RhinoplastyRhinoplasty-- Nasal TipNasal TipJean Paul Font MDJean Paul Font MDRaghuRaghu AthreAthre MD MDUniversity of Texas Medical BranchUniversity of Texas Medical BranchDepartment of OtolaryngologyDepartment of OtolaryngologyMarch 31 2009

History of History of RhinoplastyRhinoplasty

500 BC Ancient India 500 BC Ancient India SushrutaSushrutandashndash Reconstruct traumatic noses including Reconstruct traumatic noses including

amputated as a punishment for crimes amputated as a punishment for crimes

In 1845 German Johann Friedrich In 1845 German Johann Friedrich DieffenbachDieffenbachndashndash Published a procedure for Published a procedure for

reductionstraightening a deviated nose reductionstraightening a deviated nose using external incisionsusing external incisions

History of Modern History of Modern RhinoplastyRhinoplasty

In 1907 Jacques Joseph In 1907 Jacques Joseph published his published his Treatise on Treatise on RhinoplastyRhinoplastyndashndash Detailed nasal deformities and Detailed nasal deformities and

surgical treatmentssurgical treatmentsndashndash Some of these procedures and Some of these procedures and

instruments are used todayinstruments are used todayndashndash Describe the first suture in tip Describe the first suture in tip

rhinoplastyrhinoplasty the orthopedic suture the orthopedic suture

Consider by many as the father Consider by many as the father of modern facial plastic surgeryof modern facial plastic surgery

IntroductionIntroduction

Important considerations in primary Important considerations in primary rhinoplastyrhinoplastyndashndash Airway functionAirway functionndashndash Precise assessment of the deformityPrecise assessment of the deformityndashndash Nasal support mechanisms Nasal support mechanisms ndashndash Soft tissue skin envelopeSoft tissue skin envelopendashndash Postoperative scar contracture and Postoperative scar contracture and

healing (modifications over the lifetime of healing (modifications over the lifetime of the patient)the patient)

PrePre--Op AssessmentOp Assessment

Functional airway Functional airway problemsproblemsndashndash Medical managementMedical management--

Intermittent obstruction Intermittent obstruction from mucosal inflammationfrom mucosal inflammation

ndashndash Surgically correctableSurgically correctableSeptalSeptal deviation or spursdeviation or spursLarge Large turbinatesturbinatesNasal deformitydeviationNasal deformitydeviationNasal valve collapseNasal valve collapse

CottleCottle ManeuverManeuver

Asses Internal Valve

External Valve CollapseExternal Valve Collapse

Collapse of lobule on Collapse of lobule on inspirationinspiration

Loss of Lower lateral Loss of Lower lateral cartilages supportcartilages support

Improvement of Improvement of breathingbreathingndashndash Modified Modified CottleCottle ManeuverManeuver

Palpation of the nosePalpation of the nose

Shape position and Shape position and strength of the nasal strength of the nasal structuresstructures

Trace the Trace the LLCsLLCsndashndash PositionPositionndashndash StabilityStability

Tip supportTip support-- Test Tip RecoilTest Tip Recoil

Major tip support mechanismsMajor tip support mechanismsndashndash Strength of Lower lateral Strength of Lower lateral

cartilagecartilagendashndash Attachment of the medial Attachment of the medial cruracrura

to Septumto Septumndashndash Attachment of upper lateral Attachment of upper lateral

cartilage to cartilage to alaralar cartilagecartilage

Minor tip support mechanismsMinor tip support mechanismsndashndash Dorsal septumDorsal septumndashndash InterdomalInterdomal ligamentsligamentsndashndash Membranous septumMembranous septumndashndash Nasal spineNasal spinendashndash Surrounding skin and soft tissuesSurrounding skin and soft tissuesndashndash AlarAlar sidewallssidewalls

Photographic DocumentationPhotographic Documentation

Allow for more detailed Allow for more detailed evaluationevaluation

FullFull--face face ndashndash FrontalFrontalndashndash LateralLateralndashndash ObliqueObliquendashndash Base viewBase viewndashndash Smiling viewSmiling view

CloseClose--up views up views ndashndash Skin AssessmentSkin Assessment

Frankfort lineFrankfort line

History of History of RhinoplastyRhinoplasty

500 BC Ancient India 500 BC Ancient India SushrutaSushrutandashndash Reconstruct traumatic noses including Reconstruct traumatic noses including

amputated as a punishment for crimes amputated as a punishment for crimes

In 1845 German Johann Friedrich In 1845 German Johann Friedrich DieffenbachDieffenbachndashndash Published a procedure for Published a procedure for

reductionstraightening a deviated nose reductionstraightening a deviated nose using external incisionsusing external incisions

History of Modern History of Modern RhinoplastyRhinoplasty

In 1907 Jacques Joseph In 1907 Jacques Joseph published his published his Treatise on Treatise on RhinoplastyRhinoplastyndashndash Detailed nasal deformities and Detailed nasal deformities and

surgical treatmentssurgical treatmentsndashndash Some of these procedures and Some of these procedures and

instruments are used todayinstruments are used todayndashndash Describe the first suture in tip Describe the first suture in tip

rhinoplastyrhinoplasty the orthopedic suture the orthopedic suture

Consider by many as the father Consider by many as the father of modern facial plastic surgeryof modern facial plastic surgery

IntroductionIntroduction

Important considerations in primary Important considerations in primary rhinoplastyrhinoplastyndashndash Airway functionAirway functionndashndash Precise assessment of the deformityPrecise assessment of the deformityndashndash Nasal support mechanisms Nasal support mechanisms ndashndash Soft tissue skin envelopeSoft tissue skin envelopendashndash Postoperative scar contracture and Postoperative scar contracture and

healing (modifications over the lifetime of healing (modifications over the lifetime of the patient)the patient)

PrePre--Op AssessmentOp Assessment

Functional airway Functional airway problemsproblemsndashndash Medical managementMedical management--

Intermittent obstruction Intermittent obstruction from mucosal inflammationfrom mucosal inflammation

ndashndash Surgically correctableSurgically correctableSeptalSeptal deviation or spursdeviation or spursLarge Large turbinatesturbinatesNasal deformitydeviationNasal deformitydeviationNasal valve collapseNasal valve collapse

CottleCottle ManeuverManeuver

Asses Internal Valve

External Valve CollapseExternal Valve Collapse

Collapse of lobule on Collapse of lobule on inspirationinspiration

Loss of Lower lateral Loss of Lower lateral cartilages supportcartilages support

Improvement of Improvement of breathingbreathingndashndash Modified Modified CottleCottle ManeuverManeuver

Palpation of the nosePalpation of the nose

Shape position and Shape position and strength of the nasal strength of the nasal structuresstructures

Trace the Trace the LLCsLLCsndashndash PositionPositionndashndash StabilityStability

Tip supportTip support-- Test Tip RecoilTest Tip Recoil

Major tip support mechanismsMajor tip support mechanismsndashndash Strength of Lower lateral Strength of Lower lateral

cartilagecartilagendashndash Attachment of the medial Attachment of the medial cruracrura

to Septumto Septumndashndash Attachment of upper lateral Attachment of upper lateral

cartilage to cartilage to alaralar cartilagecartilage

Minor tip support mechanismsMinor tip support mechanismsndashndash Dorsal septumDorsal septumndashndash InterdomalInterdomal ligamentsligamentsndashndash Membranous septumMembranous septumndashndash Nasal spineNasal spinendashndash Surrounding skin and soft tissuesSurrounding skin and soft tissuesndashndash AlarAlar sidewallssidewalls

Photographic DocumentationPhotographic Documentation

Allow for more detailed Allow for more detailed evaluationevaluation

FullFull--face face ndashndash FrontalFrontalndashndash LateralLateralndashndash ObliqueObliquendashndash Base viewBase viewndashndash Smiling viewSmiling view

CloseClose--up views up views ndashndash Skin AssessmentSkin Assessment

Frankfort lineFrankfort line

History of Modern History of Modern RhinoplastyRhinoplasty

In 1907 Jacques Joseph In 1907 Jacques Joseph published his published his Treatise on Treatise on RhinoplastyRhinoplastyndashndash Detailed nasal deformities and Detailed nasal deformities and

surgical treatmentssurgical treatmentsndashndash Some of these procedures and Some of these procedures and

instruments are used todayinstruments are used todayndashndash Describe the first suture in tip Describe the first suture in tip

rhinoplastyrhinoplasty the orthopedic suture the orthopedic suture

Consider by many as the father Consider by many as the father of modern facial plastic surgeryof modern facial plastic surgery

IntroductionIntroduction

Important considerations in primary Important considerations in primary rhinoplastyrhinoplastyndashndash Airway functionAirway functionndashndash Precise assessment of the deformityPrecise assessment of the deformityndashndash Nasal support mechanisms Nasal support mechanisms ndashndash Soft tissue skin envelopeSoft tissue skin envelopendashndash Postoperative scar contracture and Postoperative scar contracture and

healing (modifications over the lifetime of healing (modifications over the lifetime of the patient)the patient)

PrePre--Op AssessmentOp Assessment

Functional airway Functional airway problemsproblemsndashndash Medical managementMedical management--

Intermittent obstruction Intermittent obstruction from mucosal inflammationfrom mucosal inflammation

ndashndash Surgically correctableSurgically correctableSeptalSeptal deviation or spursdeviation or spursLarge Large turbinatesturbinatesNasal deformitydeviationNasal deformitydeviationNasal valve collapseNasal valve collapse

CottleCottle ManeuverManeuver

Asses Internal Valve

External Valve CollapseExternal Valve Collapse

Collapse of lobule on Collapse of lobule on inspirationinspiration

Loss of Lower lateral Loss of Lower lateral cartilages supportcartilages support

Improvement of Improvement of breathingbreathingndashndash Modified Modified CottleCottle ManeuverManeuver

Palpation of the nosePalpation of the nose

Shape position and Shape position and strength of the nasal strength of the nasal structuresstructures

Trace the Trace the LLCsLLCsndashndash PositionPositionndashndash StabilityStability

Tip supportTip support-- Test Tip RecoilTest Tip Recoil

Major tip support mechanismsMajor tip support mechanismsndashndash Strength of Lower lateral Strength of Lower lateral

cartilagecartilagendashndash Attachment of the medial Attachment of the medial cruracrura

to Septumto Septumndashndash Attachment of upper lateral Attachment of upper lateral

cartilage to cartilage to alaralar cartilagecartilage

Minor tip support mechanismsMinor tip support mechanismsndashndash Dorsal septumDorsal septumndashndash InterdomalInterdomal ligamentsligamentsndashndash Membranous septumMembranous septumndashndash Nasal spineNasal spinendashndash Surrounding skin and soft tissuesSurrounding skin and soft tissuesndashndash AlarAlar sidewallssidewalls

Photographic DocumentationPhotographic Documentation

Allow for more detailed Allow for more detailed evaluationevaluation

FullFull--face face ndashndash FrontalFrontalndashndash LateralLateralndashndash ObliqueObliquendashndash Base viewBase viewndashndash Smiling viewSmiling view

CloseClose--up views up views ndashndash Skin AssessmentSkin Assessment

Frankfort lineFrankfort line

IntroductionIntroduction

Important considerations in primary Important considerations in primary rhinoplastyrhinoplastyndashndash Airway functionAirway functionndashndash Precise assessment of the deformityPrecise assessment of the deformityndashndash Nasal support mechanisms Nasal support mechanisms ndashndash Soft tissue skin envelopeSoft tissue skin envelopendashndash Postoperative scar contracture and Postoperative scar contracture and

healing (modifications over the lifetime of healing (modifications over the lifetime of the patient)the patient)

PrePre--Op AssessmentOp Assessment

Functional airway Functional airway problemsproblemsndashndash Medical managementMedical management--

Intermittent obstruction Intermittent obstruction from mucosal inflammationfrom mucosal inflammation

ndashndash Surgically correctableSurgically correctableSeptalSeptal deviation or spursdeviation or spursLarge Large turbinatesturbinatesNasal deformitydeviationNasal deformitydeviationNasal valve collapseNasal valve collapse

CottleCottle ManeuverManeuver

Asses Internal Valve

External Valve CollapseExternal Valve Collapse

Collapse of lobule on Collapse of lobule on inspirationinspiration

Loss of Lower lateral Loss of Lower lateral cartilages supportcartilages support

Improvement of Improvement of breathingbreathingndashndash Modified Modified CottleCottle ManeuverManeuver

Palpation of the nosePalpation of the nose

Shape position and Shape position and strength of the nasal strength of the nasal structuresstructures

Trace the Trace the LLCsLLCsndashndash PositionPositionndashndash StabilityStability

Tip supportTip support-- Test Tip RecoilTest Tip Recoil

Major tip support mechanismsMajor tip support mechanismsndashndash Strength of Lower lateral Strength of Lower lateral

cartilagecartilagendashndash Attachment of the medial Attachment of the medial cruracrura

to Septumto Septumndashndash Attachment of upper lateral Attachment of upper lateral

cartilage to cartilage to alaralar cartilagecartilage

Minor tip support mechanismsMinor tip support mechanismsndashndash Dorsal septumDorsal septumndashndash InterdomalInterdomal ligamentsligamentsndashndash Membranous septumMembranous septumndashndash Nasal spineNasal spinendashndash Surrounding skin and soft tissuesSurrounding skin and soft tissuesndashndash AlarAlar sidewallssidewalls

Photographic DocumentationPhotographic Documentation

Allow for more detailed Allow for more detailed evaluationevaluation

FullFull--face face ndashndash FrontalFrontalndashndash LateralLateralndashndash ObliqueObliquendashndash Base viewBase viewndashndash Smiling viewSmiling view

CloseClose--up views up views ndashndash Skin AssessmentSkin Assessment

Frankfort lineFrankfort line

PrePre--Op AssessmentOp Assessment

Functional airway Functional airway problemsproblemsndashndash Medical managementMedical management--

Intermittent obstruction Intermittent obstruction from mucosal inflammationfrom mucosal inflammation

ndashndash Surgically correctableSurgically correctableSeptalSeptal deviation or spursdeviation or spursLarge Large turbinatesturbinatesNasal deformitydeviationNasal deformitydeviationNasal valve collapseNasal valve collapse

CottleCottle ManeuverManeuver

Asses Internal Valve

External Valve CollapseExternal Valve Collapse

Collapse of lobule on Collapse of lobule on inspirationinspiration

Loss of Lower lateral Loss of Lower lateral cartilages supportcartilages support

Improvement of Improvement of breathingbreathingndashndash Modified Modified CottleCottle ManeuverManeuver

Palpation of the nosePalpation of the nose

Shape position and Shape position and strength of the nasal strength of the nasal structuresstructures

Trace the Trace the LLCsLLCsndashndash PositionPositionndashndash StabilityStability

Tip supportTip support-- Test Tip RecoilTest Tip Recoil

Major tip support mechanismsMajor tip support mechanismsndashndash Strength of Lower lateral Strength of Lower lateral

cartilagecartilagendashndash Attachment of the medial Attachment of the medial cruracrura

to Septumto Septumndashndash Attachment of upper lateral Attachment of upper lateral

cartilage to cartilage to alaralar cartilagecartilage

Minor tip support mechanismsMinor tip support mechanismsndashndash Dorsal septumDorsal septumndashndash InterdomalInterdomal ligamentsligamentsndashndash Membranous septumMembranous septumndashndash Nasal spineNasal spinendashndash Surrounding skin and soft tissuesSurrounding skin and soft tissuesndashndash AlarAlar sidewallssidewalls

