Nasal Tip Plasty Techniques for Asians

AsianTipPlasty
CHAPTER | 06
I. Basics of nasal tip plasty 1: Tip suture technique
II. The basic of nasal tip plasty 2: Cartilage graft
III. Application of nasal tip plasty 1: Projection
IV. Application of nasal tip plasty 2 : Correction for a blunt nasal tip and long nose
V. Advanced techniqies of the nasal tip plasty : Short nose correction
VI. The causes and solutions for unsatisfactory nasal tip plasty among Asians
ASIANRHINOPLASTY

Nasal tip plasty is the most important part of rhinoplasty, and is an operation that completes rhinoplasty as the
final step. Alar cartilage (lower lateral cartilage) shows great differences in size, shape, and supporting force
depending on race and individual property(Fig. 6-1). Unlike the upper lateral cartilage, alar cartilage is not supported
by nasal septum but supported only by the surrounding soft-tissues. In result, tip drooping occurs when soft-tissues
becomes damaged. If the operator inserts silicone implant into the nasal tip, alar cartilage that is not supported by
nasal septum may not be able to bear the weight and pressure of implant, which can result in polybeak deformity
(Fig. 6-2). Of course, silicone implant located at the tip may add excessive force to the tip having the risk of
protrusion as it penetrates through the skin (Fig. 6-3). Therefore, in order to obtain successful result of nasal tip
plasty, it is necessary to fully understand anatomic features of alar cartilage and soft tissue, their impacts on the
shape of tip, variety of effects of tip plasty, and the expected final result.
We can observe a variety of shapes in the tip of nose from Asians, but generally Asian noses compared with
those of Caucasians are typically found to have thick skin, weak and thin cartilage, retracted columella, and blunt
alar lobule (Fig. 6-4). This adverse feature limits change in the shape of nasal tip, and various methods has been
attempted in order to overcome such limitations. In addition, compared with Caucasians, Asians have different
view of beauty and anatomical structures. For this reason, it is difficult to create the tip of nose with a clear outline
and distinct angle. There’s a great deal of variability between individuals even in the preference of shape. In order
to perform nasal tip plasty, it is important to correctly analyze nasal width, outline, volume, symmetry, rotation,
support, projection, and alar lobule-columelar relation, and necessary to observe them from multilateral aspects;
front side, lateral side, oblique side, and basal side.
Most important factors for Asians, especially Koreans, are rotation and projection. That is, major concerns of
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AsianTipPlasty
ASIAN RHINOPLASTY
CHAPTER | 06

Koreans who want to have rhinoplasty are height of nasal tip and whether the nasal tip is upturned up or not. There
is a great deal of variability between individuals in the preference of volume of the nasal tip. Some people lay stress
on oriental tradition that considers blunt nasal tip as good fortune, but some want to change blunt nasal tip into slim
and refined shape. Therefore, it is necessary to consult the patient about width or volume of nasal tip before
operation, and further to be accustomed to surgical methods that change the volume.
With regard to an ideal tip of nose, it is recommended for the line to be naturally connected from the glabellar
area to the end of nose but in a somewhat round shape on frontal view. In this case, nostrils should not show in
excess and alar rims at both sides need to be in a gentle sea gull shape (Fig. 6-5). In lateral view, it is ideal that alar
rims should not be retracted or hanging so that it properly matches the nasal columella without the length exposed
in 2~4mm (Fig. 6-6). Proper nasolabial angle is 90~95’. And it is recommended that the height of nose occupies
55~60% of the nasal length (Fig. 6-7). At the base, it is ideal to keep not too broad a nasal base, gentle triangular
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ASIANRHINOPLASTY
Fig.6-1 Racialdifferencesofalarcartilageanatomy
a,b : Caucasian alar cartilage is usually large and well developed. c,d: It is not uncommon that Asian alar cartilage is small and weak.
c
a
d
b
Fig.6-2 Polybeakdeformity a: The drooped nose tip as the alar cartilage was pressed by the pressure of the silicone implant, b: Correction made through
silicone replacement and tip revision with columella strut with septal cartilage
a b
Fig.6-3 Extrusionofsiliconeimplantthroughthethinnedtipskin
Implant placement to the nasal tip has a risk of implant exposure through
the skin.
Fig.6-4 CommontipandlobuleinAsiannose
Fig.6-6 IdeallateralviewFig.6-5 NoseshapespreferredamongKoreans

avoiding excessive cut of the supporting structure at the nasal tip and reinforcing the support using columella strut
or septal extension graft (Fig. 6-9).
3) Basic concepts of nasal tip plasty
Basic principle of nasal tip plasty can be explained by the triangle theory of Anderson. Anderson suggested that
rotation and projection of nasal tip can be adjusted by deforming two lateral crura and medial crus of lower lateral
cartilage in view that nasal tip is supported by those three just like camera being supported by tripod (Fig. 6-10).
Assuming two lateral crura and medial crura are three legs, Anderson insisted that one of three legs being cut may
cause the length to decrease resulting in the rotation toward such direction.
In other words, cutting the leg at lower part will decrease tip projection allowing it to move downward, while
cutting the lateral crus will increase tip projection allowing it to make cephalic rotation upward.
Extending the leg at lower part with plumping graft will let the nasal tip face upward while cutting the lateral
crus in addition will increase projection and rotation of nasal tip even more.
As such, the most important factor that decides shape and support of tip is alar cartilage, and many surgical
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nose, not excessively exaggerated infratip lobule, and nostrils in tear drop shape (Fig. 6-8). Above all, however, it is
important to obtain a natural shape of nasal tip that well matches the face and a whole nose, especially the height of
nose rather than such ideal standards. It is not desirable to emphasize the projection of nasal tip resulting in an
upturned nose or the nasal tip is being projected too much not properly matching the length or size of nose, or the
whole face.
1) Purpose of nasal tip plasty
Generally speaking, the shape of nose with its tip slightly lifted looks more beautiful than the nose with its tip
drooped or flat nose. Therefore, nasal tip plasty is performed for tip projection, tip rotation, or blunt tip correction.
Nasal tip plasty is carried out through precise manipulation of cartilage using anatomical features of alar cartilage.
The final purpose of nasal tip plasty is to achieve a minute, settled and beautiful shape. Anatomical analysis
before or during the course of surgery is very important because the every patient has different alar cartilages. In
any case, it always requires keeping symmetry without fail. In addition, it is necessary to master various surgical
skills as well as good understanding of the surgical method and graft materials in use.
2) Support of nasal tip
It is important to exactly understand the supporting structures of nasal tip before the tip plasty. It is the alar
cartilage that decides shape and height of nasal tip. Alar cartilages are made of medial and lateral crus, which are
connected with the pyriform aperture by accessory cartilage. Accessory cartilage connects lateral crus of alar
cartilage and pyriform aperture, which generally consists of several pieces. The structure connected as such is
called the hinge complex. Alar cartilage is not supported by any fixed structure, but by the surrounding skin or soft
tissues among which and the suspensory ligament, scroll area, and soft tissue in between and below the medial
crus. Therefore, any damage or collapse of these soft tissues during operation may cause change in tip height.
Especially when the tip is found to be easily pressed and its elastic force is too weak before the surgery, it requires
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ASIANRHINOPLASTY
Fig.6-8 IdealbasalviewFig.6-7 Nasolabialangleofidealnose
Fig.6-9 Weakmedialcrus a: Short columella with weak medial crus, b: Weak elasticity and easily pushed when pressing the nasal tip, c: Medial crus is
short and weak, d: columella strut for the reinfocement of medial crus
c
a
d
b

I. Basics of nasal tip plasty 1: Tip suture technique
Compared with Caucasians, Asians have thick skin on the nasal tip and small lower lateral cartilage. Therefore it
is difficult in reality to obtain the change in shape of nasal tip with only tip suture technique of lower lateral
cartilage. Accordingly, cartilage graft is broadly adopted, compared with tip suture technique in nasal tip plasty for
Asian. Nevertheless, using the tip suture technique properly may enable to achieve the change in the shape of nasal
tip as desired. Although the tip suture technique alone is not so effective, it can strengthen the structure for cartilage
graft. Also, combined use with cartilage graft may help induce an effective change in the shape. The effect obtained
from tip suture technique includes projection, rotation, and volume reduction of nasal tip. External approach compared
to intrannasal approach is advantageous for performing an effective tip suture technique.
1.Medialcruralsuture
(1) Method
Operation can be done at the mid-point between the medial crus of bilateral alar cartilages (Fig. 6-11). Mainly
#5-0 Nylon or PDS sutures are used for suture material, and round needle is recommended for avoiding
damage to cartilage.
(2) Effects
a. Correcting asymmetry of medial crus of alar cartilage
b. Correcting asymmetry of the position of alar cartilage (Fig. 6-12).
c. Narrowing the width of the nasal columella, if it is broad
d. Reinforcing the force that supports the nasal tip.
(3) Limitation
The force that supports the tip is too weak with only medial crural suture technique. Therefore, the attempt of
raising the tip with this tip suture technique is insufficient. It is recommended to consider it as an additional
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method of tip plasty also gives importance to modifying the shape of alar cartilage.
In addition to alar cartilage, another important factor for shape and support of tip is caudal portion of nasal
septum. Most important part of tip plasty is solidly bearing in a structural manner so that nasal tip can endure the
tension of soft tissue of the nasal tip skin that is covered again after surgery and the force of injury that generates for
a long time after surgery.
There are three important factors for supporting nasal tip; size and elasticity of alar cartilage, scroll area of upper
lateral cartilage and alar cartilage, and lastly soft tissue between and around medial crura of alar cartilage, which are
called major supporting structures of nasal tip.
Also there are many other supporting structures of nasal tip including the area where interdomal ligament and alar
cartilage are connected with pyriform aperture, etc. These supporting structures of tip can be often damaged during
the surgery. In that case, this area must be restored or reinforced if necessary so that the tip can be supported properly.
In order to obtain a nasal tip that keeps a stable condition for a long time without any side effect, it is
recommended to reduce cutting and damaging the tissues, including cartilage of nasal tip and re-arrange the tissue
or deform the shape to finally achieve the desired shape of nasal tip.
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ASIANRHINOPLASTY
Fig.6-10 Anderson’stripodtheory
a: shortening of medial crus: caudal rotation, b: shortening of lateral crus: cephalic rotation, c: shortening of both crus: tip lowering, d; plumping graft: tip
projection and cephalic rotation, e: plumping graft and shortening of lateral crus: tip projection and cephalic rotation
a
e
cb
d
Fig.6-11 Intercruralsuture

