Nasal Tip Refinement Surgery
Refining the shape of your nasal tip can have a major impact on the look of your nose, and your face as a whole. Therefore, if you would like to refine the appearance of your nasal tip, it is very important that you choose the right surgeon to perform your rhinoplasty procedure. Patients travel from around the world to undergo tip sculpting and refinement with New York City facial plastic surgeon Dr. Rizk, as he is an expert that specializes in nose surgery and revision rhinoplasties.
If you choose to have your nasal tip resculpted with Dr. Rizk, he will likely combine several techniques. The procedure will be individually tailored to fit your unique circumstance. If you are interested in learning more about having rhinoplasty for nasal tip refinement in NYC, do not hesitate to contact Dr. Rizk’s office and book a consultation today.
Tip Cartilage Sculpturing Principles
In order to alter the nasal tip, the rhinoplasty surgeon must use his clinical diagnostic skills to achieve an accurate diagnosis of the deformity. Inspection and palpation of the contour, thickness, bulk, resilience, strength, and extent of alar (lower lateral cartilages) with their surrounding soft tissues and bony relationships are important.
Surgical decisions related to incisional approaches and alar sculpting techniques should depend principally on the anatomy of the tip dynamics. The technical steps in tip surgery should accomplish cartilage contouring by the most conservative manner possible, preserving or reorienting structures in preference to resection.
In reduction rhinoplasty, a reduction in volume or reorienting cartilage is performed so that the final altered alar cartilages will retain their positive characteristics while removing the undesirable features. Tip surgery is almost always a compromise or a series of compromises. Typically any surgical tip alteration results in some form of support sacrifice, so it is very important to support the tip with cartilage grafts if tip support is weakened in other ways.
Several important principles are worth emphasizing when considering alar cartilage or tip cartilage contouring. According to Dr. Rizk, an expert New York facial plastic surgeon and rhinoplasty specialist, these principles apply in the overwhelming majority of rhinoplasty patients he sees.
Almost all tip techniques share the principle of volume reduction of the alar or tip cartilages, except in revision rhinoplasty where too much was removed in the previous rhinoplasty. Usually, the reduction is confined to the broad cephalic portions of the lateral crus and dome, with an occasional thinning resection of the medial crural contribution to the dome. This volume reduction may include a portion of the "scroll" formed by the upper lateral cartilage-alar cartilage relationship.
Alar volume reduction creates a dead space that ultimately will be filled with scar tissue, undergoing contracture in a variable manner. This space may eventually be diminished by an upward rotation of the alar cartilage. To reduce scar formation and cephalic contraction, all underlying vestibular skin residuals from alar resection should be preserved.
Preserving a complete caudal strip of intact cartilage, extending from the medial crura footplates to the lateral cephalic-most tip of the alar crus, is entirely possible and desirable in the majority of rhinoplasty patients. With this technique, tip support and projection are enhanced, irregularities in healing are minimized, symmetry is probable, and relative resistance to cephalic tip rotation is retained. The more alar cartilage left undisturbed consistent with adequate aesthetic tip correction, the more predictable is the healing process.
The laterocephalic portion of the lateral crus, attached by connective tissue to the bony pyriform margin, should be left intact and not resected. Support for the lateral nasal sidewall is preserved (avoiding potential inspiratory collapse or external nasal valve collapse), possible dimpling stigmata are avoided, and potential undesirable alar cephalic retraction is unlikely.
In the vast majority of rhinoplasties, the surgeon preserves or increases the existing projection of the nasal tip; much less often is a reduction in tip projection required. Therefore, identifying and preserving the tip defining point of the alar cartilage dome is mandatory for optimum tip definition and projection.
In patients in whom preservation of a complete strip of alar cartilage does not result in satisfactory definition and refinement of the nasal tip, a shape or position change may be induced in the residual intact alar cartilage strip with suture techniques. This can be done without resorting to a vertical dome division or interruption of the complete strip.