Photographic DocumentationPhotographic Documentation

Allow for more detailed Allow for more detailed evaluationevaluation

FullFull--face face ndashndash FrontalFrontalndashndash LateralLateralndashndash ObliqueObliquendashndash Base viewBase viewndashndash Smiling viewSmiling view

CloseClose--up views up views ndashndash Skin AssessmentSkin Assessment

Frankfort lineFrankfort line

External Valve CollapseExternal Valve Collapse

Collapse of lobule on Collapse of lobule on inspirationinspiration

Loss of Lower lateral Loss of Lower lateral cartilages supportcartilages support

Improvement of Improvement of breathingbreathingndashndash Modified Modified CottleCottle ManeuverManeuver

Palpation of the nosePalpation of the nose

Shape position and Shape position and strength of the nasal strength of the nasal structuresstructures

Trace the Trace the LLCsLLCsndashndash PositionPositionndashndash StabilityStability

Tip supportTip support-- Test Tip RecoilTest Tip Recoil

Major tip support mechanismsMajor tip support mechanismsndashndash Strength of Lower lateral Strength of Lower lateral

cartilagecartilagendashndash Attachment of the medial Attachment of the medial cruracrura

to Septumto Septumndashndash Attachment of upper lateral Attachment of upper lateral

cartilage to cartilage to alaralar cartilagecartilage

Minor tip support mechanismsMinor tip support mechanismsndashndash Dorsal septumDorsal septumndashndash InterdomalInterdomal ligamentsligamentsndashndash Membranous septumMembranous septumndashndash Nasal spineNasal spinendashndash Surrounding skin and soft tissuesSurrounding skin and soft tissuesndashndash AlarAlar sidewallssidewalls

Photographic DocumentationPhotographic Documentation

Allow for more detailed Allow for more detailed evaluationevaluation

FullFull--face face ndashndash FrontalFrontalndashndash LateralLateralndashndash ObliqueObliquendashndash Base viewBase viewndashndash Smiling viewSmiling view

CloseClose--up views up views ndashndash Skin AssessmentSkin Assessment

Frankfort lineFrankfort line

Palpation of the nosePalpation of the nose

Shape position and Shape position and strength of the nasal strength of the nasal structuresstructures

Trace the Trace the LLCsLLCsndashndash PositionPositionndashndash StabilityStability

Tip supportTip support-- Test Tip RecoilTest Tip Recoil

Major tip support mechanismsMajor tip support mechanismsndashndash Strength of Lower lateral Strength of Lower lateral

cartilagecartilagendashndash Attachment of the medial Attachment of the medial cruracrura

to Septumto Septumndashndash Attachment of upper lateral Attachment of upper lateral

cartilage to cartilage to alaralar cartilagecartilage

Minor tip support mechanismsMinor tip support mechanismsndashndash Dorsal septumDorsal septumndashndash InterdomalInterdomal ligamentsligamentsndashndash Membranous septumMembranous septumndashndash Nasal spineNasal spinendashndash Surrounding skin and soft tissuesSurrounding skin and soft tissuesndashndash AlarAlar sidewallssidewalls

Photographic DocumentationPhotographic Documentation

Allow for more detailed Allow for more detailed evaluationevaluation

FullFull--face face ndashndash FrontalFrontalndashndash LateralLateralndashndash ObliqueObliquendashndash Base viewBase viewndashndash Smiling viewSmiling view

CloseClose--up views up views ndashndash Skin AssessmentSkin Assessment

Frankfort lineFrankfort line

Tip supportTip support-- Test Tip RecoilTest Tip Recoil

Major tip support mechanismsMajor tip support mechanismsndashndash Strength of Lower lateral Strength of Lower lateral

cartilagecartilagendashndash Attachment of the medial Attachment of the medial cruracrura

to Septumto Septumndashndash Attachment of upper lateral Attachment of upper lateral

cartilage to cartilage to alaralar cartilagecartilage

Minor tip support mechanismsMinor tip support mechanismsndashndash Dorsal septumDorsal septumndashndash InterdomalInterdomal ligamentsligamentsndashndash Membranous septumMembranous septumndashndash Nasal spineNasal spinendashndash Surrounding skin and soft tissuesSurrounding skin and soft tissuesndashndash AlarAlar sidewallssidewalls

Photographic DocumentationPhotographic Documentation

Allow for more detailed Allow for more detailed evaluationevaluation

FullFull--face face ndashndash FrontalFrontalndashndash LateralLateralndashndash ObliqueObliquendashndash Base viewBase viewndashndash Smiling viewSmiling view

CloseClose--up views up views ndashndash Skin AssessmentSkin Assessment

Frankfort lineFrankfort line

Photographic DocumentationPhotographic Documentation

Allow for more detailed Allow for more detailed evaluationevaluation

FullFull--face face ndashndash FrontalFrontalndashndash LateralLateralndashndash ObliqueObliquendashndash Base viewBase viewndashndash Smiling viewSmiling view

CloseClose--up views up views ndashndash Skin AssessmentSkin Assessment

Frankfort lineFrankfort line

Frankfort lineFrankfort line

Nasal TipNasal Tip

RotationRotation

ProjectionProjection

DefinitionDefinition

Facial AnalysisFacial Analysis

Nasal tip rotationNasal tip rotationndashndash Along a radius based at Along a radius based at

the EACthe EAC

ndashndash Rotation increases along Rotation increases along the upper portion of the the upper portion of the arcarc

Facial AnalysisFacial Analysis

NasolabialNasolabial angleanglendashndash MaleMale

9090oo to 95to 95oo

ndashndash FemaleFemale9595oo to 110to 110oo

RotationRotation

Facial AnalysisFacial Analysis

Nasal projectionndash Facial plane

Vertical line connecting the nasion with alargroove

ndash Nasal tip distance from facial plane (Perpendicular line)

Facial AnalysisFacial Analysis

Tip projectionTip projectionndashndash Goodes methodGoodes methodndashndash Ratio of BARatio of BA

055 to 060055 to 060

A

B

Facial AnalysisFacial Analysis

NasomentalNasomental angleanglendashndash Nasal dorsum to tip Nasal dorsum to tip

Tip to Tip to pogonionpogonionndashndash 120 to 130120 to 130oo

Posterior Posterior pogoniumpogoniumndashndash Illusion of increase Illusion of increase

projectionprojection

Facial AnalysisFacial Analysis

Line dropped from lower Line dropped from lower lip vermillionlip vermillionndashndash Female = posterior to Female = posterior to

vertical line vertical line ndashndash Male = at vertical lineMale = at vertical line

Chin ImplantChin Implantndashndash SagitalSagital planeplanendashndash Does not affect vertical or Does not affect vertical or

transverse problemstransverse problems

Facial AnalysisFacial Analysis

DefinitionDefinition

Caudal ViewCaudal Viewndashndash Equilateral TriangleEquilateral Trianglendashndash Divided into three Divided into three

equivalent unitequivalent unitndashndash Tip is 13 of basal Tip is 13 of basal

viewview

Facial AnalysisFacial Analysis

Lateral viewLateral viewndashndash Ideal AlaIdeal Ala--toto--tip tip

lobular complex lobular complex ratio is 11ratio is 11

Definition

Computer Image Modification ProgramsComputer Image Modification Programs

Increasingly popular for consultation of Increasingly popular for consultation of cosmetic patientscosmetic patientsValuable Valuable ndashndash Patient might have unrealistic goals for surgeryPatient might have unrealistic goals for surgeryndashndash Accurate image can focused a reasonable goal Accurate image can focused a reasonable goal

Unrealistic images will inevitably lead to an Unrealistic images will inevitably lead to an unhappy patientunhappy patientUnderUnder--promise Overpromise Over--deliverdeliver

Nasal SkinNasal Skin--Soft Tissue Envelope Soft Tissue Envelope (SSTE)(SSTE)

ThickThick--skinnedskinnedndashndash Tip definition is challengingTip definition is challenging

ndashndash Augment framework to project into the thick skinAugment framework to project into the thick skin

ndashndash InelasticInelastic-- may be difficult to drapemay be difficult to drapeDead spaceDead space-- scarringscarring

ndashndash Does not show small irregularityDoes not show small irregularity

Nasal SkinNasal Skin--Soft Tissue Envelope Soft Tissue Envelope (SSTE)(SSTE)

Thin skinThin skinndashndash Irregularities becoming visible Irregularities becoming visible

or palpableor palpableEnsure that all bony Ensure that all bony cartilaginous grafts and cartilaginous grafts and implants are precisely positioned implants are precisely positioned and smoothly contouredand smoothly contoured

ndashndash Draping is easierDraping is easier

Facial AnalysisFacial Analysis

Nasal tip rotationNasal tip rotationndashndash Along a radius based at Along a radius based at

the EACthe EAC

ndashndash Rotation increases along Rotation increases along the upper portion of the the upper portion of the arcarc

Facial AnalysisFacial Analysis

NasolabialNasolabial angleanglendashndash MaleMale

9090oo to 95to 95oo

ndashndash FemaleFemale9595oo to 110to 110oo

RotationRotation

Facial AnalysisFacial Analysis

Nasal projectionndash Facial plane

Vertical line connecting the nasion with alargroove

ndash Nasal tip distance from facial plane (Perpendicular line)

Facial AnalysisFacial Analysis

Tip projectionTip projectionndashndash Goodes methodGoodes methodndashndash Ratio of BARatio of BA

055 to 060055 to 060

A

B

Facial AnalysisFacial Analysis

NasomentalNasomental angleanglendashndash Nasal dorsum to tip Nasal dorsum to tip

Tip to Tip to pogonionpogonionndashndash 120 to 130120 to 130oo

Posterior Posterior pogoniumpogoniumndashndash Illusion of increase Illusion of increase

projectionprojection

Facial AnalysisFacial Analysis

Line dropped from lower Line dropped from lower lip vermillionlip vermillionndashndash Female = posterior to Female = posterior to

vertical line vertical line ndashndash Male = at vertical lineMale = at vertical line

Chin ImplantChin Implantndashndash SagitalSagital planeplanendashndash Does not affect vertical or Does not affect vertical or

transverse problemstransverse problems

Facial AnalysisFacial Analysis

DefinitionDefinition

Caudal ViewCaudal Viewndashndash Equilateral TriangleEquilateral Trianglendashndash Divided into three Divided into three

equivalent unitequivalent unitndashndash Tip is 13 of basal Tip is 13 of basal

viewview

Facial AnalysisFacial Analysis

Lateral viewLateral viewndashndash Ideal AlaIdeal Ala--toto--tip tip

lobular complex lobular complex ratio is 11ratio is 11

Definition

Computer Image Modification ProgramsComputer Image Modification Programs

Increasingly popular for consultation of Increasingly popular for consultation of cosmetic patientscosmetic patientsValuable Valuable ndashndash Patient might have unrealistic goals for surgeryPatient might have unrealistic goals for surgeryndashndash Accurate image can focused a reasonable goal Accurate image can focused a reasonable goal

Unrealistic images will inevitably lead to an Unrealistic images will inevitably lead to an unhappy patientunhappy patientUnderUnder--promise Overpromise Over--deliverdeliver

Nasal SkinNasal Skin--Soft Tissue Envelope Soft Tissue Envelope (SSTE)(SSTE)

ThickThick--skinnedskinnedndashndash Tip definition is challengingTip definition is challenging

ndashndash Augment framework to project into the thick skinAugment framework to project into the thick skin

ndashndash InelasticInelastic-- may be difficult to drapemay be difficult to drapeDead spaceDead space-- scarringscarring

ndashndash Does not show small irregularityDoes not show small irregularity

Nasal SkinNasal Skin--Soft Tissue Envelope Soft Tissue Envelope (SSTE)(SSTE)

Thin skinThin skinndashndash Irregularities becoming visible Irregularities becoming visible

or palpableor palpableEnsure that all bony Ensure that all bony cartilaginous grafts and cartilaginous grafts and implants are precisely positioned implants are precisely positioned and smoothly contouredand smoothly contoured

ndashndash Draping is easierDraping is easier

Facial AnalysisFacial Analysis

NasolabialNasolabial angleanglendashndash MaleMale

9090oo to 95to 95oo

ndashndash FemaleFemale9595oo to 110to 110oo

RotationRotation

Facial AnalysisFacial Analysis

Nasal projectionndash Facial plane

Vertical line connecting the nasion with alargroove

ndash Nasal tip distance from facial plane (Perpendicular line)

Facial AnalysisFacial Analysis

Tip projectionTip projectionndashndash Goodes methodGoodes methodndashndash Ratio of BARatio of BA

055 to 060055 to 060

A

B

Facial AnalysisFacial Analysis

NasomentalNasomental angleanglendashndash Nasal dorsum to tip Nasal dorsum to tip

Tip to Tip to pogonionpogonionndashndash 120 to 130120 to 130oo

Posterior Posterior pogoniumpogoniumndashndash Illusion of increase Illusion of increase

projectionprojection

Facial AnalysisFacial Analysis

Line dropped from lower Line dropped from lower lip vermillionlip vermillionndashndash Female = posterior to Female = posterior to

vertical line vertical line ndashndash Male = at vertical lineMale = at vertical line

Chin ImplantChin Implantndashndash SagitalSagital planeplanendashndash Does not affect vertical or Does not affect vertical or

transverse problemstransverse problems

Facial AnalysisFacial Analysis

DefinitionDefinition

Caudal ViewCaudal Viewndashndash Equilateral TriangleEquilateral Trianglendashndash Divided into three Divided into three

equivalent unitequivalent unitndashndash Tip is 13 of basal Tip is 13 of basal

viewview

Facial AnalysisFacial Analysis

Lateral viewLateral viewndashndash Ideal AlaIdeal Ala--toto--tip tip

lobular complex lobular complex ratio is 11ratio is 11

Definition

Computer Image Modification ProgramsComputer Image Modification Programs

Increasingly popular for consultation of Increasingly popular for consultation of cosmetic patientscosmetic patientsValuable Valuable ndashndash Patient might have unrealistic goals for surgeryPatient might have unrealistic goals for surgeryndashndash Accurate image can focused a reasonable goal Accurate image can focused a reasonable goal

Unrealistic images will inevitably lead to an Unrealistic images will inevitably lead to an unhappy patientunhappy patientUnderUnder--promise Overpromise Over--deliverdeliver

Nasal SkinNasal Skin--Soft Tissue Envelope Soft Tissue Envelope (SSTE)(SSTE)

ThickThick--skinnedskinnedndashndash Tip definition is challengingTip definition is challenging

ndashndash Augment framework to project into the thick skinAugment framework to project into the thick skin

ndashndash InelasticInelastic-- may be difficult to drapemay be difficult to drapeDead spaceDead space-- scarringscarring

ndashndash Does not show small irregularityDoes not show small irregularity

Nasal SkinNasal Skin--Soft Tissue Envelope Soft Tissue Envelope (SSTE)(SSTE)

Thin skinThin skinndashndash Irregularities becoming visible Irregularities becoming visible

or palpableor palpableEnsure that all bony Ensure that all bony cartilaginous grafts and cartilaginous grafts and implants are precisely positioned implants are precisely positioned and smoothly contouredand smoothly contoured

ndashndash Draping is easierDraping is easier

Facial AnalysisFacial Analysis

Nasal projectionndash Facial plane

Vertical line connecting the nasion with alargroove

ndash Nasal tip distance from facial plane (Perpendicular line)

Facial AnalysisFacial Analysis

Tip projectionTip projectionndashndash Goodes methodGoodes methodndashndash Ratio of BARatio of BA