suture technique that assist the supporting force by performing columella strut, septal extension graft, or
cartilage onlay graft, etc.
2.Transdomalsuture
1) Method
This is a method of changing the shape of domal segment by performing horizontal mattress suture on the domal
segment of alar cartilage (Fig. 6-13). For the tip suture technique #5-0 Nylon or PDS is mainly used, and it is
important to have the symmetry kept all the time. If there is asymmetry in both domes, the operator can supplement
symmetrical condition by substituting the transdomal sutures of different size (Fig. 6-14). In this case, there could be
change in the shape of nasal tip depending on the position or tension of suture material.
As suture is placed at longer distance outward from the dome apex, lateral crura narrows more resulting in the
increased effect of the tip projection and volume reduction of nasal tip. Excessive narrowing, however, may result
in the buckling of lateral crura, and the occurrence of pinched tip or alar collapse. (Fig. 6-15). The fore-mentioned tip
suture technique by dissection of the vestibular skin below the dome and middle crus of alar cartilage may reduce
the volume further or project the nasal tip (Fig. 6-16).
2) Effects
a. Reducing the width of nasal tip caused by decreasing the distance between domes, and thereby correcting the
blunt nasal tip (Fig. 6-17),
b. Slightly projecting the nasal tip.
c. Rotating the nasal tip toward cephalic or caudal side depending on the suture position.
d. These effects, however, are very limited for Asian whose alar cartilage is small.
3) Caution
a. When transdomal suture is excessively performed for Asian whose alar cartilage is small, it may result in
pinched tip or ala collapse (Fig. 6-15).
b. When cephalic rotation of lateral crus occurs in patients with alar retraction due to transdomal suture, pay
closer attention to the possibility that alar retraction may worsen (Fig. 6-18).
3.Interdomalsuture
1) Method
It is the suture technique of tightening both sides of domal segments of alar cartilages (Fig. 6-19).
2) Effect
a. Reducing the width of tip by decreasing the angle of domal divergence
b. Slightly increasing the length of nasal tip
c. Correcting the asymmetrical dome, if any
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ASIANRHINOPLASTY
Fig. 6-12 Intercrural suture for the correction of asymmetrically cephalic positioned right alar
cartilage a: Retracted alar rim on the right side, b, c: Cephalically positioned alar cartilage on the right
side, d: right alar cartilage is released from the upper lateral cartilage and advanced caudally, e, f:
intercrural suture for the fixation of advanced right alar cartilage, g, h, i: After intercrural suture, right
alar cartilage is placed at the same position as the left alar cartilage., j: postop.(implant deviation
correction & tip plasty)
a b c
d e f
g h i
j

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ASIANRHINOPLASTY
Fig.6-13 Transdomalsuture
g
e
c
a
h
f
d
b
Fig.6-15 Pinchedtip
Fig.6-14 Asymmetricallydesignedtransdomalsutureforthecorrectionoftipasymmetry a,b: before the tie of asymmetircally planned transdomal
suture for the correction of alar cartilage asymmetry), c,d: After transdomal suture, tip symmetry is achieved.
c
a
d
b

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ASIANRHINOPLASTY
Fig.6-16 Subdomalunderminingandtransdomalsuture
e
c
a
f
d
b
Fig.6-17 Transdomalsutureforthecorrectionofboxytip
a: boxy tip, b: alar cartilage is big, domal divergence is large. c: interdomal suture, d: interdomal distance is decreased but tip volume change is not so
apparent immediately after interdomal suture, e: transdomal suture (domal divergence is decreased, and round convex lateral crus became more straight
and less convex), f: immediate postop. (Tip volume is decreased, and square-shaped boxy tip appearance is changed into triangular shape.)
e
c
a
f
d
b

4.Medialcrural-septalsuture
1) Method
It is carried out in such a manner of suturing the caudal portion of nasal septum and medial crus of alar cartilage
(Fig. 6-21). The tip may be projected or lowered depending on the sutured position of medial crus and caudal
septum, but this method enables the nasal columella to be simply pulled backward only (Fig. 6-22). Such effect is
very useful in correcting long nose or hanging columella (Fig. 6-23). This method can be used together with
columella strut graft (Fig. 6-24).
2) Effect
a. Tip projecting
b. Cephalic rotation of tip (reducing the length of nose)
c. Tip lowering
d. Correcting the hanging columella (Fig.11-28, Fig. 11-30)
(3) Caution
a. When the tip is projected resulting in the increase in interdomal distance, it should be supplemented using
interdomal suture, etc.
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d. Covering the end region of graft so that the graft cannot be exposed in case of columella strut or septal
extension graft.
e. Preventing the graft cartilage from interposing between two domes resulting in the decrease in the height in
case of the tip onlay graft (Fig. 6-20).
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ASIANRHINOPLASTY
Fig.6-18 Alarretractioncanbeexaggeratedafterinappropriatetransdomalsuture.
a: Preop., b: After transdomal suture, right side ala retraction became worse than preop.
a b
Fig.6-19 Interdomalsuture
b
a
c
Fig.6-20 Tiponlaygraftimpingementbetweenbothalardomes
resultsintipheightloss.
a: tip onlay graft without intedomal suture, b: conchal cartilage visible
between both domes, c: tip onlay graft based on interdomal suture
a b
c

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ASIANRHINOPLASTY
Fig.6-21 Medialcrural-septalsuture
a: Medial crural-septal suture, b~e: Operation sequences (The 1st suture begins at the right side medial crus, and then caudal septum and finally ends at
the left side medial crus. The suture will be tied with appropriate tension.)
d
b
a
e
c
Fig.6-22 Tipheightchangeaccordingtothelevelofmedialcrural-septalsuture
Fig.6-23 Medialcrural-septalsutureforthecorrectionofhangingcolumella
a: preop. view of hanging columella, b: Both alar cartilages are dissected via endonasal approach, c: strip resection of curved caudal portion of medial crus,
d: medial crural-septal suture, e: Suture is being tied. Interdomal suture and conchal cartilage onlay graft was also done. f: postop. view
e
c
a
f
d
b

5.Lateralcruralspanningsuture
1) Method
This method was introduced by Tebbetts, which is carried out in such a manner of correcting the bulging shape of
lateral crus at both sides of alar cartilage and narrowing the distance between both lateral crura. This method enables
to pull the middle 1/3 portion of both lateral crura together with horizontal mattress (Fig. 6-26). Be careful that too
strong a suture may result in the buckling of lateral crus (Fig.6-27).
2) Effect
a. Correcting the lateral crural convexity (Fig. 6-28)
b. Decreasing the interdomal distance
c. Decreasing the tip volume (Fig. 6-29)
d. Tip projection
e. This suture pushes the dome toward the caudal direction, but it may cause reverse phenomena (cephalic
rotation) depending on the force or position (Fig. 6-30).
3) Caution
a. Dome may be caudally rotated but the caudal margin of lateral crus can be rotated cephalically, and therefore
the suture of the patient with mild alar retraction may worsen the alar retraction. In this case, this suture
should not be adopted (Fig. 6-31).
b. In order to obtain sufficient caudal rotation at the nasal tip, it is effective to fully release the alar cartilage at
the scroll area or pyriform ligament. Otherwise, the position of tip can move to in a reverse direction (cephalic
rotation).
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b. This technique can be performed only when caudal septum is straight. If there is any caudal septal deviation,
surgeon should use this suture after correcting it.
c. It is difficult to use this suture when alar cartilage is too weak and small as found in the nose of Asians. If
medial crus is pulled too much, it is possible for columella retraction to occur (Fig. 6-25). When using this
suture only, this suture is accessory to other procedures than to just for tip projection. It is appropriate to use
this technique for the purpose of assisting other technique rather than attempting to project the nasal tip using
this suture technique alone.
d. In case of using this suture for the purpose of tip projection, surgeon has to be careful because cephalic
rotation may occur at the nasal tip. Therefore, pay close attention to prevent short nose. When undesired
cephalic rotation occurs, surgeon has to supplementarily rotate the tip toward the caudal direction.
e. The tension of suture is case dependent. Surgeon does not have to suture medial crus and caudal septum
together to touch each other. Be careful that excessive suture tension may cause columella retraction.
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Fig.6-24 Medialcrural-septalsuturecanbeusedtogetherwithcolumellastrutgraft.
a: preop. view of hanging columella, b,c: intraop., d: postop. view
c
a
d
b
Fig.6-25 Retractedcolumellaaftermedialcrural-septalsuture

