to be easily revealed and transmitted through that think skin. Even mistakes that we make, even changes that are not intended. So with thin skin it is very critical that the contour has to be right. This is the Reichstag-Building in Berlin and Christo, a famous artist, covered it with a gigantic sheet. Now, with a sheet covering a building like this there is nothing left to the imagination as to what is underneath that. In rhinoplasty it’s the same thing, with thin skin because it will conform to exactly what’s underneath the skin envelope, the contour has to be made very very smooth.
There is a whole host of maneuvers that we use to create an aesthetically favorable tip. This include excision (removing some tissue), shortening of the limbs of the structures that make the tripod of the tip, using sutures to change the angle or shapes of the various components of the tip cartilages, using structural grafting, or grafting on top of the infrastructure of the tip, or repositioning the native structures. Now all of these techniques are valid techniques and it depends on the execution. Overall, the success of surgery should depend on the selection of these techniques, meticulous technique and fine tunes and adjustments. If the tip is too wide the treatment can be very conservative, excisional techniques. If the tip is wide and the deformity is severe more structural, reorientation is necessary.
Today I am going to talk about when the tip is isolated or pinched. This is the situation when the tip bracketed by vertical shadows on either side, creating harsh lines caused by some pinching of the nostril margin. This represents a technique called the lateral crural struts graph which is placed on the underside of each of the native lateral crus which form the sides of the nostrils. This is a very powerful technique used to create this triangular shape at the base. The straight, unbroken transition from the tip to the base ensures there is no harsh shadows, in that area, along the nostril margin.
The steps involved;
First establishing some support at the tip, at the base, between the nostrils so the tip position can be set. In this case increasing the projection and rotation of the tip by suturing the tip cartilages to this anchoring graph in the middle. Once the position of tip is set a very small excision and removal of cartilage is undertaken, from the top of the tip cartilage, along the area called the lateral crus which is the side of the tip cartilage. The lateral crural struts graph is then introduced underneath the lateral crus to allow the curvature of the lateral crus, which may be unfavorable or pinched, to become one that’s straight, that can complete the triangular shape at the base.
This technique can be used in primary rhinoplasty, in situations where someone has a very wide, bulbous nose. In this situation the cartilage is bulged outwards to create a very boxy shape on the base. Using the lateral crural struts graph I am able to create a much more triangular shape and allow the nose to shadow more appropriately in the frontal view.
Tip isolation is a different type of problem but it is related. In this situation you see harsh shadow on either side of the tip cartilahes. You can see it in this actress. Sometimes it can be a result of prior surgery where the isolation may have happened on one side but not on the other. This is a characteristic basal view of someone with this type of problem. Unlike the previous patient where the cartilage is bulged outwards to create a boxy shape, these cartilages cave inwards to create this pinched appearance. It creates a situation where there are harsh shadows on both sides of the tip. In the central portion there is a bright light reflection. On this outer portion, because of that concavity there are these deep shadow and this results in what is called an isolated tip. So the same technique that was used before the lateral crural struts graph is used in this direction between the tip and the base to convert this isolated tip into one that is stronger and more triangular which allows the silhouette of the base to go from an “S” shape to a straight line shape. This creates a significant improvement in terms of how the nose shadows on the frontal view which of course is the most important view.
Overall, the nasal tip represents one of the most challenging areas in rhinoplasty because it is so three dimensional, because of the incredible diversity in the way the cartilage is oriented. The graph that we describe is a very powerful technique that can covert a very bulbous tip into one that is triangular, or an isolated tip, in which the side walls of the nostril are pinched creating harsh light and shadow also into a triangular tip. This is a common technique that I use. It is one that can be tailored to fit a variety of noses. It is one that I have used several times to create outstanding rhinoplasty results.
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