055 to 060055 to 060

A

B

Facial AnalysisFacial Analysis

NasomentalNasomental angleanglendashndash Nasal dorsum to tip Nasal dorsum to tip

Tip to Tip to pogonionpogonionndashndash 120 to 130120 to 130oo

Posterior Posterior pogoniumpogoniumndashndash Illusion of increase Illusion of increase

projectionprojection

Facial AnalysisFacial Analysis

Line dropped from lower Line dropped from lower lip vermillionlip vermillionndashndash Female = posterior to Female = posterior to

vertical line vertical line ndashndash Male = at vertical lineMale = at vertical line

Chin ImplantChin Implantndashndash SagitalSagital planeplanendashndash Does not affect vertical or Does not affect vertical or

transverse problemstransverse problems

Facial AnalysisFacial Analysis

DefinitionDefinition

Caudal ViewCaudal Viewndashndash Equilateral TriangleEquilateral Trianglendashndash Divided into three Divided into three

equivalent unitequivalent unitndashndash Tip is 13 of basal Tip is 13 of basal

viewview

Facial AnalysisFacial Analysis

Lateral viewLateral viewndashndash Ideal AlaIdeal Ala--toto--tip tip

lobular complex lobular complex ratio is 11ratio is 11

Definition

Computer Image Modification ProgramsComputer Image Modification Programs

Increasingly popular for consultation of Increasingly popular for consultation of cosmetic patientscosmetic patientsValuable Valuable ndashndash Patient might have unrealistic goals for surgeryPatient might have unrealistic goals for surgeryndashndash Accurate image can focused a reasonable goal Accurate image can focused a reasonable goal

Unrealistic images will inevitably lead to an Unrealistic images will inevitably lead to an unhappy patientunhappy patientUnderUnder--promise Overpromise Over--deliverdeliver

Nasal SkinNasal Skin--Soft Tissue Envelope Soft Tissue Envelope (SSTE)(SSTE)

ThickThick--skinnedskinnedndashndash Tip definition is challengingTip definition is challenging

ndashndash Augment framework to project into the thick skinAugment framework to project into the thick skin

ndashndash InelasticInelastic-- may be difficult to drapemay be difficult to drapeDead spaceDead space-- scarringscarring

ndashndash Does not show small irregularityDoes not show small irregularity

Nasal SkinNasal Skin--Soft Tissue Envelope Soft Tissue Envelope (SSTE)(SSTE)

Thin skinThin skinndashndash Irregularities becoming visible Irregularities becoming visible

or palpableor palpableEnsure that all bony Ensure that all bony cartilaginous grafts and cartilaginous grafts and implants are precisely positioned implants are precisely positioned and smoothly contouredand smoothly contoured

ndashndash Draping is easierDraping is easier

Facial AnalysisFacial Analysis

Tip projectionTip projectionndashndash Goodes methodGoodes methodndashndash Ratio of BARatio of BA

055 to 060055 to 060

A

B

Facial AnalysisFacial Analysis

NasomentalNasomental angleanglendashndash Nasal dorsum to tip Nasal dorsum to tip

Tip to Tip to pogonionpogonionndashndash 120 to 130120 to 130oo

Posterior Posterior pogoniumpogoniumndashndash Illusion of increase Illusion of increase

projectionprojection

Facial AnalysisFacial Analysis

Line dropped from lower Line dropped from lower lip vermillionlip vermillionndashndash Female = posterior to Female = posterior to

vertical line vertical line ndashndash Male = at vertical lineMale = at vertical line

Chin ImplantChin Implantndashndash SagitalSagital planeplanendashndash Does not affect vertical or Does not affect vertical or

transverse problemstransverse problems

Facial AnalysisFacial Analysis

DefinitionDefinition

Caudal ViewCaudal Viewndashndash Equilateral TriangleEquilateral Trianglendashndash Divided into three Divided into three

equivalent unitequivalent unitndashndash Tip is 13 of basal Tip is 13 of basal

viewview

Facial AnalysisFacial Analysis

Lateral viewLateral viewndashndash Ideal AlaIdeal Ala--toto--tip tip

lobular complex lobular complex ratio is 11ratio is 11

Definition

Computer Image Modification ProgramsComputer Image Modification Programs

Increasingly popular for consultation of Increasingly popular for consultation of cosmetic patientscosmetic patientsValuable Valuable ndashndash Patient might have unrealistic goals for surgeryPatient might have unrealistic goals for surgeryndashndash Accurate image can focused a reasonable goal Accurate image can focused a reasonable goal

Unrealistic images will inevitably lead to an Unrealistic images will inevitably lead to an unhappy patientunhappy patientUnderUnder--promise Overpromise Over--deliverdeliver

Nasal SkinNasal Skin--Soft Tissue Envelope Soft Tissue Envelope (SSTE)(SSTE)

ThickThick--skinnedskinnedndashndash Tip definition is challengingTip definition is challenging

ndashndash Augment framework to project into the thick skinAugment framework to project into the thick skin

ndashndash InelasticInelastic-- may be difficult to drapemay be difficult to drapeDead spaceDead space-- scarringscarring

ndashndash Does not show small irregularityDoes not show small irregularity

Nasal SkinNasal Skin--Soft Tissue Envelope Soft Tissue Envelope (SSTE)(SSTE)

Thin skinThin skinndashndash Irregularities becoming visible Irregularities becoming visible

or palpableor palpableEnsure that all bony Ensure that all bony cartilaginous grafts and cartilaginous grafts and implants are precisely positioned implants are precisely positioned and smoothly contouredand smoothly contoured

ndashndash Draping is easierDraping is easier

Facial AnalysisFacial Analysis

NasomentalNasomental angleanglendashndash Nasal dorsum to tip Nasal dorsum to tip

Tip to Tip to pogonionpogonionndashndash 120 to 130120 to 130oo

Posterior Posterior pogoniumpogoniumndashndash Illusion of increase Illusion of increase

projectionprojection

Facial AnalysisFacial Analysis

Line dropped from lower Line dropped from lower lip vermillionlip vermillionndashndash Female = posterior to Female = posterior to

vertical line vertical line ndashndash Male = at vertical lineMale = at vertical line

Chin ImplantChin Implantndashndash SagitalSagital planeplanendashndash Does not affect vertical or Does not affect vertical or

transverse problemstransverse problems

Facial AnalysisFacial Analysis

DefinitionDefinition

Caudal ViewCaudal Viewndashndash Equilateral TriangleEquilateral Trianglendashndash Divided into three Divided into three

equivalent unitequivalent unitndashndash Tip is 13 of basal Tip is 13 of basal

viewview

Facial AnalysisFacial Analysis

Lateral viewLateral viewndashndash Ideal AlaIdeal Ala--toto--tip tip

lobular complex lobular complex ratio is 11ratio is 11

Definition

Computer Image Modification ProgramsComputer Image Modification Programs

Increasingly popular for consultation of Increasingly popular for consultation of cosmetic patientscosmetic patientsValuable Valuable ndashndash Patient might have unrealistic goals for surgeryPatient might have unrealistic goals for surgeryndashndash Accurate image can focused a reasonable goal Accurate image can focused a reasonable goal

Unrealistic images will inevitably lead to an Unrealistic images will inevitably lead to an unhappy patientunhappy patientUnderUnder--promise Overpromise Over--deliverdeliver

Nasal SkinNasal Skin--Soft Tissue Envelope Soft Tissue Envelope (SSTE)(SSTE)

ThickThick--skinnedskinnedndashndash Tip definition is challengingTip definition is challenging

ndashndash Augment framework to project into the thick skinAugment framework to project into the thick skin

ndashndash InelasticInelastic-- may be difficult to drapemay be difficult to drapeDead spaceDead space-- scarringscarring

ndashndash Does not show small irregularityDoes not show small irregularity

Nasal SkinNasal Skin--Soft Tissue Envelope Soft Tissue Envelope (SSTE)(SSTE)

Thin skinThin skinndashndash Irregularities becoming visible Irregularities becoming visible

or palpableor palpableEnsure that all bony Ensure that all bony cartilaginous grafts and cartilaginous grafts and implants are precisely positioned implants are precisely positioned and smoothly contouredand smoothly contoured

ndashndash Draping is easierDraping is easier

Facial AnalysisFacial Analysis

Line dropped from lower Line dropped from lower lip vermillionlip vermillionndashndash Female = posterior to Female = posterior to

vertical line vertical line ndashndash Male = at vertical lineMale = at vertical line

Chin ImplantChin Implantndashndash SagitalSagital planeplanendashndash Does not affect vertical or Does not affect vertical or

transverse problemstransverse problems

Facial AnalysisFacial Analysis

DefinitionDefinition

Caudal ViewCaudal Viewndashndash Equilateral TriangleEquilateral Trianglendashndash Divided into three Divided into three

equivalent unitequivalent unitndashndash Tip is 13 of basal Tip is 13 of basal

viewview

Facial AnalysisFacial Analysis

Lateral viewLateral viewndashndash Ideal AlaIdeal Ala--toto--tip tip

lobular complex lobular complex ratio is 11ratio is 11

Definition

Computer Image Modification ProgramsComputer Image Modification Programs

Increasingly popular for consultation of Increasingly popular for consultation of cosmetic patientscosmetic patientsValuable Valuable ndashndash Patient might have unrealistic goals for surgeryPatient might have unrealistic goals for surgeryndashndash Accurate image can focused a reasonable goal Accurate image can focused a reasonable goal

Unrealistic images will inevitably lead to an Unrealistic images will inevitably lead to an unhappy patientunhappy patientUnderUnder--promise Overpromise Over--deliverdeliver

Nasal SkinNasal Skin--Soft Tissue Envelope Soft Tissue Envelope (SSTE)(SSTE)

ThickThick--skinnedskinnedndashndash Tip definition is challengingTip definition is challenging

ndashndash Augment framework to project into the thick skinAugment framework to project into the thick skin

ndashndash InelasticInelastic-- may be difficult to drapemay be difficult to drapeDead spaceDead space-- scarringscarring

ndashndash Does not show small irregularityDoes not show small irregularity

Nasal SkinNasal Skin--Soft Tissue Envelope Soft Tissue Envelope (SSTE)(SSTE)

Thin skinThin skinndashndash Irregularities becoming visible Irregularities becoming visible

or palpableor palpableEnsure that all bony Ensure that all bony cartilaginous grafts and cartilaginous grafts and implants are precisely positioned implants are precisely positioned and smoothly contouredand smoothly contoured

ndashndash Draping is easierDraping is easier

Facial AnalysisFacial Analysis

DefinitionDefinition

Caudal ViewCaudal Viewndashndash Equilateral TriangleEquilateral Trianglendashndash Divided into three Divided into three

equivalent unitequivalent unitndashndash Tip is 13 of basal Tip is 13 of basal

viewview

Facial AnalysisFacial Analysis

Lateral viewLateral viewndashndash Ideal AlaIdeal Ala--toto--tip tip

lobular complex lobular complex ratio is 11ratio is 11

Definition

Computer Image Modification ProgramsComputer Image Modification Programs

Increasingly popular for consultation of Increasingly popular for consultation of cosmetic patientscosmetic patientsValuable Valuable ndashndash Patient might have unrealistic goals for surgeryPatient might have unrealistic goals for surgeryndashndash Accurate image can focused a reasonable goal Accurate image can focused a reasonable goal

Unrealistic images will inevitably lead to an Unrealistic images will inevitably lead to an unhappy patientunhappy patientUnderUnder--promise Overpromise Over--deliverdeliver

Nasal SkinNasal Skin--Soft Tissue Envelope Soft Tissue Envelope (SSTE)(SSTE)

ThickThick--skinnedskinnedndashndash Tip definition is challengingTip definition is challenging

ndashndash Augment framework to project into the thick skinAugment framework to project into the thick skin

ndashndash InelasticInelastic-- may be difficult to drapemay be difficult to drapeDead spaceDead space-- scarringscarring

ndashndash Does not show small irregularityDoes not show small irregularity

Nasal SkinNasal Skin--Soft Tissue Envelope Soft Tissue Envelope (SSTE)(SSTE)

Thin skinThin skinndashndash Irregularities becoming visible Irregularities becoming visible

or palpableor palpableEnsure that all bony Ensure that all bony cartilaginous grafts and cartilaginous grafts and implants are precisely positioned implants are precisely positioned and smoothly contouredand smoothly contoured

ndashndash Draping is easierDraping is easier

Facial AnalysisFacial Analysis

Lateral viewLateral viewndashndash Ideal AlaIdeal Ala--toto--tip tip

lobular complex lobular complex ratio is 11ratio is 11

Definition

Computer Image Modification ProgramsComputer Image Modification Programs

Increasingly popular for consultation of Increasingly popular for consultation of cosmetic patientscosmetic patientsValuable Valuable ndashndash Patient might have unrealistic goals for surgeryPatient might have unrealistic goals for surgeryndashndash Accurate image can focused a reasonable goal Accurate image can focused a reasonable goal

Unrealistic images will inevitably lead to an Unrealistic images will inevitably lead to an unhappy patientunhappy patientUnderUnder--promise Overpromise Over--deliverdeliver

Nasal SkinNasal Skin--Soft Tissue Envelope Soft Tissue Envelope (SSTE)(SSTE)

ThickThick--skinnedskinnedndashndash Tip definition is challengingTip definition is challenging

ndashndash Augment framework to project into the thick skinAugment framework to project into the thick skin

ndashndash InelasticInelastic-- may be difficult to drapemay be difficult to drapeDead spaceDead space-- scarringscarring

ndashndash Does not show small irregularityDoes not show small irregularity

Nasal SkinNasal Skin--Soft Tissue Envelope Soft Tissue Envelope (SSTE)(SSTE)

Thin skinThin skinndashndash Irregularities becoming visible Irregularities becoming visible

or palpableor palpableEnsure that all bony Ensure that all bony cartilaginous grafts and cartilaginous grafts and implants are precisely positioned implants are precisely positioned and smoothly contouredand smoothly contoured

ndashndash Draping is easierDraping is easier

Computer Image Modification ProgramsComputer Image Modification Programs

Increasingly popular for consultation of Increasingly popular for consultation of cosmetic patientscosmetic patientsValuable Valuable ndashndash Patient might have unrealistic goals for surgeryPatient might have unrealistic goals for surgeryndashndash Accurate image can focused a reasonable goal Accurate image can focused a reasonable goal

Unrealistic images will inevitably lead to an Unrealistic images will inevitably lead to an unhappy patientunhappy patientUnderUnder--promise Overpromise Over--deliverdeliver

Nasal SkinNasal Skin--Soft Tissue Envelope Soft Tissue Envelope (SSTE)(SSTE)

ThickThick--skinnedskinnedndashndash Tip definition is challengingTip definition is challenging

ndashndash Augment framework to project into the thick skinAugment framework to project into the thick skin

ndashndash InelasticInelastic-- may be difficult to drapemay be difficult to drapeDead spaceDead space-- scarringscarring

ndashndash Does not show small irregularityDoes not show small irregularity

Nasal SkinNasal Skin--Soft Tissue Envelope Soft Tissue Envelope (SSTE)(SSTE)

Thin skinThin skinndashndash Irregularities becoming visible Irregularities becoming visible

or palpableor palpableEnsure that all bony Ensure that all bony cartilaginous grafts and cartilaginous grafts and implants are precisely positioned implants are precisely positioned and smoothly contouredand smoothly contoured

ndashndash Draping is easierDraping is easier

Nasal SkinNasal Skin--Soft Tissue Envelope Soft Tissue Envelope (SSTE)(SSTE)