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Fig.6-26 Lateralcruralspanningsuture
a: Lateral crural spanning suture, b, c: intraop. view, d: Spanning suture is not impossible via endonasal approach.
c
a
d
b
Fig.6-27 Bucklingoflateralcruscausedbyinappropriatelateralcrural
spanningsuturedonepreviously
Fig.6-28 Lateralcruralconvexity isreducedbyhorizontalmattresstypeoflateralcruralspanningsuture.
Fig.6-29 Tipvolumereductionafterlateralcruralspanningsuture a,b: preop. view, c,d: postop. view
c
a
d
b

6.Lateralcruralsteal(medializationoflateralcrus)
1) Method
This method was introduced by Kridel et. al., which is carried out in such a manner of suturing the lateral region
of the dome, that is, gathering the proximal portion of lateral crura together. This method has the effect of
projecting the nasal tip by changing lateral crus into medial crus (Fig. 6-32). This technique can be conducted
independently or together with columella strut or septal extension graft (Fig. 6-33).
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ASIANRHINOPLASTY
Fig.6-30 Caudalrotationofdomebylateralcruralspanningsuture
There is an asymmetry of alar dome and a twisted medial crus (a,b). Columella strut graft (c) for the tip projection may cause the cephalic rotation of alar
dome (d). Spanning suture of distal lateral crus (e,f) causes the caudal rotation of alar dome (g) even if it is a very minimal effect.
g
e
c
a
h
f
d
b
Fig.6-31 Patientwithmildalarretraction
Fig.6-32 Lateralcruralsteal(medializationoflateralcrus)

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2) Effect
a. Tip projection
b. Cephalic rotation of nasal tip (Fig. 6-34)
c. Blunt tip correction (Fig. 6-35)
d. Changing the shape of nostril into elongated triangular shape (Fig. 6-35)
(3) Caution
This technique is very effective in projecting the tip in case of the patient whose alar cartilage is large and strong as
in Caucasians. But for Asian whose alar cartilage is small and weak, this technique is not sufficient enough and
therefore, tip onlay graft or shield graft should be used concurrently (Fig.6-36).
Especially, patients with weak medial crus may decrease in nasal tip height as the weak medial crus is twisted
after the lateral crural steal, which should be supplemented through columella strut graft, etc. (Fig. 6-118, Fig. 6-120).
In addition, short and upturned nose can be turned into dissatisfied shape as the alar cartilage can be rotated
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Fig.6-33 Columellastrutandmedializationoflateralcrus
c
a
d
b
Fig.6-34 Cephalicrotationofnasaltipafterlateralcruralsteal
a,b,c: before medialization of lateral crus (lateral crural steal), d,e,f: Alar dome is rotated cephalically after medialization of lateral crus.
e
c
a
f
d
b

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towards a more cephalic direction with this technique. Therefore, in addition to this, other techniques that may
supplement the problem caused by cephalic rotation of dome should be applied (Fig. 6-37).
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Fig.6-35 Tipvolumeandnostrilshapechangeafterlateralcruralsteal
a,b: preop. c,d: postop. (Tip volume was decreased, and nostril was changed into more vertical and triangular shape)
c
a
d
b
Fig.6-36 Lateralcruralstealcombinedwithcolumellastrutgraftandshieldgraft a: preop., b: postop.
a b
Fig. 6-37 Cephalic rotation from lateral crural steal and its prevention a,b: cephalic rotation of dome after lateral crural steal, c,d: spanning suture of
lateral crus, e: caudal rotation of dome by spanning suture of lateral crus, f,g: Traction of alar cartilage to caudal direction and suturing the lateral crus to
the upper lateral cartilage (derotation suture), h: more caudal rotation of dome by derotation suture
g
e
c
a
h
f
d
b

The cartilage harvested from ear or nasal septum is most frequently used and the width at the upper part is set to
be about 6~8mm to display the tip defining point. The border area is made to be more inclined to display smooth
curve after the surgery. In general, it is placed about 2~3mm is above the alar dome for better projection but in case
of Koreans it is maximized. For those with thick skin and thin cartilage, the back of the grafted cartilage is
reinforced by conducting additional cartilage graft to prevent tilting backward. By doing so, better result can be
achieved (Fig. 6-38).
In conducting shield graft for those who have weak alar cartilage, it seems to be well during a surgery; however, the
weak alar cartilage fails to maintain the shape of the the nasal tip that was extended by the shield graft, causing cephalic
rotation after suturing the skin. In such case, an additional surgery to reinforce the weak alar cartilage should be
conducted. Derotation suture, derotation graft, or septal extension graft are applicable in these cases (Fig.6-39,Fig.6-62).
2) On-lay graft
On-lay graft is one of the methods that can be easily used and indicates laying more than one layer of overlapped
cartilage on the dome of the alar cartilage. To display tip defining point, the cartilage from the nasal septum or ear is
used by laying a layer or several layers as high as desired in a width of 6~8mm (Fig. 6-40). Since the ear cartilage is
curved compared to that of the nasal septum, it is easy to create a smooth profile when laying on the dome.
The following should be considered during on-lay graft.
a. In case of a gap between the domes of the alar cartilage or weak lateral crus, the effect of projecting the nasal
tip can be lost as the on-lay overlapped cartilage is stuck between the two domes. In such case, interdomal
suture is conducted before performing on-lay graft (Fig. 6-20).
b. In case of promoting on-lay graft in multiple layers, the medial crus of the alar cartilage must be strong
enough to support the layers. Otherwise, the tip projecting effect may be lost as the weak medial crus is
deviated by the force of the on-lay graft (Fig. 6-41). Therefore in case of very weak medial crus, it should be
firmly supported with columellar strut graft for maximal projection (Fig. 6-42).
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II. The basic of nasal tip plasty 2: Cartilage graft
Most rhinoplasty for Asians is a surgery that heightens the dorsum and projeccts the nasal tip and a surgery while
a bulbous and short nose is frequently as well. The alar cartilage of Asians is often small and weak compared with
that of the Caucasians with disadvantages for nasal tip plastry. Since it is limited to change the shape of the nasal tip
by simple suture alone, cartilage graft is necessary for the nasal tip plasty of most Asians.
The cartilage that is harvested from the nasal septum or ear is frequently used at the nasal tip plasty. In case of
endonasal approach, the cartilage is inserted in the space provided in the nasal tip or tip onlay graft is conducted
after exposing the alar cartilage and reinforcing the medial crus through columella strut graft. Open rhinoplasty
incision enables more effective suture and fixing of the cartilage and can bring variety of effects to the nasal tip by
implementing shield graft, cap graft, columellar strut graft, etc.
1) Shield graft
Shield graft is a shield-shaped graft at the front- and bottom-end of the nose tip. In other words, it is a graft
placed throughout the middle crus and dome. It is effective in increasing nasal tip projection, enables a defined
intratip lobule, and improves shape of the nasal tip by helping to lengthen the nose (Fig. 6-38).
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ASIANRHINOPLASTY
Fig.6-38 Shieldgraft
Fig.6-39 Shieldgraftandderotationgraft
a : The alar dome position is being maintained well after shield graft.
b:Butinthecaseofweallateralcrus,alardomeisrotatedcephalicallyafterskinrepair.Insuchacase,derotationsutureorderotationgraftmaybeneeded.
alar cartilage
shield graft
a b

c. The grafted cartilage can be seen in patients with a thin skin layer (Fig. 6-43). To prevent this, it is important to
thin the edges of the cartilage by trimming it well (Fig. 6-44). In preventing visible grafted cartilage through
thin skin layer, the cartilage can be weakened (Fig. 6-45) or the cartilage graft can be covered with the fascia or
AlloDerm (Fig. 6-46).
3) Columellar strut graft
Columellar strut graft is one of the most frequently used basic surgical methods to project the nasal tip. The cartilage
to be grafted is inserted between the medial crura of the alar catilages in shape of a column, and it should be fixed
without protrusion above or anterior to the crus (Fig. 6-47). As for materials for the strut, nasal septal cartilage which is
thin, straight shaped, and easy to harvest is most frequently used; however, the ear, costal, or allogenous costal
cartilage can be used as an alternative for patients with limited the nasal septum.
Principles for projecting the nasal tip with the columellar strut graft are as follows.
a. The nasal tip can be projected by promoting interdomal suture, transdomal suture, or medialization of the
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ASIANRHINOPLASTY
Fig. 6-41 Tip onlay graft may distort the weak medial crus. a: unfavorable tip height after tip onlay graft, b: conchal cartilage onlay graft is visible, c:
After removal of conchal cartilage and scar tissue, we can see that cartilage onlay graft might distort the weak medial crus, which may be one of the causes
of unfavorable low tip height. d: columella strut graft for the straightening of medial crus
c
a
d
b
Fig.6-40 Tiponlaygraft
Fig.6-42 Columellastrutandtiponlaygraft Fig.6-43 Visibleconchalcartilageonlaygraftontip
Fig.6-44 Taperingofcartilagegraft