If a decision is made to interrupt the complete strip to achieve added narrowing refinement for an added definition or increased projection or additional rotation, which might rarely be necessary for thick-skinned rhinoplasty patients, the overlying skin envelope must be very thick to camouflage any irregularities or offsets. These irregularities or offsets would otherwise become palpable and or visible in the long-term postoperative period in thin skin patients requesting rhinoplasty.
Using Rib Cartilage for Revision Rhinoplasty
When the results of a rhinoplasty procedure are unsatisfactory, revision rhinoplasty may be performed. During this procedure, there are a few types of cartilage that may be used in reconstructing the nasal framework, including cartilage from the septum, ear or ribs. Rib cartilage is a safe option that works well to support or add to areas of collapse. It works particularly well as a source of support for the nasal tip when a sturdy, flat piece of cartilage is required.
Dr. Rizk prefers to harvest cartilage from the septum if possible. However, in many cases, this is not an option, as it may have already been harvested in the original procedure. When this is the case, Dr. Rizk may use ear or rib cartilage. He prefers not to use the patient’s own rib cartilage due to the scarring it can cause, as well as potential risks such as injury to the lung or pleura (the layer of tissue surrounding the lung). Pneumothorax (accumulation of air around the lung) is another possible side effect that should be avoided at all costs. Therefore, Dr. Rizk obtains irradiated rib cartilage from a rib bank.
Tip Support Mechanisms
Understanding major and lesser tip support mechanisms plays an all-important role in executing tip incisions in tip-contouring procedures. These support mechanisms consist of the contour, size, and strength of the lateral crura, the attachment of the medial crural footplates to the caudal septum, along with the size and strength of the medial crura, the attachment of the caudal edge of the upper lateral cartilage to the cephalic edge of the alar cartilages.
Some additional elements that are still of vital importance to tip support include the nasal tip ligamentous aponeurosis, the cartilaginous dorsum, the nasal spine, the strength and resilience of the medial crura and the thickness of the tip skin and subcutaneous tissues, and the supportive strength of the alar sidewalls.
In every surgical procedure of the nasal tip, the operation will ultimately result in either the preservation of tip projection, an increase in tip projection, or a decrease in tip projection. Different anatomic cases are regularly encountered in a diverse rhinoplasty practice such as Dr. Rizk's where he sees people of various ethnicities from around the world. In the majority of rhinoplasties, however, it is critical to preserve and maintain the already existing tip projection, while favorably altering the contour and attitude of the alar cartilages and avoiding at all costs the loss of vital tip support with a consequent potential decrease in projection (tip ptosis). Respecting tip support mechanisms results in a predictable outcome.
Therefore, it can be assumed that the appropriate incisions should be followed to preserve as many tip support mechanisms as possible. Alar sculpting techniques should likewise respect the principle by conserving the volume and integrity of the lateral crus while maintaining an intact complete caudal strip of the alar cartilage. With these precepts in mind, the appropriate incisions, approaches, and tip sculpting techniques will be discussed.
The Importance of Incision Placement
Incisions are a way to gain access to the underlying cartilaginous and soft tissue substructures of the nose. Sculpturing of the tip cartilages, suture techniques, and grafting techniques can create changes in contour, projection of the nasal tip, and projection/rotation of the nasal tip by changing the position of the alar cartilages (lower lateral cartilages) and their relationship to other structures including the caudal nasal septum. The choice of incisions depends on the anatomy of the tip and its related nasal structures. Less invasive incisions are preferred since they result in a faster healing process.
The incisions selected to gain access to the nasal tip should provide unobstructed visualization and access to the alar cartilages. The incision selection should also preserve whenever possible the important tip support mechanisms, avoid interference with other incisions contemplated in the same area and lend itself well to healing without contracture or scarring. The different alar cartilage incisions to gain access to the nasal tip through the endonasal rhinoplasty approach include the intercartilaginous, transcartilaginous, and marginal (rim) incisions.
Both the intercartilaginous and the transcartilaginous incisions may be used as the only incisions to approach the alar cartilages, especially when a volume reduction of the medial cephalic portion of the lateral crus is desired. This one incision creates less trauma and a faster rhinoplasty recovery with less scarring and more control. Through the intercartilaginous incision, retrograde, or eversion approach can be accomplished. The cartilage splitting approach is carried out through the transcartilaginous incision.