ThickThick--skinnedskinnedndashndash Tip definition is challengingTip definition is challenging

ndashndash Augment framework to project into the thick skinAugment framework to project into the thick skin

ndashndash InelasticInelastic-- may be difficult to drapemay be difficult to drapeDead spaceDead space-- scarringscarring

ndashndash Does not show small irregularityDoes not show small irregularity

Nasal SkinNasal Skin--Soft Tissue Envelope Soft Tissue Envelope (SSTE)(SSTE)

Thin skinThin skinndashndash Irregularities becoming visible Irregularities becoming visible

or palpableor palpableEnsure that all bony Ensure that all bony cartilaginous grafts and cartilaginous grafts and implants are precisely positioned implants are precisely positioned and smoothly contouredand smoothly contoured

ndashndash Draping is easierDraping is easier

Nasal SkinNasal Skin--Soft Tissue Envelope Soft Tissue Envelope (SSTE)(SSTE)

Thin skinThin skinndashndash Irregularities becoming visible Irregularities becoming visible

or palpableor palpableEnsure that all bony Ensure that all bony cartilaginous grafts and cartilaginous grafts and implants are precisely positioned implants are precisely positioned and smoothly contouredand smoothly contoured

ndashndash Draping is easierDraping is easier

Surgical ApproachSurgical Approach

EndonasalEndonasal approaches approaches ndashndash Ideal for patients with subtle deformitiesIdeal for patients with subtle deformities

External External rhinoplastyrhinoplastyndashndash Wider exposure and access affordedWider exposure and access afforded

Nasal TipNasal Tip

RotationRotation

ProjectionProjection

DefinitionDefinition

Tripod theory

First proposed by Anderson JR (1969)

Tripodndash Lateral cruras= two posterior legs ndash Conjoined medial cruras = anterior

third leg

Helps predict the tip rotationndash Tilt in the direction of the shorter leg

Cephalic rotationndash Shortening of the lateral crurasndash Lengthening medial cruras

Tip Rotation

Common presenting situationsndash Ptotic Tipndash Overrrotated nose

Techniques to alter tip rotationndash Associated with modification of the tripod

PtoticPtotic TipTip

Caudal tip rotationCaudal tip rotation

Acute Acute nasolabialnasolabial angleanglendashndash ltMale 90ltMale 90oo to 95to 95oo

ndashndash ltFemale 95ltFemale 95oo to 110to 110oo

Tip Rotation

Nasal TipNasal Tip

RotationRotation

ProjectionProjection

DefinitionDefinition

Tripod theory

First proposed by Anderson JR (1969)

Tripodndash Lateral cruras= two posterior legs ndash Conjoined medial cruras = anterior

third leg

Helps predict the tip rotationndash Tilt in the direction of the shorter leg

Cephalic rotationndash Shortening of the lateral crurasndash Lengthening medial cruras

Tip Rotation

Common presenting situationsndash Ptotic Tipndash Overrrotated nose

Techniques to alter tip rotationndash Associated with modification of the tripod

PtoticPtotic TipTip

Caudal tip rotationCaudal tip rotation

Acute Acute nasolabialnasolabial angleanglendashndash ltMale 90ltMale 90oo to 95to 95oo

ndashndash ltFemale 95ltFemale 95oo to 110to 110oo

Tip Rotation

Tripod theory

First proposed by Anderson JR (1969)

Tripodndash Lateral cruras= two posterior legs ndash Conjoined medial cruras = anterior

third leg

Helps predict the tip rotationndash Tilt in the direction of the shorter leg

Cephalic rotationndash Shortening of the lateral crurasndash Lengthening medial cruras

Tip Rotation

Common presenting situationsndash Ptotic Tipndash Overrrotated nose

Techniques to alter tip rotationndash Associated with modification of the tripod

PtoticPtotic TipTip

Caudal tip rotationCaudal tip rotation

Acute Acute nasolabialnasolabial angleanglendashndash ltMale 90ltMale 90oo to 95to 95oo

ndashndash ltFemale 95ltFemale 95oo to 110to 110oo

Tip Rotation

Tip Rotation

Common presenting situationsndash Ptotic Tipndash Overrrotated nose

Techniques to alter tip rotationndash Associated with modification of the tripod

PtoticPtotic TipTip

Caudal tip rotationCaudal tip rotation

Acute Acute nasolabialnasolabial angleanglendashndash ltMale 90ltMale 90oo to 95to 95oo

ndashndash ltFemale 95ltFemale 95oo to 110to 110oo

Tip Rotation

PtoticPtotic TipTip

Caudal tip rotationCaudal tip rotation

Acute Acute nasolabialnasolabial angleanglendashndash ltMale 90ltMale 90oo to 95to 95oo

ndashndash ltFemale 95ltFemale 95oo to 110to 110oo

Tip Rotation

PtoticPtotic TipTip

Inherited

Common acquire causesndash Nasal traumandash Aging facendash Previous rhinoplasty

Loss of tip support mechanismsLoss of tip support mechanismsndashndash Loss of Loss of integrity of the medial and lateral integrity of the medial and lateral cruracrurandashndash Loss of attachment of the medial Loss of attachment of the medial cruracrura to septumto septumndashndash Loss of attachment of upper lateral to lower lateralsLoss of attachment of upper lateral to lower laterals

Management of Management of PtoticPtotic TipTip

Treatment base on Tripodndash Strengthening or elongating of

the medial crura

ndash Trimming of the lateral crura

ndash Shortening caudal septum

ndash Restore support mechanism

Medial Medial CruraCrura SurgerySurgery

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

Strengthen of Strengthen of medial medial cruracrura

Secondary effectsSecondary effectsndashndash Tip narrowing Tip narrowing ndashndash Increased Increased

projectionprojection

PtoticPtotic TipTip

Interdomal Suturendashndash Strengthen of Strengthen of

medial medial cruracrura

ndashndash Secondary effectsSecondary effectsTip narrowing Tip narrowing Increased projectionIncreased projection

Medial Medial CruraCrura SurgerySurgery

PtoticPtotic TipTip

Medial Medial CruraCrura SurgerySurgery

Medial crura strut graftndashndash Strengthen of Strengthen of

medial medial cruracrurandashndash Elongate the medial Elongate the medial

crurascruras (position (position dependent)dependent)

ndashndash Cephalic rotationCephalic rotation

PtoticPtotic TipTip

Lateral crura surgery

Cephalic trimndash Rotates tip

cephalically by creating a gap between the LLC and Upper Lateral Cartilage

ndash LLC scars upwardsndash Improve definition

PtoticPtotic tiptip

Cephalic Trim

PtoticPtotic tiptip

Cephalic TrimPtoticPtotic tiptip

Lateral crura surgery

Weakened Complete Stripsndash Augments cephalic

rotationndash May compromise tip

support

PtoticPtotic tiptip

Interrupted Stripndash Spring-tension of

LLC is release and significant rotation can occur

ndash Sacrifices major tip support mechanism may darr tip projection

Lateral crura surgery

PtoticPtotic tiptip

Lateral crura surgery

Resuturingndash Lateral Crural Overlay Technique increases

rotation and decreases projection

PtoticPtotic tiptip

Onlay cartilaginous tip graft

PtoticPtotic tiptip

Rotation Rotation OverrotatedOverrotated (Short (Short Nose)Nose)

Excessive cephalic trim of the lateral Excessive cephalic trim of the lateral cruracruraOverresectionOverresection of the caudal septumof the caudal septum

OverrotatedOverrotated (Short Nose)(Short Nose)

ManagementManagementndashndash Caudal Caudal septalseptal

extension graftextension graftndashndash Minor deformities Minor deformities

ColumellarColumellarplumping graftsplumping grafts

Tip Definition

Common presenting situationsndash Boulbus Tipndash Pinch tip

Decrease nasal tip definition

ndash Wide interdomal distance

ndash Wide domes

ndash Weak alar cartilage

ndashndash Thick amp inelastic skinThick amp inelastic skin

Bulbous TipBulbous Tip

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Suture techniqueSuture technique

ndashndash The The TransdomalTransdomal SutureSutureMattress sutureMattress sutureTip narrowingTip narrowing

ndashndash Narrows Narrows domaldomal archarch

Increased tip projectionIncreased tip projection

ndashndash Medial Medial CruraCrura Suture Suture ndash Interdomal Suture

DefinitionDefinition

Dome division with binding suturendash Narrows the nasal tip

Narrowing the domal arch

ndash Increase tip projection

Management of Bulbous TipManagement of Bulbous Tip

DefinitionDefinition

Pinched TipPinched Tip

Excessive narrowing of the domesExcessive narrowing of the domesndashndash Excessive tightening of Excessive tightening of domaldomal suturessuturesndashndash Dome divisionDome division

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

The lateral The lateral cruracrura suturesuturendashndash Horizontal mattress Horizontal mattress

suture (cephalic)suture (cephalic)ndashndash Narrows tipNarrows tip

Decreased convexity of Decreased convexity of the lateral the lateral cruracrura

ndashndash Decreased Decreased interdomalinterdomaldistancedistance

ndashndash Caudal repositioning of Caudal repositioning of the domesthe domes

ndashndash Nose is elongatedNose is elongated

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Cephalic trim

DefinitionDefinition

Lateral nasal wall weaknessLateral nasal wall weakness

AlarAlar cartilage weakeningcartilage weakeningndashndash Aggressive cephalic trimAggressive cephalic trimndashndash Cephalic positioning of the Cephalic positioning of the

lateral lateral cruracrura

External Valve collapseExternal Valve collapse

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Shield graftShield graftndashndash Provide augmentation Provide augmentation

to the tipto the tipndashndash Protrudes into thick Protrudes into thick

skinskinndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

DefinitionDefinition

Projection

Link to rotation and definitionSimilar techniquesCommon presenting situationndash Pollybeak

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

Management of Management of PtoticPtotic TipTip

Treatment base on Tripodndash Strengthening or elongating of

the medial crura

ndash Trimming of the lateral crura

ndash Shortening caudal septum

ndash Restore support mechanism

Medial Medial CruraCrura SurgerySurgery

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

Strengthen of Strengthen of medial medial cruracrura

Secondary effectsSecondary effectsndashndash Tip narrowing Tip narrowing ndashndash Increased Increased

projectionprojection

PtoticPtotic TipTip

Interdomal Suturendashndash Strengthen of Strengthen of

medial medial cruracrura

ndashndash Secondary effectsSecondary effectsTip narrowing Tip narrowing Increased projectionIncreased projection

Medial Medial CruraCrura SurgerySurgery

PtoticPtotic TipTip

Medial Medial CruraCrura SurgerySurgery

Medial crura strut graftndashndash Strengthen of Strengthen of

medial medial cruracrurandashndash Elongate the medial Elongate the medial

crurascruras (position (position dependent)dependent)

ndashndash Cephalic rotationCephalic rotation

PtoticPtotic TipTip

Lateral crura surgery

Cephalic trimndash Rotates tip

cephalically by creating a gap between the LLC and Upper Lateral Cartilage

ndash LLC scars upwardsndash Improve definition

PtoticPtotic tiptip

Cephalic Trim

PtoticPtotic tiptip

Cephalic TrimPtoticPtotic tiptip

Lateral crura surgery

Weakened Complete Stripsndash Augments cephalic

rotationndash May compromise tip

support

PtoticPtotic tiptip

Interrupted Stripndash Spring-tension of

LLC is release and significant rotation can occur

ndash Sacrifices major tip support mechanism may darr tip projection

Lateral crura surgery

PtoticPtotic tiptip

Lateral crura surgery

Resuturingndash Lateral Crural Overlay Technique increases

rotation and decreases projection

PtoticPtotic tiptip

Onlay cartilaginous tip graft

PtoticPtotic tiptip

Rotation Rotation OverrotatedOverrotated (Short (Short Nose)Nose)

Excessive cephalic trim of the lateral Excessive cephalic trim of the lateral cruracruraOverresectionOverresection of the caudal septumof the caudal septum

OverrotatedOverrotated (Short Nose)(Short Nose)

ManagementManagementndashndash Caudal Caudal septalseptal

extension graftextension graftndashndash Minor deformities Minor deformities

ColumellarColumellarplumping graftsplumping grafts

Tip Definition

Common presenting situationsndash Boulbus Tipndash Pinch tip

Decrease nasal tip definition

ndash Wide interdomal distance

ndash Wide domes

ndash Weak alar cartilage

ndashndash Thick amp inelastic skinThick amp inelastic skin

Bulbous TipBulbous Tip

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Suture techniqueSuture technique

ndashndash The The TransdomalTransdomal SutureSutureMattress sutureMattress sutureTip narrowingTip narrowing

ndashndash Narrows Narrows domaldomal archarch

Increased tip projectionIncreased tip projection

ndashndash Medial Medial CruraCrura Suture Suture ndash Interdomal Suture

DefinitionDefinition

Dome division with binding suturendash Narrows the nasal tip

Narrowing the domal arch

ndash Increase tip projection

Management of Bulbous TipManagement of Bulbous Tip

DefinitionDefinition

Pinched TipPinched Tip

Excessive narrowing of the domesExcessive narrowing of the domesndashndash Excessive tightening of Excessive tightening of domaldomal suturessuturesndashndash Dome divisionDome division

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

The lateral The lateral cruracrura suturesuturendashndash Horizontal mattress Horizontal mattress

suture (cephalic)suture (cephalic)ndashndash Narrows tipNarrows tip

Decreased convexity of Decreased convexity of the lateral the lateral cruracrura

ndashndash Decreased Decreased interdomalinterdomaldistancedistance

ndashndash Caudal repositioning of Caudal repositioning of the domesthe domes

ndashndash Nose is elongatedNose is elongated

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Cephalic trim

DefinitionDefinition

Lateral nasal wall weaknessLateral nasal wall weakness

AlarAlar cartilage weakeningcartilage weakeningndashndash Aggressive cephalic trimAggressive cephalic trimndashndash Cephalic positioning of the Cephalic positioning of the

lateral lateral cruracrura

External Valve collapseExternal Valve collapse

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Shield graftShield graftndashndash Provide augmentation Provide augmentation

to the tipto the tipndashndash Protrudes into thick Protrudes into thick

skinskinndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

DefinitionDefinition

Projection

Link to rotation and definitionSimilar techniquesCommon presenting situationndash Pollybeak

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

Medial Medial CruraCrura SurgerySurgery

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

Strengthen of Strengthen of medial medial cruracrura

Secondary effectsSecondary effectsndashndash Tip narrowing Tip narrowing ndashndash Increased Increased

projectionprojection

PtoticPtotic TipTip

Interdomal Suturendashndash Strengthen of Strengthen of

medial medial cruracrura

ndashndash Secondary effectsSecondary effectsTip narrowing Tip narrowing Increased projectionIncreased projection