lateral crus at the upper part around the strut tip after inserting the strut. Also, it is possible to sustain and
support the force and weight of the onlay graft. In other words, it works to reinforce the effect of various
suture techniques that project the nasal tip or onlay graft (Fig. 6-48).
b. It prevents tip height loss caused by the deviated meidal crus as the strut reinforces the medial crus(Fig.6-49).
c. It prevents lowering of the nasal tip as the tip is pulled downward when smiling.
Columellar strut is classified into fixed type that contacts the ANS and floating type that is separated from the
ANS (Fig. 6-50). The floating type is recommended as cushion effect is preserved when pressing the nasal tip.
Therefore, it is smooth when touching the nasal tip and presents natural nose tip when smiling. Although the strut
doesn’t directly contact ANS, the effect of the nose tip support and projection is relatively good, and such
columellar strut graft works as firm support along with shield graft or cap graft to obtain more projected nasal tip.
When requiring much stronger projection of the nasal tip, a long column in contact with the ANS is used (Fixed
type). In this case, the nasal tip gets hard after the surgery and the shape of the tip becomes fixed when smiling
causing an artificial shape.
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ASIANRHINOPLASTY
Fig.6-45 Cartilagecrusher
c
a
d
b
Fig.6-46 CoveringtheseptalcartilagegraftwiththinAlloderm
Fig.6-47 Columellastrutgraft
Fig.6-48 Roleofcolumellastrutgraft
a: strut graft inserted between both medial crus, b,c: Three sutures(5-0 PDS) are enough for the fixation of strut., d: interdomal suture above the strut
c
a
d
b

177
The surgical process is as follows.
a. Harvest of the cartilage to be grafted
The cartilage that is mainly used is nasal septal cartilage. For the harvest of the nasal septal cartilage, dorsal
approach is recommended if possible. This method minimizes tip drooping in comparison to intercrural
approach as it minimizes damages of soft tissues between the medial crura of alar cartilages (Refere to
Chapter 1).
After harvesting the nasal septal cartilage, a columellar strut is designed. The desireable width and length is
about 3mm and 12-25mm respectively (Fig. 6-51). In case of limitation in harvest of the nasal septal cartilage,
it is possible to use conchal cartilage, autogenous rib cartilage, and homologous rib cartilage (Fig. 6-52). Since
conchal cartilage is curvy, two layers are evenly spread and symmetrically attached for straightening or spread
by using horizontal double mattress suture.
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ASIANRHINOPLASTY
Fig.6-49 Columellastrutforthestraighteningoftwistedmedialcrus a: Weak and twisted medial crus causes tip height loss. B: The height of the tip
can be increased more than 3-4mm by speading the twisted medial crus in ucse of columella strut.
a b
Fig.6-50 Twotypesofcolumellastrutgraft
Floating type(left), fixed type(right)
Fig.6-51 Septalcartilageforcolumellastrutgraft
Fig.6-52 Conchalcartilageforcolumellastrutgraft
a,b: preop., c,d: One pair of curved conchal cartilages are sutured together to make a straight columella. e,f: posop. (The two-layered conchal cartilage
tends to thicken the columella more in comparison with the septum cartilage.)
e
c
a
f
d
b

179
b. Dissection between the medial crura
Since the medial crura of the alar cartilages are supported and maintained by soft tissue, it is important to
preserve it for the prevention of nasal tip drooping. Therefore, in case of dissection between the medial crura,
this soft tissue has to be well preserved for the columella strut graft. It is better to promote dissection through
broadening the space to insert the strut by putting a scissor between the soft tissues, rather than cutting the soft
tissues between the medial crura (Fig. 6-53). In case of cutting the soft tissue, it is limited to the correction of a
short nose and retracted columella.
c. Before suturing the columella strut, the medial crura of both parts are temporarily fixed with a 26-gauge
needle before suture. Such is helpful for the maintenance of symmetry of the nasal tip (Fig. 6-54).
d. For fixation, #5-0 PDS suture is used but a round needle must be used. Sutures between strut and the meidal
crura are performed in about 3 areas. After fixation, the upper part of the strut shouldn’t be exposed through
the interdomal suture. Additional suture techniques like transdomal suture or lateral crural steal can be done.
If the strut is not fixed symmetrically, the columella becomes deviated and the nostrils become asymmetric
(Fig. Must be aware (6-55)). It is also possible to increase showing of the nasal columella by using a wide
graft (Fig. 6-56).
Columella strut graft is performed independently or combined with additional cartilage graft. In case of
Asians, an additional cartilage graft is frequently done due to the characteristic of the alar cartilage. For
example, shield graft or onlay graft can be combined together after columella strut graft for additional
projection of the nasal tip (Fig. 6-57).
In case of very weak alar cartilages, the tip results in cephalic rotation after columella strut as the weak lateral
crus fails to sustain the force of the strut. If this is neglected, the nose becomes shorter and nostrils show is
worsened. In this case, it may require onlay graft or lateral crural strut graft of the lateral crura to reinforce the
lateral crus or derotation graft that directly pushes down the nasal tip toward a longitudinal direction (Fig. 6-58,
Fig. 6-71).
The nasal tip can be more projected after conducting columella strut through medialization of the lateral crus
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ASIANRHINOPLASTY
Fig.6-53 Pocketformationforthecolumellastrut
Fig.6-54 Proceduresofcolumellastrutgrft a: strut inserted between both medial crus, b: needle fixation helps symmetric suture of columella strut, c: 3
stitches are enough for the strut fixation, d, e, f: lateral crural steal(medialization of lateral crus)
e
c
a
f
d
b

and due to the anatomical direction of the lateral crus, the nasal tip moves toward the cephalic rotation of tip
(Fig. 6-59). Therefore, columella strut graft can be applied for correction of long nose (Fig. 6-60). However,
round tip is displayed when the cephalic rotated tip is seen on profile so to supplement this, it is advised to use
a shield graft or onlay graft (Fig. 6-61).
4) Septal extension graft
Septal extension graft is mainly used to extend the length of a short nose; however, it is also powerful graft that
can project the nasal tip or promote columella projection. There are three types of septal extension graft (Fig. 6-62);
extended spreader type, batten type, and direct extension type. The extended spreader type is a method of fixing
between dorsal area of nasal septum and upper lateral cartilages (Fig. 6-63). Graft can be used unilaterally or
billiterally to the dorsal nasal septum. When correcting a deviated and short nose, unilateral graft enables spread of
the upper lateral cartilage at the concave area, so it is effective to simultaneously correct a deviated nose (Fig. 6-64).
For the extended spreader type, it is advised to design the shape of the graft in a hockey stick appearance as shown
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ASIANRHINOPLASTY
Fig.6-55 Nostrilasymmetryduetoobliquecolumellastrut(earcartilage)
Fig.6-56 Lowercolumllaprojectionwithseptalcartilagestrut
Fig.6-57 Conchalcartilageonlaygraftabovethecolumellastrutgraft a: preop., c: postop.
a b c
Fig.6-58 Derotatongrafttopushthealarcartilagecaudally
Fig.6-59 Roundedtipappearanceduetocephaicrotationofdomeaftercolumellastrutgraft
Derotation graft
Alar cartilage

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ASIANRHINOPLASTY
Fig.6-61 Roundedtipaftercolumellastrutgraft
a; rounded tip appearance after columella strut graft onlay, b: Shield graft can improve the rounded tip.
a b
Fig.6-62 Threetypesofseptalextensiongraft a: extended spreader type, b: batten type, c: direct extension type
a b c
Fig.6-60 Columellastrutgraftforthelongnosecorrection a: preop., b: postop.
a b Fig.6-63 Extendedspreadertypeofseptalextensiongraft a: unilateral graft, b: bilateral graft
a b
Fig.6-64 Extendedspreadertypeofseptalextensiongraft(unilateral) a,b: preop. view, c: unilateral extended spreader type of septal extension graft,
d,e: postop. view(We can see the correction of deviated upper lateral cartilage as well as short nose correction)
d
ca
e
b
graft cartilage
upper lateral cartilage
dorsal septum

185
in Fig. 6-65 to match the direction and position of the cartilage tip to be grafted with the dome of the alar cartilage.
It is mainly used for the extension of the nasal length.
Batten type is the most frequently used method as it is easy to shape and fix the graft in comparison to other
types. It is a method that directly fixes the graft at the caudal part of the nasal septum or throughout the caudal part
and dorsal area (Fig. 6-66) while being a very effective and powerful method for tip lengthening. In batten type,
length can be extended alone or length extension as well as tip projection is possible depending on the position of
the end-point of the graft. Also, it is possible to project the tip without lengthening (Fig. 6-67).
Since the location of the nasal tip is decided by fixing the dome of the alar cartilage at the end-point of the septal
extension graft, the height and position of the nasal tip for batten type is easily controlled as intended by an
operating surgeon. Thus, it is considered to be a very convenient and effective surgical method.
When performing methods like suture technique or columella strut in case of the nasal tip plasty of Asians, many
patients have very weak alar cartilage and thick skin compared to those of Caucasians. Thus, the position of the alar
cartilage dome may be formed at more cephalic part than desired position or formed lower than desired height.
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ASIANRHINOPLASTY
Fig.6-65 Hockeystickshapedgraft(extendedspreadertype)
Fig.6-66 Battentypeofseptalextensiongraft Fig.6-67 Variousapplicationsofbattentypeofseptalextensiongraft a: tip lengthening, b: tip lengthening and projection, c: tip projection only
a
b
c