Although both the intercartilaginous and transcartilaginous incisional approaches may be used, it is important to emphasize that these incisions divide and ultimately eliminate one of the vital major tip support mechanisms: the attachment between the caudal aspect of the upper lateral cartilage and the cephalic aspect of the alar cartilages (lower lateral cartilages).
Marginal columellar incisions may be created high or low at the columella. If carefully done, and limited in length, the cartilage-splitting nature of this approach enhances delicate repair of the incision, actually splinting it while healing progresses. Cartilage tip grafts, columellar struts or battens, and augmenting "plumping" grafts positioned at the nasolabial angle may be secured in the precise pockets provided through these marginal columellar incisions.
Midline skin incisions in the caudal columella are best avoided in favor of lateral marginal incisions, however, they are not objectionable and camouflage favorably if carefully executed and repaired. In selected patients, the external rhinoplasty approach may be useful to expose the tip and superstructure of the nose through an irregular inverted V incision on the caudal columella and connect with the marginal alar cartilage incision on either side.
Dr. Rizk’s Tip Sculpting and Refining Techniques
Each rhinoplasty patient is unique. Some patients require complex procedures involving numerous rhinoplasty techniques, while others can benefit from minor revisions or even non-surgical treatments. Even a non-surgical nose job with Botox or Dysport can have a significant effect on some patients. However, these treatments cannot be used to make major changes such as reducing the size of a large nasal tip.
Surgical rhinoplasty tip techniques focus primarily on refining the lower lateral cartilages, because they have a major impact on how the nasal tip looks. Generally speaking, tip refinement with Dr. Rizk usually involves removing some of this cartilage, as well as defatting and suturing techniques. This combination allows Dr. Rizk to enlarge, reduce, rotate, narrow or otherwise alter the shape of the nasal tip.
Here are some of the more important tip refinement techniques Dr. Rizk is renowned for:
In the hands of an experienced rhinoplasty specialist such as Dr. Rizk, nasal suturing techniques can be a very effective way to safely narrow and refine the nasal tip. Suturing techniques are an excellent way to avoid over-resection of nasal cartilage, which can lead to a pinched look in the nasal tip.
Nasal suturing techniques are often used for patients with bulbous nasal tips. Suturing can give the tip a more triangular shape. Typically, permanent sutures are placed in the dome area, often above and below the tip. The lower lateral cartilages are then narrowed, flattened and/or reshaped.
A significant benefit of nasal suturing techniques is that they are sometimes reversible. If you and Dr. Rizk decide that the outcome is not perfect, the sutures can often be removed and the nasal tip further refined. In addition, Dr. Rizk’s suturing techniques can leave the nose stronger than it was prior to surgery.
Another technique Dr. Rizk uses in nasal tip refinement procedures is the defatting of the skin, along with cartilage fat reduction. These techniques add definition to the nasal tip. Defatting involves the removal of fat from thick skin in order to make it thinner. To perform the technique, Dr. Rizk uses a high-definition telescope and tiny incisions. Defatting the skin makes other revisions made during rhinoplasty more apparent; if the skin is too thick, it is difficult to see certain structural changes made during nose surgery.
Cartilage defatting involves the removal of a layer of fat from the area above the nasal tip cartilages; these are sometimes called alar cartilage fat pads. In some cases, Dr. Rizk may perform nostril defatting as well.
Grafting techniques are often used in patients who require additional tip projection and definition. Tip projection is one of the most crucial components of an attractive nose. The noses of people with poor tip projection typically look thick or “heavy.” To achieve good projection, the tip must have proper support. This is where grafting techniques come in, as grafts can provide significant support. Depending on the needs of the individual patient, one or more of several types of grafts may be used during nasal tip refinement, including onlay grafts, umbrella grafts, and others.
Nasal grafts are common in ethnic rhinoplasty procedures because many ethnic rhinoplasty patients have thick skin that leads to poor projection and a bulbous-looking tip. In these procedures, grafts are often used in conjunction with a columellar strut for medial columellar support.