Medial Medial CruraCrura SurgerySurgery

PtoticPtotic TipTip

Medial Medial CruraCrura SurgerySurgery

Medial crura strut graftndashndash Strengthen of Strengthen of

medial medial cruracrurandashndash Elongate the medial Elongate the medial

crurascruras (position (position dependent)dependent)

ndashndash Cephalic rotationCephalic rotation

PtoticPtotic TipTip

Lateral crura surgery

Cephalic trimndash Rotates tip

cephalically by creating a gap between the LLC and Upper Lateral Cartilage

ndash LLC scars upwardsndash Improve definition

PtoticPtotic tiptip

Cephalic Trim

PtoticPtotic tiptip

Cephalic TrimPtoticPtotic tiptip

Lateral crura surgery

Weakened Complete Stripsndash Augments cephalic

rotationndash May compromise tip

support

PtoticPtotic tiptip

Interrupted Stripndash Spring-tension of

LLC is release and significant rotation can occur

ndash Sacrifices major tip support mechanism may darr tip projection

Lateral crura surgery

PtoticPtotic tiptip

Lateral crura surgery

Resuturingndash Lateral Crural Overlay Technique increases

rotation and decreases projection

PtoticPtotic tiptip

Onlay cartilaginous tip graft

PtoticPtotic tiptip

Rotation Rotation OverrotatedOverrotated (Short (Short Nose)Nose)

Excessive cephalic trim of the lateral Excessive cephalic trim of the lateral cruracruraOverresectionOverresection of the caudal septumof the caudal septum

OverrotatedOverrotated (Short Nose)(Short Nose)

ManagementManagementndashndash Caudal Caudal septalseptal

extension graftextension graftndashndash Minor deformities Minor deformities

ColumellarColumellarplumping graftsplumping grafts

Tip Definition

Common presenting situationsndash Boulbus Tipndash Pinch tip

Decrease nasal tip definition

ndash Wide interdomal distance

ndash Wide domes

ndash Weak alar cartilage

ndashndash Thick amp inelastic skinThick amp inelastic skin

Bulbous TipBulbous Tip

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Suture techniqueSuture technique

ndashndash The The TransdomalTransdomal SutureSutureMattress sutureMattress sutureTip narrowingTip narrowing

ndashndash Narrows Narrows domaldomal archarch

Increased tip projectionIncreased tip projection

ndashndash Medial Medial CruraCrura Suture Suture ndash Interdomal Suture

DefinitionDefinition

Dome division with binding suturendash Narrows the nasal tip

Narrowing the domal arch

ndash Increase tip projection

Management of Bulbous TipManagement of Bulbous Tip

DefinitionDefinition

Pinched TipPinched Tip

Excessive narrowing of the domesExcessive narrowing of the domesndashndash Excessive tightening of Excessive tightening of domaldomal suturessuturesndashndash Dome divisionDome division

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

The lateral The lateral cruracrura suturesuturendashndash Horizontal mattress Horizontal mattress

suture (cephalic)suture (cephalic)ndashndash Narrows tipNarrows tip

Decreased convexity of Decreased convexity of the lateral the lateral cruracrura

ndashndash Decreased Decreased interdomalinterdomaldistancedistance

ndashndash Caudal repositioning of Caudal repositioning of the domesthe domes

ndashndash Nose is elongatedNose is elongated

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Cephalic trim

DefinitionDefinition

Lateral nasal wall weaknessLateral nasal wall weakness

AlarAlar cartilage weakeningcartilage weakeningndashndash Aggressive cephalic trimAggressive cephalic trimndashndash Cephalic positioning of the Cephalic positioning of the

lateral lateral cruracrura

External Valve collapseExternal Valve collapse

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Shield graftShield graftndashndash Provide augmentation Provide augmentation

to the tipto the tipndashndash Protrudes into thick Protrudes into thick

skinskinndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

DefinitionDefinition

Projection

Link to rotation and definitionSimilar techniquesCommon presenting situationndash Pollybeak

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

Interdomal Suturendashndash Strengthen of Strengthen of

medial medial cruracrura

ndashndash Secondary effectsSecondary effectsTip narrowing Tip narrowing Increased projectionIncreased projection

Medial Medial CruraCrura SurgerySurgery

PtoticPtotic TipTip

Medial Medial CruraCrura SurgerySurgery

Medial crura strut graftndashndash Strengthen of Strengthen of

medial medial cruracrurandashndash Elongate the medial Elongate the medial

crurascruras (position (position dependent)dependent)

ndashndash Cephalic rotationCephalic rotation

PtoticPtotic TipTip

Lateral crura surgery

Cephalic trimndash Rotates tip

cephalically by creating a gap between the LLC and Upper Lateral Cartilage

ndash LLC scars upwardsndash Improve definition

PtoticPtotic tiptip

Cephalic Trim

PtoticPtotic tiptip

Cephalic TrimPtoticPtotic tiptip

Lateral crura surgery

Weakened Complete Stripsndash Augments cephalic

rotationndash May compromise tip

support

PtoticPtotic tiptip

Interrupted Stripndash Spring-tension of

LLC is release and significant rotation can occur

ndash Sacrifices major tip support mechanism may darr tip projection

Lateral crura surgery

PtoticPtotic tiptip

Lateral crura surgery

Resuturingndash Lateral Crural Overlay Technique increases

rotation and decreases projection

PtoticPtotic tiptip

Onlay cartilaginous tip graft

PtoticPtotic tiptip

Rotation Rotation OverrotatedOverrotated (Short (Short Nose)Nose)

Excessive cephalic trim of the lateral Excessive cephalic trim of the lateral cruracruraOverresectionOverresection of the caudal septumof the caudal septum

OverrotatedOverrotated (Short Nose)(Short Nose)

ManagementManagementndashndash Caudal Caudal septalseptal

extension graftextension graftndashndash Minor deformities Minor deformities

ColumellarColumellarplumping graftsplumping grafts

Tip Definition

Common presenting situationsndash Boulbus Tipndash Pinch tip

Decrease nasal tip definition

ndash Wide interdomal distance

ndash Wide domes

ndash Weak alar cartilage

ndashndash Thick amp inelastic skinThick amp inelastic skin

Bulbous TipBulbous Tip

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Suture techniqueSuture technique

ndashndash The The TransdomalTransdomal SutureSutureMattress sutureMattress sutureTip narrowingTip narrowing

ndashndash Narrows Narrows domaldomal archarch

Increased tip projectionIncreased tip projection

ndashndash Medial Medial CruraCrura Suture Suture ndash Interdomal Suture

DefinitionDefinition

Dome division with binding suturendash Narrows the nasal tip

Narrowing the domal arch

ndash Increase tip projection

Management of Bulbous TipManagement of Bulbous Tip

DefinitionDefinition

Pinched TipPinched Tip

Excessive narrowing of the domesExcessive narrowing of the domesndashndash Excessive tightening of Excessive tightening of domaldomal suturessuturesndashndash Dome divisionDome division

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

The lateral The lateral cruracrura suturesuturendashndash Horizontal mattress Horizontal mattress

suture (cephalic)suture (cephalic)ndashndash Narrows tipNarrows tip

Decreased convexity of Decreased convexity of the lateral the lateral cruracrura

ndashndash Decreased Decreased interdomalinterdomaldistancedistance

ndashndash Caudal repositioning of Caudal repositioning of the domesthe domes

ndashndash Nose is elongatedNose is elongated

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Cephalic trim

DefinitionDefinition

Lateral nasal wall weaknessLateral nasal wall weakness

AlarAlar cartilage weakeningcartilage weakeningndashndash Aggressive cephalic trimAggressive cephalic trimndashndash Cephalic positioning of the Cephalic positioning of the

lateral lateral cruracrura

External Valve collapseExternal Valve collapse

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Shield graftShield graftndashndash Provide augmentation Provide augmentation

to the tipto the tipndashndash Protrudes into thick Protrudes into thick

skinskinndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

DefinitionDefinition

Projection

Link to rotation and definitionSimilar techniquesCommon presenting situationndash Pollybeak

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

Medial Medial CruraCrura SurgerySurgery

Medial crura strut graftndashndash Strengthen of Strengthen of

medial medial cruracrurandashndash Elongate the medial Elongate the medial

crurascruras (position (position dependent)dependent)

ndashndash Cephalic rotationCephalic rotation

PtoticPtotic TipTip

Lateral crura surgery

Cephalic trimndash Rotates tip

cephalically by creating a gap between the LLC and Upper Lateral Cartilage

ndash LLC scars upwardsndash Improve definition

PtoticPtotic tiptip

Cephalic Trim

PtoticPtotic tiptip

Cephalic TrimPtoticPtotic tiptip

Lateral crura surgery

Weakened Complete Stripsndash Augments cephalic

rotationndash May compromise tip

support

PtoticPtotic tiptip

Interrupted Stripndash Spring-tension of

LLC is release and significant rotation can occur

ndash Sacrifices major tip support mechanism may darr tip projection

Lateral crura surgery

PtoticPtotic tiptip

Lateral crura surgery

Resuturingndash Lateral Crural Overlay Technique increases

rotation and decreases projection

PtoticPtotic tiptip

Onlay cartilaginous tip graft

PtoticPtotic tiptip

Rotation Rotation OverrotatedOverrotated (Short (Short Nose)Nose)

Excessive cephalic trim of the lateral Excessive cephalic trim of the lateral cruracruraOverresectionOverresection of the caudal septumof the caudal septum

OverrotatedOverrotated (Short Nose)(Short Nose)

ManagementManagementndashndash Caudal Caudal septalseptal

extension graftextension graftndashndash Minor deformities Minor deformities

ColumellarColumellarplumping graftsplumping grafts

Tip Definition

Common presenting situationsndash Boulbus Tipndash Pinch tip

Decrease nasal tip definition

ndash Wide interdomal distance

ndash Wide domes

ndash Weak alar cartilage

ndashndash Thick amp inelastic skinThick amp inelastic skin

Bulbous TipBulbous Tip

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Suture techniqueSuture technique

ndashndash The The TransdomalTransdomal SutureSutureMattress sutureMattress sutureTip narrowingTip narrowing

ndashndash Narrows Narrows domaldomal archarch

Increased tip projectionIncreased tip projection

ndashndash Medial Medial CruraCrura Suture Suture ndash Interdomal Suture

DefinitionDefinition

Dome division with binding suturendash Narrows the nasal tip

Narrowing the domal arch

ndash Increase tip projection

Management of Bulbous TipManagement of Bulbous Tip

DefinitionDefinition

Pinched TipPinched Tip

Excessive narrowing of the domesExcessive narrowing of the domesndashndash Excessive tightening of Excessive tightening of domaldomal suturessuturesndashndash Dome divisionDome division

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

The lateral The lateral cruracrura suturesuturendashndash Horizontal mattress Horizontal mattress

suture (cephalic)suture (cephalic)ndashndash Narrows tipNarrows tip

Decreased convexity of Decreased convexity of the lateral the lateral cruracrura

ndashndash Decreased Decreased interdomalinterdomaldistancedistance

ndashndash Caudal repositioning of Caudal repositioning of the domesthe domes

ndashndash Nose is elongatedNose is elongated

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Cephalic trim

DefinitionDefinition

Lateral nasal wall weaknessLateral nasal wall weakness

AlarAlar cartilage weakeningcartilage weakeningndashndash Aggressive cephalic trimAggressive cephalic trimndashndash Cephalic positioning of the Cephalic positioning of the

lateral lateral cruracrura

External Valve collapseExternal Valve collapse

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Shield graftShield graftndashndash Provide augmentation Provide augmentation

to the tipto the tipndashndash Protrudes into thick Protrudes into thick

skinskinndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

DefinitionDefinition

Projection

Link to rotation and definitionSimilar techniquesCommon presenting situationndash Pollybeak

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

Lateral crura surgery

Cephalic trimndash Rotates tip

cephalically by creating a gap between the LLC and Upper Lateral Cartilage

ndash LLC scars upwardsndash Improve definition

PtoticPtotic tiptip

Cephalic Trim

PtoticPtotic tiptip

Cephalic TrimPtoticPtotic tiptip

Lateral crura surgery

Weakened Complete Stripsndash Augments cephalic

rotationndash May compromise tip

support

PtoticPtotic tiptip

Interrupted Stripndash Spring-tension of

LLC is release and significant rotation can occur

ndash Sacrifices major tip support mechanism may darr tip projection

Lateral crura surgery

PtoticPtotic tiptip

Lateral crura surgery

Resuturingndash Lateral Crural Overlay Technique increases

rotation and decreases projection

PtoticPtotic tiptip

Onlay cartilaginous tip graft

PtoticPtotic tiptip

Rotation Rotation OverrotatedOverrotated (Short (Short Nose)Nose)

Excessive cephalic trim of the lateral Excessive cephalic trim of the lateral cruracruraOverresectionOverresection of the caudal septumof the caudal septum

OverrotatedOverrotated (Short Nose)(Short Nose)

ManagementManagementndashndash Caudal Caudal septalseptal

extension graftextension graftndashndash Minor deformities Minor deformities

ColumellarColumellarplumping graftsplumping grafts

Tip Definition

Common presenting situationsndash Boulbus Tipndash Pinch tip

Decrease nasal tip definition

ndash Wide interdomal distance

ndash Wide domes

ndash Weak alar cartilage

ndashndash Thick amp inelastic skinThick amp inelastic skin

Bulbous TipBulbous Tip

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Suture techniqueSuture technique

ndashndash The The TransdomalTransdomal SutureSutureMattress sutureMattress sutureTip narrowingTip narrowing

ndashndash Narrows Narrows domaldomal archarch

Increased tip projectionIncreased tip projection

ndashndash Medial Medial CruraCrura Suture Suture ndash Interdomal Suture

DefinitionDefinition

Dome division with binding suturendash Narrows the nasal tip

Narrowing the domal arch

ndash Increase tip projection

Management of Bulbous TipManagement of Bulbous Tip

DefinitionDefinition

Pinched TipPinched Tip

Excessive narrowing of the domesExcessive narrowing of the domesndashndash Excessive tightening of Excessive tightening of domaldomal suturessuturesndashndash Dome divisionDome division

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

The lateral The lateral cruracrura suturesuturendashndash Horizontal mattress Horizontal mattress

suture (cephalic)suture (cephalic)ndashndash Narrows tipNarrows tip

Decreased convexity of Decreased convexity of the lateral the lateral cruracrura

ndashndash Decreased Decreased interdomalinterdomaldistancedistance

ndashndash Caudal repositioning of Caudal repositioning of the domesthe domes

ndashndash Nose is elongatedNose is elongated

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Cephalic trim

DefinitionDefinition

Lateral nasal wall weaknessLateral nasal wall weakness

AlarAlar cartilage weakeningcartilage weakeningndashndash Aggressive cephalic trimAggressive cephalic trimndashndash Cephalic positioning of the Cephalic positioning of the

lateral lateral cruracrura

External Valve collapseExternal Valve collapse

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Shield graftShield graftndashndash Provide augmentation Provide augmentation

to the tipto the tipndashndash Protrudes into thick Protrudes into thick

skinskinndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

DefinitionDefinition

Projection

Link to rotation and definitionSimilar techniquesCommon presenting situationndash Pollybeak

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

Cephalic Trim

PtoticPtotic tiptip

Cephalic TrimPtoticPtotic tiptip

Lateral crura surgery

Weakened Complete Stripsndash Augments cephalic

rotationndash May compromise tip

support

PtoticPtotic tiptip

Interrupted Stripndash Spring-tension of

LLC is release and significant rotation can occur

ndash Sacrifices major tip support mechanism may darr tip projection

Lateral crura surgery

PtoticPtotic tiptip

Lateral crura surgery

Resuturingndash Lateral Crural Overlay Technique increases

rotation and decreases projection

PtoticPtotic tiptip

Onlay cartilaginous tip graft

PtoticPtotic tiptip

Rotation Rotation OverrotatedOverrotated (Short (Short Nose)Nose)

Excessive cephalic trim of the lateral Excessive cephalic trim of the lateral cruracruraOverresectionOverresection of the caudal septumof the caudal septum