187
Septal extension graft enables the surgery as intended by the surgeon since it allows accurate formation of the graft
shape and nasal tip. For this reason, this method is favorable for rhinoplasty among Asians and it has wide range of
application once this method is familiar. However, the nasal tip becomes hard with less mobility.
As for the materials of septal extension graft, nasal septal cartilage is widely used but autogenous rib cartilage or
homologous rib cartilage can be used as well (Fig. 6-68). If the size of the harvested nasal septum cartilage is
insufficient, the effect of the septal extension graft may be unsatisfactory, and the solution for this is explained in
detail in Chapter 10.
5) Alar rim graft (alar contour graft)
Alar rim graft is a technique that can be effectively used among Asians with weak and small alar cartilages. It is a
cartilage graft along the alar rim (Fig. 6-69). The indications of this technique are as follows (Fig. 6-70).
a. Correction of alar retraction
b. Correction of pinched tip
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ASIANRHINOPLASTY
Fig.6-68 Autogenous&homologousribcartilagefortheseptalextensiongraft a, b: autogenous rib cartilage, c, d: homologous rib cartilage
c
a
d
b
Fig.6-69 Alarcontourgraft
b, c, d, e : Pocket formation along the alar rim
f : Conchal cartilage is prepared for the graft.
g, h, i, j : Graft is being inserted into the pocket.
a b c
d e f
g h i
j

6) Lateral crural onlay graft
It is a method that grafts cartilage by overlapping
it on the lateral crus (Fig. 6-71). This method aims to
reinforce the lateral crus, and its indications are as
follows (Fig. 6-72).
a. Correction of depression deformity of ala due
to buckling or loss of some part of the lateral
crura
b. Correction of pinched tip
c. Correction of exteranl valve collapse
189
c. Correction of external valve collapse
d. It is effective to naturally form the curve connected to the ala-tip by preventing retraction of the alar rim
toward the nostril when correcting asymmetry of the alar cartilage or increasing projection of the nasal tip.
Composite graft harvested from ear instead of the alar rim graft is helpful in correcting depression of alar rim
(Fig. 11-13).
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ASIANRHINOPLASTY
Fig.6-70 Indicationsofalarcontourgraft
a: correction of alar retraction on the left side, b: correction of pinched tip on both sides, c: correction of external valve collapse on the right side
a
b
c
Fig.6-71 Lateralcruralonlaygraftontheleftside
Fig.6-72 Lateralcruralonlaygraft a: correction of lateral crus buckling or disruption, b: correction of pinched tip
a
b

III. Application of nasal tip plasty 1: Projection
Projecting the nasal tip is the most necessary surgical treatment demanded in rhinoplasty for Asians. Nasal tip
projection is decided by 3 elements; premaxillary component, columellar component, and infratip lobular
component. Since development of premaxilla is insufficient among Koreans, the nasolabial junction is seen to be
recessed. Thus, retrusion of the nasolabial junction should be corrected, and the columella and infratip lobule
should be harmoniously expanded. Cartilage graft frequently causes unnatural projection as only the infratip lobular
component is projected when it is seen from the base (Fig. 6-75). It is important for a projection relevant to the nasal
dorsum, and excessive projection or emphasis of the contour at the nasal tip may be unnatural to Asians. It also
harms harmonization of the face and nose. Tip plasty may be performed alone or with dorsal heightening.
There are various ways to project the nasal tip. In the past, silicone implant that heightened the nasal bridge was
inserted up to the end of the nose to project the nasal tip as well (Fig. 3-38). This method is still performed in some
Asian countries; however with more advanced techniques of rhinoplasty, this method has become obsolete. As the
silicone implant used in this method adds pressure to the skin at the nasal tip, it may cause serious side effects by
making the tip skin thin or discolored and if it becomes worse, the skin gets perforated and the implant is exposed
(Fig. 6-76).
To supplement this, there is a surgical intervention that attaches the ear cartilage on the end of silicone. However,
this method is not perfectly free from the side effects of the nasal tip. It is possible to avoid skin perforation caused
by silicone implant; nonetheless, there is still possibility of visible the ear cartilage through the skin since the
silicone implant pressures the ear cartilage toward the skin (Fig. 6-77). Recently, silicone implant is used from the
radix to supratip and cartilage graft for the tip projection separately.
There are two ways to project the nasal tip. First is the surgery that projects the tip by placing cartilage on the
dome of alar cartilage, such as shield graft and on-lay graft through endonasal approach, and this is accompanied
with suture techniques such as interdomal suture, etc. The second way is adoption of more powerful techniques like
columella strut graft and septal extension graft through open rhinoplasty. These methods are surgical approaches to
bring more changes to the position of the dome of alar cartilage. Selection between the two techniques depends on
191
(7) Lateral crural strut graft
The lateral crural strut graft is placed under or above the lateral crus and it is secured to the crus with sutures. The
end of the graft must be placed upto the pyriform aperture (Fig. 6-73). The width of the graft is 3-4mm, and the nasal
septal cartilage is mainly used. The rib cartilage can be used as well (Fig. 6-74). The usage of the lateral crural strut
is as follows.
a. Correction of alar rim retraction
b. Correction of alar collapse
c. Correction of convex lateral crus
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ASIANRHINOPLASTY
Fig.6-73 Lateralcruralstrutgraft
Fig.6-74 Lateralcruralstrutgraft a: lateral crural strut with rib cartilage on the right side, b: columella strut and lateral crural strut on the left side
a b
Fig.6-75 Unnaturaltipprojection

The incision is performed inside the right nasal
mucosa for a right-handed surgeon but for more
symmetrical perfection, some surgeons make
incision in both nasal cavities. After incision,
dissection is conducted above the alar cartilage to
spare space around the dome for the placement of
graft. And then, nasal septal cartilage or ear
cartilage are used as a graft to pile and insert in the
space. Depending on desired shape, surgical
technique is conducted either as tip onlay graft or
shield graft (Fig. 6-78). The size of the graft
shouldn’t exceed 8mm which is the interdomal
distance, and the edges of the graft should be well trimmed to prevent external display of the graft.
Depending on position of space to where the graft is to be inserted, the nasal projection or rotation direction can
be slightly controlled. For example, space is prepared throughout the dome and infratip lobule if intending to have a
slightly long nose with projection and in case of demanding rotation cephalically with projection, the space is made
through the dome and supratip lobule before grafting the cartilage (Fig. 6-79).
Graft does not have to be fixed but it is recommended to fix it to prevent position change. It can be fixed to the
alar cartilage but as an easier method is using, 6-0 nylon suture that is connected to the graft pulled out through the
skin and then fixed with paper pillow for a week (Fig. 6-80).
It is possible to manipulate more aggressively through the exposure of the alar cartilage by dissecting and
exposing alar cartilage on both sides. With sufficient dissection above the alar cartilage, the tip projection and
rotation can be slightly increased through interdomal suture or trandomal suture without external delivery of the
cartilage. However, due to the characteristic of Asians, suture technique alone cannot create sufficient tip
projection. For this reason, suture technique should be considered as a basic role to increase the effect of cartilage
193
various conditions including the shape desired by the patient, anatomical characteristics of the nasal tip, and other
rhinoplasty techniques that are accompanied with nasal tip surgery.
In case of having strong support of the nasal tip, not too thick skin, and less deformity at the tip, cartilage graft
through endonasal approach is favorable. To obtain the tip projection that accompanies strong tip rotation,
columella strut graft or septal extension graft through the external approach is better.
1) Tip projection via endonasal approach
Endonasal approach is used when having relatively strong support at the nasal tip and it is limited in patients with
thick skin or weak medial crus of the alar cartilage. It is possible to obtain effective projection of the nasal tip with
simple manipulation but if intending to project the tip excessively, the shape may not be natural.
The incision is made along the inferior margin of the alar cartilage, starting from the inner part of the middle
columella to dome area along the inferior margin of the medial crus before processing incision according to the
inferior margin of the lateral crus (Fig. 1-65). By doing so, the incision line is located more inferior to the alar rim
edge while avoiding damages on the soft triangle.
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ASIANRHINOPLASTY
Fig.6-77 Visibleconchalcartilagethroughthethinnednasaltipskin
Fig.6-76 Exposureofsiliconeimplanttipthroughthethinnednasaltipskin Fig.6-78 Cartilageonlaygraft
Fig.6-79 Pocketformationforcartilagegraft a: pocket for the tip projection & elongation, b: pocket for the tip projection & rotation
a b
alar cartilage alar cartilage

