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Pinched Tip Virginia

One of the tell tale signs of a poorly performed nose job is a “pinched tip.” Although a few patients still desire the pointy, pinched tips of the past, the vast majority of patients seeking Rhinoplasty these days prefer aesthetic, but natural looking nasal tips.

Before we discuss how to correct a pinched tip, with a Revision Rhinoplasty, we need to discuss a few initial facts:

QUESTIONS:

1. What affects the shape of the nasal tip?
2. What changes can be made to the nasal tip during Rhinoplasty, in order to achieve a beautiful, but natural looking tip, and avoid a pinched tip?
3. What wrong surgical maneuvers result in a pinched tip?
4. How does a Rhinoplasty Specialist Surgeon correct a pinched tip during Revision Rhinoplasty?

ANSWERS:
1. Shape of the nasal tip is largely determined by:
a. Shape and size of the two adjacent Lower Lateral Cartilages (LLC)
b. Nose skin & soft tissue thickness, and character
c. Underlying Caudal septum and Anterior Septal Angle
d. Alar skin thickness and integrity

2. There are infinite types and shapes to the nasal tip. No two tips look exactly alike. Even with two very similar looking tips, the surgical maneuvers, required during Rhinoplasty, may be quite different. Some Nasal tips can be characterizes into:
a. Bulbous
b. Boxy
c. Trapezoidal
d. Asymmetric
e. Pointy
f. Amorphous
g. “Meaty”
For example, lets take a large or full nose tip, and discuss some of the various methods to refine it, during Tip Rhinoplasty. This is a very broad topic and an entire textbook can be easily dedicated just to Tip Rhinoplasty, but we shall cover this complex and comprehensive topic in a brief manner here:
One of the most popular techniques for de-bulking and reducing nose tip fullness during Rhinoplasty is the “Cephalic Trim” maneuver. This technique involves reducing the width of the Lower Lateral Cartilages (LLC) at the most crucial point relating to tip fullness. The Rhinoplasty Surgeon will meticulously trim the top (i.e. cephalic) portion of each LLC and leave behind no less than 6 to 8mm of width. What is removed creates a more refined tip. What remains supports the tip and ala.
Cephalic trims of the LLC’s can be done through an Open Rhinoplasty, or Closed Rhinoplasty. Furthermore, either of the two sub-categories of Closed Rhinoplasty can be used to carry out this maneuver: Closed Delivery Rhinoplasty & Closed Non-delivery Rhinoplasty.
In the Open Rhinoplasty, the skin is pulled back, off of the tip, and the cephalic trim is carried out. Sutures can also be placed at the domes to bend and shape the remaining LLC segment into a more favorable shape. Sutures can create the desired curvature and symmetry. In Closed Delivery Rhinoplasty, each of the LLC’s are “delivered” through the nostrils, in essence partially protruding for the surgeon to visualize and carry out the maneuver. Again, domal sutures can be placed after the cephalic trim to bend and shape these cartilages. In a Closed Non-delivery Rhinoplasty, each of the LLC’s are trimmed “in place,” from underneath. This technique does not allow for placement of dome sutures, therefore the Closed Non-delivery Rhinoplasty is ideal for the tip that has nice overall symmetry and shape but is just too wide and would benefit from de-bulking, with the cephalic trim maneuver.

3. The Lower Lateral Cartilages are the framework of the nasal tip. Removing too much cartilage during Rhinoplasty will weaken this framework. Skin draped over this framework can somewhat support itself if thick enough.
“The enemy in Rhinoplasty is scar tissue.” It is unavoidable. Scar tissue forms with every, and all surgeries. Some of it is the glue that holds things together. But excess amounts can distort the results of a nice Rhinoplasty. Scar tissue molds and matures over a two to three year period of time. During this period, the pulling and pushing forces of the scar tissue can create distortions of the nose. It is extremely important for the Rhinoplasty Surgeon to have built a nice strong framework for the nose, that can withstand and counteract these scar tissue healing forces. A nose that has been too aggressively reduced may look good on the operating table, or even at 3 months out from surgery. But almost always, it will look distorted and asymmetric several years later, necessitating a Revision Rhinoplasty
Some of the older techniques in Rhinoplasty, still used by older Plastic Surgeons, as well as their students, included aggressive resection of the Lower Lateral Cartilages. As we discussed before, the skin is an important part of the equation. Aggressive tip cartilage reduction in patients with thin skin always results in pinched and fake looking nose tips. Breathing problems can also occur. On the other hand, thicker skin, in some patients, can “stand on its own” and not collapse or get pinched as easily as thin skin. However, aggressive cartilage reduction, during Rhinoplasty, in patients with thick skin also has its own problems. The space where cartilage was removed, in thick skinned patients, fills with scar tissue. This results in even less definition of the nasal tip, resulting in an amorphous blob rather than a refined tip.

4. In both the thin and thick skinned patients, with over aggressively reduced Lower Lateral Cartilages, the correction of a pinched tip, during Revision Rhinoplasty involves adding and replacing cartilage in the tip. The proper balance has to be restored. The framework has to be re-established. Occasionally this can achieved by a skilled Rhinoplasty Specialist Surgeon through a Closed Revision Rhinoplasty. Precisely shaped cartilages can be placed into precisely shaped “pockets” to provide support. This is common for the nostril margin using alar rim grafts, or soft tissue facet grafts. Grafts can also be placed further away from the nostril margin to support the ala such as alar batten grafts. With more distorted and asymmetric pinched tips, especially in patients with thin skin, Open Revision Rhinoplasty with total lobular reconstruction is necessary. Fascia grafts may also be needed to add slight thickness to the skin to help camouflage cartilage or suture edges during healing.
In summary, beautiful and natural nasal tips are not pinched. Support is key to achieving a non-pinched nasal tip during Rhinoplasty. Support is important in prevention of a pinched tip during Primary Rhinoplasty. Addition of support is an integral part of surgical planning and execution during Revision Rhinoplasty, in correction of a pinched tip.