OverrotatedOverrotated (Short Nose)(Short Nose)

ManagementManagementndashndash Caudal Caudal septalseptal

extension graftextension graftndashndash Minor deformities Minor deformities

ColumellarColumellarplumping graftsplumping grafts

Tip Definition

Common presenting situationsndash Boulbus Tipndash Pinch tip

Decrease nasal tip definition

ndash Wide interdomal distance

ndash Wide domes

ndash Weak alar cartilage

ndashndash Thick amp inelastic skinThick amp inelastic skin

Bulbous TipBulbous Tip

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Suture techniqueSuture technique

ndashndash The The TransdomalTransdomal SutureSutureMattress sutureMattress sutureTip narrowingTip narrowing

ndashndash Narrows Narrows domaldomal archarch

Increased tip projectionIncreased tip projection

ndashndash Medial Medial CruraCrura Suture Suture ndash Interdomal Suture

DefinitionDefinition

Dome division with binding suturendash Narrows the nasal tip

Narrowing the domal arch

ndash Increase tip projection

Management of Bulbous TipManagement of Bulbous Tip

DefinitionDefinition

Pinched TipPinched Tip

Excessive narrowing of the domesExcessive narrowing of the domesndashndash Excessive tightening of Excessive tightening of domaldomal suturessuturesndashndash Dome divisionDome division

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

The lateral The lateral cruracrura suturesuturendashndash Horizontal mattress Horizontal mattress

suture (cephalic)suture (cephalic)ndashndash Narrows tipNarrows tip

Decreased convexity of Decreased convexity of the lateral the lateral cruracrura

ndashndash Decreased Decreased interdomalinterdomaldistancedistance

ndashndash Caudal repositioning of Caudal repositioning of the domesthe domes

ndashndash Nose is elongatedNose is elongated

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Cephalic trim

DefinitionDefinition

Lateral nasal wall weaknessLateral nasal wall weakness

AlarAlar cartilage weakeningcartilage weakeningndashndash Aggressive cephalic trimAggressive cephalic trimndashndash Cephalic positioning of the Cephalic positioning of the

lateral lateral cruracrura

External Valve collapseExternal Valve collapse

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Shield graftShield graftndashndash Provide augmentation Provide augmentation

to the tipto the tipndashndash Protrudes into thick Protrudes into thick

skinskinndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

DefinitionDefinition

Projection

Link to rotation and definitionSimilar techniquesCommon presenting situationndash Pollybeak

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

Cephalic TrimPtoticPtotic tiptip

Lateral crura surgery

Weakened Complete Stripsndash Augments cephalic

rotationndash May compromise tip

support

PtoticPtotic tiptip

Interrupted Stripndash Spring-tension of

LLC is release and significant rotation can occur

ndash Sacrifices major tip support mechanism may darr tip projection

Lateral crura surgery

PtoticPtotic tiptip

Lateral crura surgery

Resuturingndash Lateral Crural Overlay Technique increases

rotation and decreases projection

PtoticPtotic tiptip

Onlay cartilaginous tip graft

PtoticPtotic tiptip

Rotation Rotation OverrotatedOverrotated (Short (Short Nose)Nose)

Excessive cephalic trim of the lateral Excessive cephalic trim of the lateral cruracruraOverresectionOverresection of the caudal septumof the caudal septum

OverrotatedOverrotated (Short Nose)(Short Nose)

ManagementManagementndashndash Caudal Caudal septalseptal

extension graftextension graftndashndash Minor deformities Minor deformities

ColumellarColumellarplumping graftsplumping grafts

Tip Definition

Common presenting situationsndash Boulbus Tipndash Pinch tip

Decrease nasal tip definition

ndash Wide interdomal distance

ndash Wide domes

ndash Weak alar cartilage

ndashndash Thick amp inelastic skinThick amp inelastic skin

Bulbous TipBulbous Tip

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Suture techniqueSuture technique

ndashndash The The TransdomalTransdomal SutureSutureMattress sutureMattress sutureTip narrowingTip narrowing

ndashndash Narrows Narrows domaldomal archarch

Increased tip projectionIncreased tip projection

ndashndash Medial Medial CruraCrura Suture Suture ndash Interdomal Suture

DefinitionDefinition

Dome division with binding suturendash Narrows the nasal tip

Narrowing the domal arch

ndash Increase tip projection

Management of Bulbous TipManagement of Bulbous Tip

DefinitionDefinition

Pinched TipPinched Tip

Excessive narrowing of the domesExcessive narrowing of the domesndashndash Excessive tightening of Excessive tightening of domaldomal suturessuturesndashndash Dome divisionDome division

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

The lateral The lateral cruracrura suturesuturendashndash Horizontal mattress Horizontal mattress

suture (cephalic)suture (cephalic)ndashndash Narrows tipNarrows tip

Decreased convexity of Decreased convexity of the lateral the lateral cruracrura

ndashndash Decreased Decreased interdomalinterdomaldistancedistance

ndashndash Caudal repositioning of Caudal repositioning of the domesthe domes

ndashndash Nose is elongatedNose is elongated

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Cephalic trim

DefinitionDefinition

Lateral nasal wall weaknessLateral nasal wall weakness

AlarAlar cartilage weakeningcartilage weakeningndashndash Aggressive cephalic trimAggressive cephalic trimndashndash Cephalic positioning of the Cephalic positioning of the

lateral lateral cruracrura

External Valve collapseExternal Valve collapse

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Shield graftShield graftndashndash Provide augmentation Provide augmentation

to the tipto the tipndashndash Protrudes into thick Protrudes into thick

skinskinndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

DefinitionDefinition

Projection

Link to rotation and definitionSimilar techniquesCommon presenting situationndash Pollybeak

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

Lateral crura surgery

Weakened Complete Stripsndash Augments cephalic

rotationndash May compromise tip

support

PtoticPtotic tiptip

Interrupted Stripndash Spring-tension of

LLC is release and significant rotation can occur

ndash Sacrifices major tip support mechanism may darr tip projection

Lateral crura surgery

PtoticPtotic tiptip

Lateral crura surgery

Resuturingndash Lateral Crural Overlay Technique increases

rotation and decreases projection

PtoticPtotic tiptip

Onlay cartilaginous tip graft

PtoticPtotic tiptip

Rotation Rotation OverrotatedOverrotated (Short (Short Nose)Nose)

Excessive cephalic trim of the lateral Excessive cephalic trim of the lateral cruracruraOverresectionOverresection of the caudal septumof the caudal septum

OverrotatedOverrotated (Short Nose)(Short Nose)

ManagementManagementndashndash Caudal Caudal septalseptal

extension graftextension graftndashndash Minor deformities Minor deformities

ColumellarColumellarplumping graftsplumping grafts

Tip Definition

Common presenting situationsndash Boulbus Tipndash Pinch tip

Decrease nasal tip definition

ndash Wide interdomal distance

ndash Wide domes

ndash Weak alar cartilage

ndashndash Thick amp inelastic skinThick amp inelastic skin

Bulbous TipBulbous Tip

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Suture techniqueSuture technique

ndashndash The The TransdomalTransdomal SutureSutureMattress sutureMattress sutureTip narrowingTip narrowing

ndashndash Narrows Narrows domaldomal archarch

Increased tip projectionIncreased tip projection

ndashndash Medial Medial CruraCrura Suture Suture ndash Interdomal Suture

DefinitionDefinition

Dome division with binding suturendash Narrows the nasal tip

Narrowing the domal arch

ndash Increase tip projection

Management of Bulbous TipManagement of Bulbous Tip

DefinitionDefinition

Pinched TipPinched Tip

Excessive narrowing of the domesExcessive narrowing of the domesndashndash Excessive tightening of Excessive tightening of domaldomal suturessuturesndashndash Dome divisionDome division

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

The lateral The lateral cruracrura suturesuturendashndash Horizontal mattress Horizontal mattress

suture (cephalic)suture (cephalic)ndashndash Narrows tipNarrows tip

Decreased convexity of Decreased convexity of the lateral the lateral cruracrura

ndashndash Decreased Decreased interdomalinterdomaldistancedistance

ndashndash Caudal repositioning of Caudal repositioning of the domesthe domes

ndashndash Nose is elongatedNose is elongated

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Cephalic trim

DefinitionDefinition

Lateral nasal wall weaknessLateral nasal wall weakness

AlarAlar cartilage weakeningcartilage weakeningndashndash Aggressive cephalic trimAggressive cephalic trimndashndash Cephalic positioning of the Cephalic positioning of the

lateral lateral cruracrura

External Valve collapseExternal Valve collapse

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Shield graftShield graftndashndash Provide augmentation Provide augmentation

to the tipto the tipndashndash Protrudes into thick Protrudes into thick

skinskinndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

DefinitionDefinition

Projection

Link to rotation and definitionSimilar techniquesCommon presenting situationndash Pollybeak

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

Interrupted Stripndash Spring-tension of

LLC is release and significant rotation can occur

ndash Sacrifices major tip support mechanism may darr tip projection

Lateral crura surgery

PtoticPtotic tiptip

Lateral crura surgery

Resuturingndash Lateral Crural Overlay Technique increases

rotation and decreases projection

PtoticPtotic tiptip

Onlay cartilaginous tip graft

PtoticPtotic tiptip

Rotation Rotation OverrotatedOverrotated (Short (Short Nose)Nose)

Excessive cephalic trim of the lateral Excessive cephalic trim of the lateral cruracruraOverresectionOverresection of the caudal septumof the caudal septum

OverrotatedOverrotated (Short Nose)(Short Nose)

ManagementManagementndashndash Caudal Caudal septalseptal

extension graftextension graftndashndash Minor deformities Minor deformities

ColumellarColumellarplumping graftsplumping grafts

Tip Definition

Common presenting situationsndash Boulbus Tipndash Pinch tip

Decrease nasal tip definition

ndash Wide interdomal distance

ndash Wide domes

ndash Weak alar cartilage

ndashndash Thick amp inelastic skinThick amp inelastic skin

Bulbous TipBulbous Tip

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Suture techniqueSuture technique

ndashndash The The TransdomalTransdomal SutureSutureMattress sutureMattress sutureTip narrowingTip narrowing

ndashndash Narrows Narrows domaldomal archarch

Increased tip projectionIncreased tip projection

ndashndash Medial Medial CruraCrura Suture Suture ndash Interdomal Suture

DefinitionDefinition

Dome division with binding suturendash Narrows the nasal tip

Narrowing the domal arch

ndash Increase tip projection

Management of Bulbous TipManagement of Bulbous Tip

DefinitionDefinition

Pinched TipPinched Tip

Excessive narrowing of the domesExcessive narrowing of the domesndashndash Excessive tightening of Excessive tightening of domaldomal suturessuturesndashndash Dome divisionDome division

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

The lateral The lateral cruracrura suturesuturendashndash Horizontal mattress Horizontal mattress

suture (cephalic)suture (cephalic)ndashndash Narrows tipNarrows tip

Decreased convexity of Decreased convexity of the lateral the lateral cruracrura

ndashndash Decreased Decreased interdomalinterdomaldistancedistance

ndashndash Caudal repositioning of Caudal repositioning of the domesthe domes

ndashndash Nose is elongatedNose is elongated

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Cephalic trim

DefinitionDefinition

Lateral nasal wall weaknessLateral nasal wall weakness

AlarAlar cartilage weakeningcartilage weakeningndashndash Aggressive cephalic trimAggressive cephalic trimndashndash Cephalic positioning of the Cephalic positioning of the

lateral lateral cruracrura

External Valve collapseExternal Valve collapse

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Shield graftShield graftndashndash Provide augmentation Provide augmentation

to the tipto the tipndashndash Protrudes into thick Protrudes into thick

skinskinndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

DefinitionDefinition

Projection

Link to rotation and definitionSimilar techniquesCommon presenting situationndash Pollybeak

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

Lateral crura surgery

Resuturingndash Lateral Crural Overlay Technique increases

rotation and decreases projection

PtoticPtotic tiptip

Onlay cartilaginous tip graft

PtoticPtotic tiptip

Rotation Rotation OverrotatedOverrotated (Short (Short Nose)Nose)

Excessive cephalic trim of the lateral Excessive cephalic trim of the lateral cruracruraOverresectionOverresection of the caudal septumof the caudal septum

OverrotatedOverrotated (Short Nose)(Short Nose)

ManagementManagementndashndash Caudal Caudal septalseptal

extension graftextension graftndashndash Minor deformities Minor deformities

ColumellarColumellarplumping graftsplumping grafts

Tip Definition

Common presenting situationsndash Boulbus Tipndash Pinch tip

Decrease nasal tip definition

ndash Wide interdomal distance

ndash Wide domes

ndash Weak alar cartilage

ndashndash Thick amp inelastic skinThick amp inelastic skin

Bulbous TipBulbous Tip

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Suture techniqueSuture technique

ndashndash The The TransdomalTransdomal SutureSutureMattress sutureMattress sutureTip narrowingTip narrowing

ndashndash Narrows Narrows domaldomal archarch

Increased tip projectionIncreased tip projection

ndashndash Medial Medial CruraCrura Suture Suture ndash Interdomal Suture

DefinitionDefinition

Dome division with binding suturendash Narrows the nasal tip

Narrowing the domal arch

ndash Increase tip projection

Management of Bulbous TipManagement of Bulbous Tip

DefinitionDefinition

Pinched TipPinched Tip

Excessive narrowing of the domesExcessive narrowing of the domesndashndash Excessive tightening of Excessive tightening of domaldomal suturessuturesndashndash Dome divisionDome division

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

The lateral The lateral cruracrura suturesuturendashndash Horizontal mattress Horizontal mattress

suture (cephalic)suture (cephalic)ndashndash Narrows tipNarrows tip

Decreased convexity of Decreased convexity of the lateral the lateral cruracrura

ndashndash Decreased Decreased interdomalinterdomaldistancedistance

ndashndash Caudal repositioning of Caudal repositioning of the domesthe domes

ndashndash Nose is elongatedNose is elongated

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Cephalic trim

DefinitionDefinition

Lateral nasal wall weaknessLateral nasal wall weakness

AlarAlar cartilage weakeningcartilage weakeningndashndash Aggressive cephalic trimAggressive cephalic trimndashndash Cephalic positioning of the Cephalic positioning of the

lateral lateral cruracrura

External Valve collapseExternal Valve collapse

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Shield graftShield graftndashndash Provide augmentation Provide augmentation

to the tipto the tipndashndash Protrudes into thick Protrudes into thick

skinskinndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

DefinitionDefinition

Projection

Link to rotation and definitionSimilar techniquesCommon presenting situationndash Pollybeak

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

Onlay cartilaginous tip graft

PtoticPtotic tiptip

Rotation Rotation OverrotatedOverrotated (Short (Short Nose)Nose)

Excessive cephalic trim of the lateral Excessive cephalic trim of the lateral cruracruraOverresectionOverresection of the caudal septumof the caudal septum

OverrotatedOverrotated (Short Nose)(Short Nose)