various suture techniques, shield/on-lay graft, etc. can be utilized and depending on the situation, the fore-
mentioned techniques are appropriately combined for application.
Incision starts from the middle of the nasal columella by selecting the area with the narrowest width. It is advised
that the incision line crossing the nasal columella should be in stair-shaped or inverted V-shaped rather than straight
incision (Fig. 1-69). In comparison to straight incision, such methods allow less visible scars and less scar contracture.
The incision line of nasal columella is extended inside the nasal cavity and processed along with inferior margin of
the alar cartilage and through the identical incision method as in endonasal approach, the incision is progressed along
the dome of the alar cartilage and inferior margin of the lateral crus (Fig.1-70).
In case of large alar cartilage with satisfactory strength, blunt nasal tip can be corrected only through cartilage
suture techniques without columellar strut graft while obtaining projection and rotation. However in most cases, it
is difficult to obtain projection of the nasal tip only with sutures. For this reason, cartilage graft is used as well. The
most common method is using columella strut graft, shield graft, and on-lay graft along with interdomal suture.
Interdomal suture and columella strut graft are used to reinforce tip support while shield graft and on-lay graft are
applied to project the tip on the reinforced supportive structure (Fig. 6-82).
Septal extension graft provides the most powerful support for the nasal tip. It becomes a powerful means not
only to extend the nasal length but also to project the nasal tip (Fig. 6-83). Regarding septal extensioin graft, not
many cases require additional on-lay graft or shield graft but when necessary, such methods can be accompanied.
195
graft (Fig. 6-81). Through endonasal approach, it is possible to perform spanning suture of the lateral crus or
columella strut graft. By doing so, the volume of the nasal tip can be reduced or the projection of the tip can be
more powerful.
Along the endonasal approach, it is considered
that the delivery technique with use of inframarginal
incision or intercartilagenous incision should be
selectively used for its application to Asians who
have thin and weak cartilages.
2) Tip projection by open rhinoplasty
In case of weak supportive structure and thick skin
at the nasal tip (Many Koreans or Asians belong to
this case), tip projection can be attempted through
open rhinoplasty. When the tip is projected through
open rhinoplasty, more powerful methods such as
columella strut and septal extension graft besides
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ASIANRHINOPLASTY
Fig.6-80 Pull-outsutureofcartilagegraft
a: determination of the exact position of cartilage onlay graft, b: pull out
suture, c: fixation of the graft with pillow suture
a b
c
Fig.6-81 Interdomalsutureviaendonasalapproach
Fig.6-82 Cartilagegraftfortipprojection
a,b: Columella strut to support weak medial crus acts as a strong base for
shield or onlay graft, c: Strong medial crus can sustain onlay graft well and
does not need columella strut.
a b
c

Septal extension graft allows relatively effective control of the tip rotation and projection while enabling control
of the tip height or position as intended by the surgeon. Also, it is possible to powerfully maintain the height of the
created nasal tip and harmoniously project premaxilla, columella, and infratip lobule. Therefore, it is an effective
method for cases demanding strong projection and rotation or cases that intends to derive natural projection in all
three parts.
Since the premaxilla of Koreans is insufficient, the subnasale is recessed. For this reason, many patients have an
acute nasolabial angle. The plumping graft is a technique to improve such demerit and grafts cartilage or bone at
the upper part of the anterior nasal spine. It improves nasolabial angle and is possible to obtain natural projection
and rotation of the nasal tip (Fig. 6-84).
IV. Application of nasal tip plasty 2
: Correction for a blunt nasal tip and long nose
1.Bluntnasaltipcorrection
A nose with excessively blunt nose tip is classified into bulbous tip and boxy tip. The normal divergence angle of
alar cartilage’s middle crus is about 60 degrees. In consideration of this, bulbous tip indicates a nasal tip with an
angle within the fore-mentioned angle with very large cartilage or a nose with unclear tip defining point and stubby
and big tip due to the large amount of the soft tissue regardless of small cartilage size. Meanwhile, boxy tip
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196
ASIANRHINOPLASTY
Fig.6-83 Septalextensiongraftfortheprojectionoftip a,b,c: preop. view, d, septal extension graft, e: fixation of alar dome to the graft tip, f,g,h:
postop. view(Op: radix augmentation with silicone implant(2mm height), tip plasty with septal extension graft)
g
e
c
a
h
f
d
b
Fig.6-84 Plumpinggraft

199
indicates big and square-shaped nasal tip with divergence angle of greater than 60 degrees (Fig. 6-85).
1) How to correct the bulbous tip
The bulbous tip has stubby and big nasal tip externally but unlike Caucasians with big alar cartilage, the alar
cartilages of Asians are not always large. Surgical intervention for the bulbous tip of Asians should be conducted in
classification of two types depending on sizes of the alar cartilages. First type is a big and well developed alar
cartilage as in Caucasians and the second type is a big and stubby nasal tip with normal or small alar cartilage but
with excess soft tissue and thick skin (Fig. 6-86).
(1) Type with large and well-deveoped alar cartilage
Since the alar cartilage is excessively large and wide, the size of the cartilage shoud be reduced by cephalic
resection of alar cartilage and narrowing of the gap between the domes of the separated alar cartilages can be
performed by interdomal or transdomal sutures(Fig. 6-87). Sometimes spanning sutures of the lateral crura are
helpful (Fig.6-88) but if it is performed too tightly, it may cause internal valve insufficiency or pinched tip.
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ASIANRHINOPLASTY
Fig.6-85 Bigtip a: bulbous tip, b: boxy tip
b
a
Fig.6-86 Twotypesofbulboustip a: bulbous tip with developed alar cartilage, b: bulbous tip with small alar cartilage
a
b
Fig.6-87 Partialresectionofthecephalicportionoflateralcrusforthebulboustipcorrection
a b

(2) Type with small alar cartilage and large amount of soft tissue
This type usually indicates stubby, round, and low nasal tip. Since alar cartilage is small, there is no need to
reduce the alar cartilage, and either interdomal suture or transdomal suture does not help in reducing the
volume of the nasal tip (Fig. 6-89).
For surgical intervention, it is suggested to lift the tip by reinforcing the small alar cartilage, along with
reducing the volume of the soft tissue. By doing so, the blunt nasal tip is improved as the shape of the tip is
changed to longer triangular shape in addition to the effect generated in the soft tissue volume reduction.
The resection of the soft tissue is performed on the elevated skin flap, and it should be performed mainly at the
central area from the nasal tip to 1/3 (lower one third of dorsum). Especially, the soft tissue at the midline must
be effectively reduced because by doing so the skin flap can be well folded based on the center to derive
maximal effect (Fig. 6-90).
When it comes to nasal tip plasty, the alar cartilage is small and has weak supportive strength. Thus, columella
strut or septal extension graft is helful in general (Fig. 6-91). In case of projecting the tip by conducting cartilage
on-lay graft after interdomal suture, the nasal tip may droop with time and bring suboptimal result in terms of
201
200
ASIANRHINOPLASTY
Fig.6-88 Spanningsutureforthecorrectionofbulboustip a: spanning suture of lateral crus after partial resection of cephalic portion of lateral crus, b:
double mattress spanning suture without parital resection of cephalic portion of lateral crus, c: preop. and postop. view
c
b
a
Fig.6-89 Bulboustipwithsmallalarcartilage a: bulbous tip, b: Alar cartilage is small. Suture technique alone has little effect on tip volume reduction.
a b
Fig.6-90 Softtissuedebulkingaroundthetipandsupratiparea
a b

203
the improvement of the round and stubby shape due to the weak support of the alar cartilage.
2) How to correct boxy tip
Boxy tip can be corrected by interdomal suture and trandomal suture. If such interventions are not sufficient, double
mattress spanning suture of the lateral crus increases the volume reduction effect at the nasal tip by improving the
convexity of the lateral crus (Fig. 6-92).
2.Longnosecorrection
In general, a long nose accompanies tip drooping and smiling tip that becomes more sagging when smiling. The
anatomical characteristics of a long nose are as follows (Fig. 6-93).
a. Long lateral crus
b. Long membranous septum
c. Low positioned caudal septum(long cartilage septum)
d. Strong depressor septi nasi muscle
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ASIANRHINOPLASTY
Fig.6-91 Bulboustipcorrection(debulkingoftipsofttissueandseptalextensiongraftwithseptalcartilage) a,b: preop., c,d: postop.
c
a
d
b
Fig.6-92 Correctionofboxytip a, b: preop., c, d: interdomal suture, e, f, g: double mattress spanning suture of lateral crus, h, i: postop., See the
decreased domal divergence angle and convexity of lateral crus.
h
e
c
a
i
f g
d
b