Furthermore, patients with under-projected tips often need umbrella grafts, which typically are positioned between the medial crura. Dr. Rizk prefers to use his patients’ own cartilage for grafts used in nasal tip refinement. The cartilage is usually taken from the septum or the ears, although sometimes a synthetic graft called Medpor may be used for definition and support. Dr. Rizk does not use silicone grafts. In addition, to customize his patients’ grafts and create smooth contours, Dr. Rizk often uses delicate dermabrading tools, as opposed to a surgical scalpel.
Tip refinement surgery is almost always a compromise. Many of the techniques used in rhinoplasty can actually weaken tip support. However, Dr. Rizk can counteract this effect with grafts, improving tip projection, lessening excess curvature and/or narrowing the nasal tip.
Why Choose Dr. Rizk for Tip Sculpting and Refinement
Rhinoplasty is generally considered the most complicated type of facial plastic surgery, and nasal tip refinement is one of the most difficult aspects of this surgery. Consequently, it is very important that you choose a rhinoplasty surgeon who is an expert in all facets of nose surgery, including nasal tip refinement. Dr. Rizk is a world-renowned facial plastic surgeon specializing in all forms of rhinoplasty. His advanced, customized techniques lead to less swelling, faster recovery and optimal outcomes. As a result, he is well-respected throughout the field of facial plastic surgery.
What is Tip Refinement Rhinoplasty?
A rhinoplasty procedure is more commonly known as a nose job. Tip refinement rhinoplasty refers to a procedure designed to specifically alter the appearance of the nasal tip. As the most protrusive area of the face, tip projection is extremely important to how a face may appear and is perceived. Contact our office in NY to learn more.
Are all tip refinement procedures the same?
Absolutely not. Tip refinement is a highly individualized procedure that specifically caters to each individual’s unique facial characteristics. Some noses may need more pronounced projection, while others require a reduction. Dr. Rizk is a double board-certified facial plastic surgeon who specializes in rhinoplasty procedures. During your consultation, he will listen to your concerns and help you consider a variety of options.
How long does tip refinement take?
Tip refinement rhinoplasty will generally last between one and two hours. More extensive alterations may require more time.
What is the surgical process like?
Patients are under sedation or anesthesia for the entire surgery. First, your doctor will examine the internal structures of the nose with a 3D high definition camera before making any incisions. Underlying cartilage is then exposed in order to perform structural alterations. Depending on individual needs, fat tissue may be removed or repositioned to allow for better definition. Your doctor may opt to use implants to fortify the nasal cartilage and reorient the tip. Grafts are also available to aid in better tip projection. All incisions will be closed using small dissolvable sutures.
Will there be any scarring?
The mucous lining of the nose generally heals very quickly, which reduces the risk of scarring. Incisions are also made entirely within the nose, so any scarring that may occur will not be visible.
What can I expect after surgery?
The postoperative regimen is extremely important to a successful procedure and is often overlooked by patients. Proper healing is essential to how the nose will appear at the end. Refrain from strenuous exercise that may stress the nose area and increase inflammation, especially any sort of contact sport. Keep the nasal canals clean to avoid bacterial buildup and infection; there are a variety of kits that can be bought at your local pharmacy that will help irrigate the nose and sinuses. If you experience pain or discomfort, ask your doctor if there are pain-relievers that are safe for you to use. If you experience excessive bleeding, extreme pain, or fever, contact your doctor immediately.
What risks are involved?
Rhinoplasty, no matter how minor, is a surgical procedure that carries with it the same risks as any invasive operation. Infection is a primary concern but is often well mitigated with the use of antibiotics and proper cleansing of the operated area. Reactions to anesthesia are extremely rare but have been known to occur. Therefore medical clearance must be granted before any rhinoplasty procedure takes place. Finally, it is important to realize that rhinoplasty is a complex cosmetic surgery, and there is no guarantee that results will match idealistic expectations.
Written by Dr. Sam Rizk
Last Modified On: 12/30/2019