ManagementManagementndashndash Caudal Caudal septalseptal

extension graftextension graftndashndash Minor deformities Minor deformities

ColumellarColumellarplumping graftsplumping grafts

Tip Definition

Common presenting situationsndash Boulbus Tipndash Pinch tip

Decrease nasal tip definition

ndash Wide interdomal distance

ndash Wide domes

ndash Weak alar cartilage

ndashndash Thick amp inelastic skinThick amp inelastic skin

Bulbous TipBulbous Tip

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Suture techniqueSuture technique

ndashndash The The TransdomalTransdomal SutureSutureMattress sutureMattress sutureTip narrowingTip narrowing

ndashndash Narrows Narrows domaldomal archarch

Increased tip projectionIncreased tip projection

ndashndash Medial Medial CruraCrura Suture Suture ndash Interdomal Suture

DefinitionDefinition

Dome division with binding suturendash Narrows the nasal tip

Narrowing the domal arch

ndash Increase tip projection

Management of Bulbous TipManagement of Bulbous Tip

DefinitionDefinition

Pinched TipPinched Tip

Excessive narrowing of the domesExcessive narrowing of the domesndashndash Excessive tightening of Excessive tightening of domaldomal suturessuturesndashndash Dome divisionDome division

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

The lateral The lateral cruracrura suturesuturendashndash Horizontal mattress Horizontal mattress

suture (cephalic)suture (cephalic)ndashndash Narrows tipNarrows tip

Decreased convexity of Decreased convexity of the lateral the lateral cruracrura

ndashndash Decreased Decreased interdomalinterdomaldistancedistance

ndashndash Caudal repositioning of Caudal repositioning of the domesthe domes

ndashndash Nose is elongatedNose is elongated

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Cephalic trim

DefinitionDefinition

Lateral nasal wall weaknessLateral nasal wall weakness

AlarAlar cartilage weakeningcartilage weakeningndashndash Aggressive cephalic trimAggressive cephalic trimndashndash Cephalic positioning of the Cephalic positioning of the

lateral lateral cruracrura

External Valve collapseExternal Valve collapse

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Shield graftShield graftndashndash Provide augmentation Provide augmentation

to the tipto the tipndashndash Protrudes into thick Protrudes into thick

skinskinndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

DefinitionDefinition

Projection

Link to rotation and definitionSimilar techniquesCommon presenting situationndash Pollybeak

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

Rotation Rotation OverrotatedOverrotated (Short (Short Nose)Nose)

Excessive cephalic trim of the lateral Excessive cephalic trim of the lateral cruracruraOverresectionOverresection of the caudal septumof the caudal septum

OverrotatedOverrotated (Short Nose)(Short Nose)

ManagementManagementndashndash Caudal Caudal septalseptal

extension graftextension graftndashndash Minor deformities Minor deformities

ColumellarColumellarplumping graftsplumping grafts

Tip Definition

Common presenting situationsndash Boulbus Tipndash Pinch tip

Decrease nasal tip definition

ndash Wide interdomal distance

ndash Wide domes

ndash Weak alar cartilage

ndashndash Thick amp inelastic skinThick amp inelastic skin

Bulbous TipBulbous Tip

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Suture techniqueSuture technique

ndashndash The The TransdomalTransdomal SutureSutureMattress sutureMattress sutureTip narrowingTip narrowing

ndashndash Narrows Narrows domaldomal archarch

Increased tip projectionIncreased tip projection

ndashndash Medial Medial CruraCrura Suture Suture ndash Interdomal Suture

DefinitionDefinition

Dome division with binding suturendash Narrows the nasal tip

Narrowing the domal arch

ndash Increase tip projection

Management of Bulbous TipManagement of Bulbous Tip

DefinitionDefinition

Pinched TipPinched Tip

Excessive narrowing of the domesExcessive narrowing of the domesndashndash Excessive tightening of Excessive tightening of domaldomal suturessuturesndashndash Dome divisionDome division

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

The lateral The lateral cruracrura suturesuturendashndash Horizontal mattress Horizontal mattress

suture (cephalic)suture (cephalic)ndashndash Narrows tipNarrows tip

Decreased convexity of Decreased convexity of the lateral the lateral cruracrura

ndashndash Decreased Decreased interdomalinterdomaldistancedistance

ndashndash Caudal repositioning of Caudal repositioning of the domesthe domes

ndashndash Nose is elongatedNose is elongated

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Cephalic trim

DefinitionDefinition

Lateral nasal wall weaknessLateral nasal wall weakness

AlarAlar cartilage weakeningcartilage weakeningndashndash Aggressive cephalic trimAggressive cephalic trimndashndash Cephalic positioning of the Cephalic positioning of the

lateral lateral cruracrura

External Valve collapseExternal Valve collapse

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Shield graftShield graftndashndash Provide augmentation Provide augmentation

to the tipto the tipndashndash Protrudes into thick Protrudes into thick

skinskinndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

DefinitionDefinition

Projection

Link to rotation and definitionSimilar techniquesCommon presenting situationndash Pollybeak

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

OverrotatedOverrotated (Short Nose)(Short Nose)

ManagementManagementndashndash Caudal Caudal septalseptal

extension graftextension graftndashndash Minor deformities Minor deformities

ColumellarColumellarplumping graftsplumping grafts

Tip Definition

Common presenting situationsndash Boulbus Tipndash Pinch tip

Decrease nasal tip definition

ndash Wide interdomal distance

ndash Wide domes

ndash Weak alar cartilage

ndashndash Thick amp inelastic skinThick amp inelastic skin

Bulbous TipBulbous Tip

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Suture techniqueSuture technique

ndashndash The The TransdomalTransdomal SutureSutureMattress sutureMattress sutureTip narrowingTip narrowing

ndashndash Narrows Narrows domaldomal archarch

Increased tip projectionIncreased tip projection

ndashndash Medial Medial CruraCrura Suture Suture ndash Interdomal Suture

DefinitionDefinition

Dome division with binding suturendash Narrows the nasal tip

Narrowing the domal arch

ndash Increase tip projection

Management of Bulbous TipManagement of Bulbous Tip

DefinitionDefinition

Pinched TipPinched Tip

Excessive narrowing of the domesExcessive narrowing of the domesndashndash Excessive tightening of Excessive tightening of domaldomal suturessuturesndashndash Dome divisionDome division

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

The lateral The lateral cruracrura suturesuturendashndash Horizontal mattress Horizontal mattress

suture (cephalic)suture (cephalic)ndashndash Narrows tipNarrows tip

Decreased convexity of Decreased convexity of the lateral the lateral cruracrura

ndashndash Decreased Decreased interdomalinterdomaldistancedistance

ndashndash Caudal repositioning of Caudal repositioning of the domesthe domes

ndashndash Nose is elongatedNose is elongated

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Cephalic trim

DefinitionDefinition

Lateral nasal wall weaknessLateral nasal wall weakness

AlarAlar cartilage weakeningcartilage weakeningndashndash Aggressive cephalic trimAggressive cephalic trimndashndash Cephalic positioning of the Cephalic positioning of the

lateral lateral cruracrura

External Valve collapseExternal Valve collapse

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Shield graftShield graftndashndash Provide augmentation Provide augmentation

to the tipto the tipndashndash Protrudes into thick Protrudes into thick

skinskinndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

DefinitionDefinition

Projection

Link to rotation and definitionSimilar techniquesCommon presenting situationndash Pollybeak

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

Tip Definition

Common presenting situationsndash Boulbus Tipndash Pinch tip

Decrease nasal tip definition

ndash Wide interdomal distance

ndash Wide domes

ndash Weak alar cartilage

ndashndash Thick amp inelastic skinThick amp inelastic skin

Bulbous TipBulbous Tip

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Suture techniqueSuture technique

ndashndash The The TransdomalTransdomal SutureSutureMattress sutureMattress sutureTip narrowingTip narrowing

ndashndash Narrows Narrows domaldomal archarch

Increased tip projectionIncreased tip projection

ndashndash Medial Medial CruraCrura Suture Suture ndash Interdomal Suture

DefinitionDefinition

Dome division with binding suturendash Narrows the nasal tip

Narrowing the domal arch

ndash Increase tip projection

Management of Bulbous TipManagement of Bulbous Tip

DefinitionDefinition

Pinched TipPinched Tip

Excessive narrowing of the domesExcessive narrowing of the domesndashndash Excessive tightening of Excessive tightening of domaldomal suturessuturesndashndash Dome divisionDome division

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

The lateral The lateral cruracrura suturesuturendashndash Horizontal mattress Horizontal mattress

suture (cephalic)suture (cephalic)ndashndash Narrows tipNarrows tip

Decreased convexity of Decreased convexity of the lateral the lateral cruracrura

ndashndash Decreased Decreased interdomalinterdomaldistancedistance

ndashndash Caudal repositioning of Caudal repositioning of the domesthe domes

ndashndash Nose is elongatedNose is elongated

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Cephalic trim

DefinitionDefinition

Lateral nasal wall weaknessLateral nasal wall weakness

AlarAlar cartilage weakeningcartilage weakeningndashndash Aggressive cephalic trimAggressive cephalic trimndashndash Cephalic positioning of the Cephalic positioning of the

lateral lateral cruracrura

External Valve collapseExternal Valve collapse

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Shield graftShield graftndashndash Provide augmentation Provide augmentation

to the tipto the tipndashndash Protrudes into thick Protrudes into thick

skinskinndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

DefinitionDefinition

Projection

Link to rotation and definitionSimilar techniquesCommon presenting situationndash Pollybeak

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

Decrease nasal tip definition

ndash Wide interdomal distance

ndash Wide domes

ndash Weak alar cartilage

ndashndash Thick amp inelastic skinThick amp inelastic skin

Bulbous TipBulbous Tip

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Suture techniqueSuture technique

ndashndash The The TransdomalTransdomal SutureSutureMattress sutureMattress sutureTip narrowingTip narrowing

ndashndash Narrows Narrows domaldomal archarch

Increased tip projectionIncreased tip projection

ndashndash Medial Medial CruraCrura Suture Suture ndash Interdomal Suture

DefinitionDefinition

Dome division with binding suturendash Narrows the nasal tip

Narrowing the domal arch

ndash Increase tip projection

Management of Bulbous TipManagement of Bulbous Tip

DefinitionDefinition

Pinched TipPinched Tip

Excessive narrowing of the domesExcessive narrowing of the domesndashndash Excessive tightening of Excessive tightening of domaldomal suturessuturesndashndash Dome divisionDome division

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

The lateral The lateral cruracrura suturesuturendashndash Horizontal mattress Horizontal mattress

suture (cephalic)suture (cephalic)ndashndash Narrows tipNarrows tip

Decreased convexity of Decreased convexity of the lateral the lateral cruracrura

ndashndash Decreased Decreased interdomalinterdomaldistancedistance

ndashndash Caudal repositioning of Caudal repositioning of the domesthe domes

ndashndash Nose is elongatedNose is elongated

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Cephalic trim

DefinitionDefinition

Lateral nasal wall weaknessLateral nasal wall weakness

AlarAlar cartilage weakeningcartilage weakeningndashndash Aggressive cephalic trimAggressive cephalic trimndashndash Cephalic positioning of the Cephalic positioning of the

lateral lateral cruracrura

External Valve collapseExternal Valve collapse

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Shield graftShield graftndashndash Provide augmentation Provide augmentation

to the tipto the tipndashndash Protrudes into thick Protrudes into thick

skinskinndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

DefinitionDefinition

Projection

Link to rotation and definitionSimilar techniquesCommon presenting situationndash Pollybeak

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

Management of Bulbous TipManagement of Bulbous Tip

Suture techniqueSuture technique

ndashndash The The TransdomalTransdomal SutureSutureMattress sutureMattress sutureTip narrowingTip narrowing

ndashndash Narrows Narrows domaldomal archarch

Increased tip projectionIncreased tip projection

ndashndash Medial Medial CruraCrura Suture Suture ndash Interdomal Suture

DefinitionDefinition

Dome division with binding suturendash Narrows the nasal tip

Narrowing the domal arch

ndash Increase tip projection

Management of Bulbous TipManagement of Bulbous Tip

DefinitionDefinition

Pinched TipPinched Tip

Excessive narrowing of the domesExcessive narrowing of the domesndashndash Excessive tightening of Excessive tightening of domaldomal suturessuturesndashndash Dome divisionDome division

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

The lateral The lateral cruracrura suturesuturendashndash Horizontal mattress Horizontal mattress

suture (cephalic)suture (cephalic)ndashndash Narrows tipNarrows tip

Decreased convexity of Decreased convexity of the lateral the lateral cruracrura

ndashndash Decreased Decreased interdomalinterdomaldistancedistance

ndashndash Caudal repositioning of Caudal repositioning of the domesthe domes

ndashndash Nose is elongatedNose is elongated

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Cephalic trim

DefinitionDefinition

Lateral nasal wall weaknessLateral nasal wall weakness

AlarAlar cartilage weakeningcartilage weakeningndashndash Aggressive cephalic trimAggressive cephalic trimndashndash Cephalic positioning of the Cephalic positioning of the

lateral lateral cruracrura

External Valve collapseExternal Valve collapse

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Shield graftShield graftndashndash Provide augmentation Provide augmentation

to the tipto the tipndashndash Protrudes into thick Protrudes into thick

skinskinndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

DefinitionDefinition

Projection

Link to rotation and definitionSimilar techniquesCommon presenting situationndash Pollybeak

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

Dome division with binding suturendash Narrows the nasal tip

Narrowing the domal arch

ndash Increase tip projection

Management of Bulbous TipManagement of Bulbous Tip

DefinitionDefinition

Pinched TipPinched Tip

Excessive narrowing of the domesExcessive narrowing of the domesndashndash Excessive tightening of Excessive tightening of domaldomal suturessuturesndashndash Dome divisionDome division

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

The lateral The lateral cruracrura suturesuturendashndash Horizontal mattress Horizontal mattress

suture (cephalic)suture (cephalic)ndashndash Narrows tipNarrows tip

Decreased convexity of Decreased convexity of the lateral the lateral cruracrura

ndashndash Decreased Decreased interdomalinterdomaldistancedistance

ndashndash Caudal repositioning of Caudal repositioning of the domesthe domes

ndashndash Nose is elongatedNose is elongated

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Cephalic trim

DefinitionDefinition

Lateral nasal wall weaknessLateral nasal wall weakness

AlarAlar cartilage weakeningcartilage weakeningndashndash Aggressive cephalic trimAggressive cephalic trimndashndash Cephalic positioning of the Cephalic positioning of the

lateral lateral cruracrura

External Valve collapseExternal Valve collapse

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Shield graftShield graftndashndash Provide augmentation Provide augmentation

to the tipto the tipndashndash Protrudes into thick Protrudes into thick

skinskinndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

DefinitionDefinition

Projection

Link to rotation and definitionSimilar techniquesCommon presenting situationndash Pollybeak

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

Pinched TipPinched Tip

Excessive narrowing of the domesExcessive narrowing of the domesndashndash Excessive tightening of Excessive tightening of domaldomal suturessuturesndashndash Dome divisionDome division

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

The lateral The lateral cruracrura suturesuturendashndash Horizontal mattress Horizontal mattress

suture (cephalic)suture (cephalic)ndashndash Narrows tipNarrows tip

Decreased convexity of Decreased convexity of the lateral the lateral cruracrura

ndashndash Decreased Decreased interdomalinterdomaldistancedistance

ndashndash Caudal repositioning of Caudal repositioning of the domesthe domes

ndashndash Nose is elongatedNose is elongated

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Cephalic trim

DefinitionDefinition

Lateral nasal wall weaknessLateral nasal wall weakness

AlarAlar cartilage weakeningcartilage weakeningndashndash Aggressive cephalic trimAggressive cephalic trimndashndash Cephalic positioning of the Cephalic positioning of the

lateral lateral cruracrura

External Valve collapseExternal Valve collapse

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Shield graftShield graftndashndash Provide augmentation Provide augmentation

to the tipto the tipndashndash Protrudes into thick Protrudes into thick

skinskinndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

DefinitionDefinition

Projection

Link to rotation and definitionSimilar techniquesCommon presenting situationndash Pollybeak