For correction, cephalic rotation of the alar cartilage should be done while correcting the fore-mentioned anatomical
characteristics. For the cephalic rotation of the nose, interdomal suture of the alar cartilage or medialization of the
lateral crus is promoted, and the factors that hinder cephalic rotation are as follows(Fig.6-94).
a. Cephalic portion of the lateral crus is large that it is interfered by the upper lateral cartilage during cephalic
rotation
b. Long lateral crus
c. Long caudal septum
d. Long membranous septum
Therefore, solving the fore-mentioned issues through surgical intervention is important to correct a long nose.
a. Partial resection of cephalic portion of the lateral crus: To solve the hindrance of the lateral crus to the upper
lateral cartilage in case of cephalic rotation, part of the cephalic portion in the lateral crus is resected. Also
through the resection of the cephalic portion after dissection of the scroll area, the scar contracture is induced;
therefore, it serves an important role for the correction of a long nose.
Although it is not commonly used among surgical intervention for Koreans compared to Caucasians, it is
used to promote slight cephalic rotation at the nasal tip to reduce the volume of the tip or ease other surgical
procedure at the nasal tip, such as suture between cartilages. Small lateral crus that is left after resection
generates buckling of the lateral crus or pinched tip or internal valve collapse. Therefore, at least 6mm of
width should be preserved (Fig. 6-95). However among Koreans, it is difficult to firmly control rotation with
this method alone since the cartilage size is small and weak as well as the skin being thick. Thus, to achieve
strong rotation, suture methods or columella strut graft should be accompanied.
b. In case of long lateral crus, segmental resection can be performed in the distal area (Fig. 6-96).
c. Strip resection of caudal septum: When the caudal septum is extended toward the caudal direction, the medial
crus is hindered by the caudal septum at the cephalic rotation of alar cartilage. Thus, this problem can be
solved through partial strip resection of the caudal septum (Fig. 6-97).
d. Strip resection of membranous septum: Strip resection for the long membranous septum is not common, but
205
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ASIANRHINOPLASTY
Fig.6-93 Anatomyoflongnose
d
c
a
e
b
Long lateral crus
Hign abutment
of lateral crus
Strong DSN m.
Long caudal
septum
Fig.6-94 Factorsthatinhibitthecephalicrotationofalarcartilage

it may be necessary for the correction of a very long nose (Fig. 6-98).
Of course, it does not mean that all the procedures mentioned above must be conducted. According to the condition
of a patient, some surgical interventions are adopted. Through the above mentioned techniques and suture methods
on alar cartilage, the length of the nose can be reduced. Nonetheless, additional surgical treatments are needed for
permanent and firm maintenance.
a. Columella strut graft (Fig. 6-99): It is the most important procedure. In case of weak medial crus in the alar
cartilage, it can prevent sagging and drooping nasal tip that occurs again after correcting a long nose with time.
b. Medial crural-septal suture(Fig. 6-100)
c. Suturing the lateral crus to the upper lateral cartilage (Fig. 6-101)
d. Resection of the depressor septi nasi muscle (Fig. 6-102)
207
206
ASIANRHINOPLASTY
Fig.6-95 Partialresectionofcephalicportionoflateralcrus
Fig. 6-96 Segmental resection of lateral crus Segmental resection in the distal lateral crus (a) is safer than in the proximal portion (b,c). However, in
Asian patient with thick tip skin, resection in the dome/proximal or mid portion does not usually produce any visible notching or irregularity(d).
c
a
d
b
Fig.6-97 Stripresectionofcaudalseptum Fig.6-98 Stripresectionofmembranousseptum
Fig.6-99 Columellastrutwithseptalcartilage Fig.6-100 Medialcrural-septalsuture
Two mid and lower medial crural-septal sutures are just about to be tied.

209
Since the correction of a long nose accompanies swelling during surgery, the nasal tip may seem to be in a more
cephallic position. The length of the nose becomes longer postoperatively and slight over correction is necessary.
Fig. 6-103 is cases of the surgery.
208
ASIANRHINOPLASTY
Fig.6-102 Depressorseptinasimuscle
Fig.6-101 Lateralcrus-upperlateralcartilagesuture
a,b: Alar cartilages are moved upward by lateral crus-upper lateral cartilage
suture. c: Resected cephalic portion(with its minimal attachment to the alar
dome) of both lateral crus can be used for pulling upward the alar cartilage
by suturing itself to the upper lateral cartilage.
a b
c
Fig.6-103 Pre-andpostop.viewoflongnosecorrection
Case I a,b: preop. view, c: wide lateral crus and medial crus, d,e: partial resection of the cephalic portion of lateral crus and strip resection of medial crus, f:
columella strut graft with septal cartilage and medial crural-septal suture, g,h: postop. view Case IIi,j: preop. view, k,l: postop. view
a b c
d e f
g h i
j k l
Resected cephalic portion
of lateral crus

The area where the lateral crus of alar cartilage is connected to the upper lateral cartilage is called the scroll area
or intercartilagenous ligament. Separation of this area through dissection is the most significant technique for short
nose correction. Dissection should be done so that the thin whitish vestibular mucosa alone becomes left between
the upper and lower lateral cartilages (Fig. 6-107). If lengthening of the alar cartilage is not sufficient with the scroll
area dissection alone, disconnection of the accessory liagmenat helps additional lengthening (Fig. 6-108). Although
211
V. Advanced techniqies of the nasal tip plasty
: Short nose correction
A short nose indicates not only short length of a nose but also excessive nostril show. Therefore, correction of a
short nose implies extension of the nose length as well as decreasing nostril show. In the past, surgeons would
forcefully extended the length of the nasal tip by inserting L-shaped silicone implant up to the tip, this technique is
still used in some Asian countries. However, it can cause very serious side effects (Fig. 6-104).
An easy way to achieve a longer nose is to heighten the nasal bridge by using an implant and shield graft with
ear cartilage at the nasal tip (Fig. 6-105). However, it is limited in changing the tip shape and nostril show does not
improve. Thus, it should be used only for the correction of a very minor short nose.
The correction of an upturned nose is one of the most challenging surgical procedure. For correction, the
cartilage at the nasal tip as well as the skin and mucosa inside the nose work as limiting factors. Thus, to overcome
all the limiting factors, it is necessary to secure enough soft tissue release and relatively firm support.
The core elements of the surgery for a short nose correction that can extend the nose length and correct nostril
shoe are as follows.
a. Sufficient release of alar cartilage from upper lateral cartilage
b. Release of soft tissue
c. Fixation of lengthened alar cartilage
1.Releaseofalarcartilagefromupperlateralcartilage
Short nose correction is a surgical procedure that transfers the alar cartilage toward the caudal direction of the
nose, and separation should be made at the three areas that are holding the alar cartilage. These three areas are
upper lateral cartilage, accessory ligament (Hinge complex), and membranous septum (Fig. 6-106).
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ASIANRHINOPLASTY
Fig.6-104 Complicationoflongnasalsiliconeimplant
Nasal tip skin shows skin thinning and redness, which means the impending
implant exposure.
Fig.6-105 Tipelongationwithshieldgraft
Fig.6-106 Threeregionsthatholdthealarcartilageandrestrainits
caudalderotation
Fig.6-107 Releaseofscrollarea(intercartilagenousligament)
a b
c
Upper lateral cartilage
Alar cartilage

1) Septal extension graft
Septal extension graft is the most frequently and effectively used surgical intervention for the correction of a
short nose among Asians. Details of septal extension graft is described in Chapter 6. Harvested autologous cartilage
is fixed at the caudal or dorsal area of the nasal septum and then the dome of alar cartilage is fixed at the tip of the
fixed cartilage. For autologous cartilage, the nasal septal cartilage is most preferred but if it is difficult to use the
nasal septal cartilage, it is possible to use costal cartilage.
For septal extension graft, mainly two methods are used (Fig. 6-111). A method that fixes the cartilage graft at the
213
membranous septum release is not always necessary, it may help lengthening of the alar cartilage; therefore, it can
be used depending on the situation (Fig. 6-109).
2.Releaseofsofttissue
Although the position of alar cartilage is moved to the caudal direction of the nose, the surgical effect cannot be
promising unless the skin is fully extended. It is suggested to conduct skin dissection as wide as possible, and
detaching of the transverse nasalis muscle that is holding the skin from both sides helps skin extension (Fig. 6-110)
3.Fixationoflengthenedalarcartilage
There are two ways to maintain the extended and fixed alar cartilage.
a. Septal extension graft
b. Derotation graft
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ASIANRHINOPLASTY
Fig.6-108 Detachmentofaccessoryligament(hingecomplex)
a b
Fig.6-109 Releaseofmembranousseptum Release of fibrous tissue from the membranous septum, retaining only the thin whitish mucosa, can be
helpful for more downward movement of the medial crus of alar cartilage.
a b
Fig.6-110 Releaseofsofttissueenvelope
a: Dissection of the skin envelope must be wide enough, b: Transverse nasalis muscle detachment
a b
Fig.6-111 Twomaintypesofseptalextensiongraftforshortnosecorrection a: batten type, b: extended spreader type
a
b Extended spreader type
Batten type

215
caudal portion or caudal and dorsal portion of the nasal septum simulataneously is called batten type, while
extended spreader type is a method that fixes the cartilage graft at the dorsal part of the nasal septum. Since batten
type is relatively easier for beginners and produces favorable outcome, it is recommended. The author also prefers
this method (Fig. 6-112). However, when correcting a deviated nose simultaneously, extended spreader type that
fixes between the upper lateral cartilage and dorsal septum may be very useful (Fig. 6-113).
When fixing alar cartilage at the tip of the grafted cartilage after the fixation of the cartilage graft to the nasal
septum, the dome area of the alar cartilage should be fixed first (Fig. 6-114). And then, the area of the lateral crus or
medial crus is additionally fixed at the graft. For fixation, #5-0 PDS suture is used. Septal extension graft is
effective if intending to obtain strong projection and caudal rotation in case of an upturned nose or severely drooped
nasal tip.
2) Derotation graft
Alar cartilage is dissected from the upper lateral cartilage and extended by moving it toward the caudal direction
of the nose. Then the graft fixed at the upper lateral cartilage extends the alar cartilage in this surgical method (Fig.
6-115).
If the size of alar cartilage is not too small and the force working cephalically towards the forehead is not
excessive, it is possible to use derotation graft. For the graft, conchal cartilage is mainly used. In case of weak medial
crus, the tip defining point tends to be lower as the alar dome becomes pressed by the derotation graft and the point
214
ASIANRHINOPLASTY
Fig.6-112 Battentypeofseptalextensiongraft
a, b: preop., c: batten type of septal extension graft, d,e: postop.
a b c
d e
Fig.6-113 Extendedspreadertypeofseptalextensiongraft a, b: preop., c, d: postop.
c
a
d
b
Fig.6-114 Fixationofalarcartilagetothe
septalextensiongraft
a,b: before fixation,
c: Fixation of upper medial crus to the graft has
been finished and now the interdomal suture is
being done.,
d,e: after interdomal sutured
a
e
b c