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

Management of Bulbous TipManagement of Bulbous Tip

The lateral The lateral cruracrura suturesuturendashndash Horizontal mattress Horizontal mattress

suture (cephalic)suture (cephalic)ndashndash Narrows tipNarrows tip

Decreased convexity of Decreased convexity of the lateral the lateral cruracrura

ndashndash Decreased Decreased interdomalinterdomaldistancedistance

ndashndash Caudal repositioning of Caudal repositioning of the domesthe domes

ndashndash Nose is elongatedNose is elongated

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Cephalic trim

DefinitionDefinition

Lateral nasal wall weaknessLateral nasal wall weakness

AlarAlar cartilage weakeningcartilage weakeningndashndash Aggressive cephalic trimAggressive cephalic trimndashndash Cephalic positioning of the Cephalic positioning of the

lateral lateral cruracrura

External Valve collapseExternal Valve collapse

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Shield graftShield graftndashndash Provide augmentation Provide augmentation

to the tipto the tipndashndash Protrudes into thick Protrudes into thick

skinskinndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

DefinitionDefinition

Projection

Link to rotation and definitionSimilar techniquesCommon presenting situationndash Pollybeak

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

Management of Bulbous TipManagement of Bulbous Tip

Cephalic trim

DefinitionDefinition

Lateral nasal wall weaknessLateral nasal wall weakness

AlarAlar cartilage weakeningcartilage weakeningndashndash Aggressive cephalic trimAggressive cephalic trimndashndash Cephalic positioning of the Cephalic positioning of the

lateral lateral cruracrura

External Valve collapseExternal Valve collapse

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Shield graftShield graftndashndash Provide augmentation Provide augmentation

to the tipto the tipndashndash Protrudes into thick Protrudes into thick

skinskinndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

DefinitionDefinition

Projection

Link to rotation and definitionSimilar techniquesCommon presenting situationndash Pollybeak

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

Lateral nasal wall weaknessLateral nasal wall weakness

AlarAlar cartilage weakeningcartilage weakeningndashndash Aggressive cephalic trimAggressive cephalic trimndashndash Cephalic positioning of the Cephalic positioning of the

lateral lateral cruracrura

External Valve collapseExternal Valve collapse

DefinitionDefinition

Management of Bulbous TipManagement of Bulbous Tip

Shield graftShield graftndashndash Provide augmentation Provide augmentation

to the tipto the tipndashndash Protrudes into thick Protrudes into thick

skinskinndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

DefinitionDefinition

Projection

Link to rotation and definitionSimilar techniquesCommon presenting situationndash Pollybeak

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

Management of Bulbous TipManagement of Bulbous Tip

Shield graftShield graftndashndash Provide augmentation Provide augmentation

to the tipto the tipndashndash Protrudes into thick Protrudes into thick

skinskinndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

DefinitionDefinition

Projection

Link to rotation and definitionSimilar techniquesCommon presenting situationndash Pollybeak

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

Projection

Link to rotation and definitionSimilar techniquesCommon presenting situationndash Pollybeak

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

Projection

Suture techniquesSuture techniquesndashndash Medial Medial CruraCrura SutureSuture

ndashndash TransdomalTransdomal SutureSuture

ndashndash InterdomalInterdomal Suture Suture

ndashndash Dome division with Dome division with binding suturesbinding sutures

Steal techniquendash Increase tip projectionndash Narrows the nasal tip

ProjectionProjection

Projection

Medial Medial CruraCrura--SeptalSeptalSutureSuturendashndash Change tip Change tip

projectionprojectionndashndash May change May change

rotationrotationndashndash Restore tip Restore tip

supportsupport

Projection

Shield graftShield graftndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

CollumelarCollumelar strutstrut

Projection

Depressor SeptiNasi Musclendash Decrease tip

projection by pulling the tip caudally and posteriorly

ndash Nasal tip ptosisndash Resection of the

muscle

Projection

Medial Medial CruraCrura--SeptalSeptalSutureSuturendashndash Change tip Change tip

projectionprojectionndashndash May change May change

rotationrotationndashndash Restore tip Restore tip

supportsupport

Projection

Shield graftShield graftndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

CollumelarCollumelar strutstrut

Projection

Depressor SeptiNasi Musclendash Decrease tip

projection by pulling the tip caudally and posteriorly

ndash Nasal tip ptosisndash Resection of the

muscle

Projection

Shield graftShield graftndashndash Increase projection by Increase projection by

as much as 8 mmas much as 8 mm

CollumelarCollumelar strutstrut

Projection

Depressor SeptiNasi Musclendash Decrease tip

projection by pulling the tip caudally and posteriorly

ndash Nasal tip ptosisndash Resection of the

muscle

Projection

Depressor SeptiNasi Musclendash Decrease tip

projection by pulling the tip caudally and posteriorly

ndash Nasal tip ptosisndash Resection of the

muscle

PollybeakPollybeak

ParkesParkes--1992 Vuyk1992 Vuyk--20002000ndashndash Most common deformity Most common deformity

after after rhinoplastyrhinoplasty

Convexity of the nasal Convexity of the nasal supratipsupratipndashndash Projecting beyond the tip Projecting beyond the tip

and the rest of the nose and the rest of the nose (parrot(parrotrsquorsquos beak)s beak)

Projection

Management of Management of PollybeakPollybeak

Restore tip supportRestore tip supportIncrease tip Increase tip projectionprojection

Projection

Illusion of Increased tip Projectionndash Removal of Dorsal

Hump

Over-projected

Reduction of Tip Projectionndash Sacrifice major tip support mechanismsndash Medial crura-septal suturendash Lateral Crural resection with resuturing

Illusion of decrease tip Projectionndash Chin implant

Conclusion

Precise assessment of the deformityPrecise assessment of the deformityndashndash Preoperative amp Preoperative amp intraoperativeintraoperative

Preserve or restore nasal support Preserve or restore nasal support mechanismsmechanismsKnowledge of individual and additive Knowledge of individual and additive effects of tipeffects of tip--modification maneuversmodification maneuvers

• Rhinoplasty- Nasal Tip
• History of Rhinoplasty
• History of Modern Rhinoplasty
• Introduction
• Pre-Op Assessment
• External Valve Collapse
• Palpation of the nose
• Tip support- Test Tip Recoil
• Photographic Documentation
• Frankfort line
• Nasal Tip
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Computer Image Modification Programs
• Nasal Skin-Soft Tissue Envelope (SSTE)
• Nasal Skin-Soft Tissue Envelope (SSTE)
• Surgical Approach
• Nasal Tip
• Tripod theory
• Tip Rotation
• Ptotic Tip
• Ptotic Tip
• Management of Ptotic Tip
• Medial Crura Surgery
• Medial Crura Surgery
• Medial Crura Surgery
• Lateral crura surgery
• Cephalic Trim
• Cephalic Trim
• Lateral crura surgery
• Lateral crura surgery
• Lateral crura surgery
• Onlay cartilaginous tip graft
• Rotation Overrotated (Short Nose)
• Overrotated (Short Nose)
• Tip Definition
• Management of Bulbous Tip
• Management of Bulbous Tip
• Pinched Tip
• Management of Bulbous Tip
• Management of Bulbous Tip
• Lateral nasal wall weakness
• Management of Bulbous Tip
• Projection
• Projection
• Projection
• Projection
• Projection
• Projection
• Pollybeak
• Management of Pollybeak
• Projection
• Over-projected
• Conclusion

Management of Management of PollybeakPollybeak

Restore tip supportRestore tip supportIncrease tip Increase tip projectionprojection

Projection

Illusion of Increased tip Projectionndash Removal of Dorsal

Hump

Over-projected

Reduction of Tip Projectionndash Sacrifice major tip support mechanismsndash Medial crura-septal suturendash Lateral Crural resection with resuturing

Illusion of decrease tip Projectionndash Chin implant

Conclusion

Precise assessment of the deformityPrecise assessment of the deformityndashndash Preoperative amp Preoperative amp intraoperativeintraoperative

Preserve or restore nasal support Preserve or restore nasal support mechanismsmechanismsKnowledge of individual and additive Knowledge of individual and additive effects of tipeffects of tip--modification maneuversmodification maneuvers

• Rhinoplasty- Nasal Tip
• History of Rhinoplasty
• History of Modern Rhinoplasty
• Introduction
• Pre-Op Assessment
• External Valve Collapse
• Palpation of the nose
• Tip support- Test Tip Recoil
• Photographic Documentation
• Frankfort line
• Nasal Tip
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Computer Image Modification Programs
• Nasal Skin-Soft Tissue Envelope (SSTE)
• Nasal Skin-Soft Tissue Envelope (SSTE)
• Surgical Approach
• Nasal Tip
• Tripod theory
• Tip Rotation
• Ptotic Tip
• Ptotic Tip
• Management of Ptotic Tip
• Medial Crura Surgery
• Medial Crura Surgery
• Medial Crura Surgery
• Lateral crura surgery
• Cephalic Trim
• Cephalic Trim
• Lateral crura surgery
• Lateral crura surgery
• Lateral crura surgery
• Onlay cartilaginous tip graft
• Rotation Overrotated (Short Nose)
• Overrotated (Short Nose)
• Tip Definition
• Management of Bulbous Tip
• Management of Bulbous Tip
• Pinched Tip
• Management of Bulbous Tip
• Management of Bulbous Tip
• Lateral nasal wall weakness
• Management of Bulbous Tip
• Projection
• Projection
• Projection
• Projection
• Projection
• Projection
• Pollybeak
• Management of Pollybeak
• Projection
• Over-projected
• Conclusion

Projection

Illusion of Increased tip Projectionndash Removal of Dorsal

Hump

Over-projected

Reduction of Tip Projectionndash Sacrifice major tip support mechanismsndash Medial crura-septal suturendash Lateral Crural resection with resuturing

Illusion of decrease tip Projectionndash Chin implant

Conclusion

Precise assessment of the deformityPrecise assessment of the deformityndashndash Preoperative amp Preoperative amp intraoperativeintraoperative

Preserve or restore nasal support Preserve or restore nasal support mechanismsmechanismsKnowledge of individual and additive Knowledge of individual and additive effects of tipeffects of tip--modification maneuversmodification maneuvers

• Rhinoplasty- Nasal Tip
• History of Rhinoplasty
• History of Modern Rhinoplasty
• Introduction
• Pre-Op Assessment
• External Valve Collapse
• Palpation of the nose
• Tip support- Test Tip Recoil
• Photographic Documentation
• Frankfort line
• Nasal Tip
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Computer Image Modification Programs
• Nasal Skin-Soft Tissue Envelope (SSTE)
• Nasal Skin-Soft Tissue Envelope (SSTE)
• Surgical Approach
• Nasal Tip
• Tripod theory
• Tip Rotation
• Ptotic Tip
• Ptotic Tip
• Management of Ptotic Tip
• Medial Crura Surgery
• Medial Crura Surgery
• Medial Crura Surgery
• Lateral crura surgery
• Cephalic Trim
• Cephalic Trim
• Lateral crura surgery
• Lateral crura surgery
• Lateral crura surgery
• Onlay cartilaginous tip graft
• Rotation Overrotated (Short Nose)
• Overrotated (Short Nose)
• Tip Definition
• Management of Bulbous Tip
• Management of Bulbous Tip
• Pinched Tip
• Management of Bulbous Tip
• Management of Bulbous Tip
• Lateral nasal wall weakness
• Management of Bulbous Tip
• Projection
• Projection
• Projection
• Projection
• Projection
• Projection
• Pollybeak
• Management of Pollybeak
• Projection
• Over-projected
• Conclusion

Over-projected

Reduction of Tip Projectionndash Sacrifice major tip support mechanismsndash Medial crura-septal suturendash Lateral Crural resection with resuturing

Illusion of decrease tip Projectionndash Chin implant

Conclusion

Precise assessment of the deformityPrecise assessment of the deformityndashndash Preoperative amp Preoperative amp intraoperativeintraoperative

Preserve or restore nasal support Preserve or restore nasal support mechanismsmechanismsKnowledge of individual and additive Knowledge of individual and additive effects of tipeffects of tip--modification maneuversmodification maneuvers

• Rhinoplasty- Nasal Tip
• History of Rhinoplasty
• History of Modern Rhinoplasty
• Introduction
• Pre-Op Assessment
• External Valve Collapse
• Palpation of the nose
• Tip support- Test Tip Recoil
• Photographic Documentation
• Frankfort line
• Nasal Tip
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Computer Image Modification Programs
• Nasal Skin-Soft Tissue Envelope (SSTE)
• Nasal Skin-Soft Tissue Envelope (SSTE)
• Surgical Approach
• Nasal Tip
• Tripod theory
• Tip Rotation
• Ptotic Tip
• Ptotic Tip
• Management of Ptotic Tip
• Medial Crura Surgery
• Medial Crura Surgery
• Medial Crura Surgery
• Lateral crura surgery
• Cephalic Trim
• Cephalic Trim
• Lateral crura surgery
• Lateral crura surgery
• Lateral crura surgery
• Onlay cartilaginous tip graft
• Rotation Overrotated (Short Nose)
• Overrotated (Short Nose)
• Tip Definition
• Management of Bulbous Tip
• Management of Bulbous Tip
• Pinched Tip
• Management of Bulbous Tip
• Management of Bulbous Tip
• Lateral nasal wall weakness
• Management of Bulbous Tip
• Projection
• Projection
• Projection
• Projection
• Projection
• Projection
• Pollybeak
• Management of Pollybeak
• Projection
• Over-projected
• Conclusion

Conclusion

Precise assessment of the deformityPrecise assessment of the deformityndashndash Preoperative amp Preoperative amp intraoperativeintraoperative

Preserve or restore nasal support Preserve or restore nasal support mechanismsmechanismsKnowledge of individual and additive Knowledge of individual and additive effects of tipeffects of tip--modification maneuversmodification maneuvers

• Rhinoplasty- Nasal Tip
• History of Rhinoplasty
• History of Modern Rhinoplasty
• Introduction
• Pre-Op Assessment
• External Valve Collapse
• Palpation of the nose
• Tip support- Test Tip Recoil
• Photographic Documentation
• Frankfort line
• Nasal Tip
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Facial Analysis
• Computer Image Modification Programs
• Nasal Skin-Soft Tissue Envelope (SSTE)
• Nasal Skin-Soft Tissue Envelope (SSTE)
• Surgical Approach
• Nasal Tip
• Tripod theory
• Tip Rotation
• Ptotic Tip
• Ptotic Tip
• Management of Ptotic Tip
• Medial Crura Surgery
• Medial Crura Surgery
• Medial Crura Surgery
• Lateral crura surgery
• Cephalic Trim
• Cephalic Trim
• Lateral crura surgery
• Lateral crura surgery
• Lateral crura surgery
• Onlay cartilaginous tip graft
• Rotation Overrotated (Short Nose)
• Overrotated (Short Nose)
• Tip Definition
• Management of Bulbous Tip
• Management of Bulbous Tip
• Pinched Tip
• Management of Bulbous Tip
• Management of Bulbous Tip
• Lateral nasal wall weakness
• Management of Bulbous Tip
• Projection
• Projection
• Projection
• Projection
• Projection
• Projection
• Pollybeak
• Management of Pollybeak
• Projection
• Over-projected
• Conclusion