VI. The causes and solutions
for unsatisfactory nasal tip plasty among Asians
1.Unsatisfactorytipheight
The causes of unsatisfactory tip height among Asians after a nasal tip plasty are as follows.
a. Weak or absent medial crus
b. Hanging medial crus
c. Absence of adequate onlay or shield graft in rounded tip(cephalic rotation of alar cartilage)
d. Thick and tight tip skin
e. Strong depressor nasi septi muscle
Let’s take a closer look for each cause.
1) Weak or absent medial crus
Medial crus supports the nasal tip and determines the tip height. Unlike Caucasians, general population have
very weak medial crus or even absent among Asians. In such cases, the tip height is very low, and it seems as if the
nose is sunken and squashy in absence of any firm supporting sensation when the nasal tip is pressed (Fig. 6-118).
Since weak medial crus of such nose fails to support the nasal tip in perforning tip on-lay graft alone, medial crus
tends to be twisted or distorted while causing lowered nasal tip (Fig. 6-119). Therefore, a patient with such nose
must be treated with tip on-lay graft while reinforcing the medial crus through columella strut or septal extension
graft (Fig. 6-120, Fig. 6-121).
2) Hanging medial crus (Fig. 6-122)
For a patient with hanging columella or those who show hanging columella when pressing the tip, performing
tip on-lay graft alone worsens hanging columella and causes tip height loss as a consequence. This results in failure
of achieving the desired tip height, thus correction of hanging columella must be performed together (Fig. 6-123).
3) Absence of onlay graft or shield graft in the situation of rounded tip caused by cephalic
rotation of alar cartilage after suture technique
Suture techniques or columella strut graft are surgical interventions commonly performed among plastic
surgeons in Asia. Since the direction of the lateral crus is toward the cephalic direction, the position of the tip after
the surgery is somewhat cephalically rotated and the lateral appearance of the nasal tip tends to be in round shape
(Fig. 6-124). Patients tend to say that the tip is upturned or not sharp enough.
Therefore for Asians with small and weak alar cartilage, suture technique should be considered a primary step
before shield graft or on-lay graft, rather than working to project the nasal tip by this technique alone. It is important
to combine proper suture technique and graft.
217
of the nasal tip appears to be drooped. In such case, it is necessary to place columella strut graft(Fig.6-116).
By adding shield graft or onlay graft to the above mentioned techniques, it is possible to derive nasal lengthening
and projection sufficiently (Fig. 6-117).
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ASIANRHINOPLASTY
Fig.6-115 Derotationgraft
Fig.6-116 Derotationgraftcombinedwithcolumellastrutgraft Fig.6-117 Shieldgraftonseptalextensiongraft

219
4) Thick and tight tip skin
For Asians, many cases involve thick and tight tip skin. As such nose fails to fully extend the tip skin after suture
technique or cartilage graft, there are many results that do not reach the desired height. Moreover, if on-lay graft is
executed without suture technique, graft cartilage cuts in the domes of the alar cartilages at both sides. For this
reason, the role to heighten the nasal tip is becomes obsolete (Fig. 6-20).
For patients with thick and tight tip skin, firm supportive power must be provided to the medial crus to withstand
the skin tension while executing on-lay graft. For this, columella strut graft or septal extension graft is essential.
5) Strong depressor septi nasi muscle
Among patients with smiling tip, tip drooping becomes obvious due to the action of DSN muscle after tip plasty.
The strong supportive power that can overcome the pulling power of muscle, for example, columella strut graft, is
essential; however, resection of the depressor muscle is also helpful (Fig. 6-125).
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ASIANRHINOPLASTY
Fig. 6-119 Long-term follow up of tip onlay graft placed on the weak medial crus a,b: Preop., This patient doesn’t have 2/3 of both medial crus (c,d),
thus, interdomal suture (e) and tip onlay graft were conducted simultaneously using conchal cartilage. The tip projection was maintained well up to 2
months after the surgery (f, h), but the nasal tip became droopy 1 year after surgery (g, i).
a b c
d e f
g h i
Fig.6-120 Columellastrutincasethemedialcrusisabsent a: absence of both medial crus, b: one pair of columella strut with septal cartilage
a b
Fig.6-118 Weakorabsentmedialcrus
a: Short and weak columella are displayed. In such case, the medial crus is weak (b) or its middle is disconnected (c).
d: Very short and weak columella due to congenital absence of both medial crus
e: Short columella(left side) and depressed ala(left side) due to congenital total absence of alar cartilage of left side
a b c
d
e

221
220
ASIANRHINOPLASTY
Fig.6-121 Septalextensiongraftincasethemedialcrusisabsent
a,b: preop., c: absence of medial crus,
d: septal extension graft with septal cartilage,
e: alar dome is fixed to the septal extension graft tip, f,g: postop. 1 yearg
e
c
a
f
d
b
Fig.6-122 Hangingcolumella
Fig.6-123 Importanceofhangingcolumellacorrectionforthetip
projection a: hanging columella, b: hanging columella aggravated when
tip is being pushed down, c: before interdomal suture, d: immediate after
interdomal suture (tip is not elevated, rather tip appears more rounded),
e: tip projection is clearly achieved immediately after hanging columella
correction (medial crural-septal suture) and tip onlay graft
c
a
d
b
e

2.Asymmetricnasaltip
a. Deviated, excessively long implant to the tip
b. Inadequate positioning of cartilage onlay graft
c. Asymmetric cartilage work-up
d. Deviated columella strut
e. Inadequate medial crural septal suture
f. Inadequate closure of incision
Details of each cause are as follows.
1) Deviated, excessively long implant to the tip
In Asia where dorsal augmentation is very common, an implant is frequently used. An implant is used only for
dorsum and use of cartilage graft is suggested for the tip plastry. However, there are some surgeons who insert an
implant up to the nasal tip. Such surgical treatment may cause skin redness at the nasal tip or exposure of the
implant. Also, in case of deviated implant, alar cartilage at the side of the tip is pressed causing asymmetric nasal
tip and nostril (Fig. 6-126). During revision surgery, the implant must be removed and the pressed alar cartilage must
be realigned. In general, it is necessary to use columella strut graft (Fig. 6-127).
223
222
ASIANRHINOPLASTY
Fig.6-124 Correctionofroundedtip(tiplesstip)
a: In an Asian patient, tip suture technique may only show the rounded tip appearance and it is not enough for the tip projection., b: Cartilage onlay graft is
necessary in such case., c: Rounded tip developed after suture technique of alar cartilage., d: More projected and attractive tip can be obtained by cartilage
onlay graft in case of rounded tip appearance caused by cephalic rotation of alar cartilage after suture technique.
c
a
d
b
Fig.6-125 Tiprevision:correctionoftipre-drooping
a,e: preop., b,f: 2 months after tip plasty with suture technique & cartilage onlay graft without columellar strut graft, c,g: Tip drooping developed (1 year
postoperatively) , d, h: Tip drooping has been corrected by columellar strut graft and depressor septi nasi m. resection.
e
a
g
cb d
f h
Fig.6-126 Tipandnostrilasymmetryfromimplanttipcompressionon
leftalarcartilage a: tip and nostril asymmetry, b: The edge of the implant
ispressingtheleftalarcartilage,c:Thedeformedalarcartilagedoesnot
recovernaturally regardless of implant removal.
a b
c

2) Inadequate positioning of cartilage on-lay graft
It is caused by failing to postion the cartilage on-lay graft or shield graft at the center of the nasal tip (Fig. 6-128).
Correction is possible by repositioning the cartilage graft at the center.
3) Asymmetric cartilage work-up
In case of asymmetric suture technique of alar cartiage, tip asymmetry occurs. Correction is possible through
new cartilage work-up; however, already deformed and distorted alar cartilage should be repositioned using a
columella strut graft (Fig. 6-129, Fig. 6-130).
4) Deviated columella strut
When a deviated columella strut is used, asymmetric nasal tip as well as nostrils may develop (Fig. 6-131). Of
course, there is no surgeon who would use a deviated strut during surgery; however, deviation may occur
postoperatively. The causes of such incidence are as follows.
a. When using weak and thin columella strut in spite of presence of asymmetric alar cartilage
b. When using the rib cartilage as a strut (delayed warping)
Such problems can be solved by removing the deviated strut and using a new strut.
5) Inadequate medial crural septal suture
If medial crural septal suture is applied to patients with caudal septal deviation, the columella as well as the nasal
tip becomes deviated. For patients with deviated caudal septum, medial crural septal suture should not be
performed without correction on the septal deviation.
6) Inadequate closure of incision
It is very important to suture the incison carefully after rhinoplasty. Suture should be done symmetrically from the
columella to the inside of the right and left nasal cavity. Otherwise, pinched tip or tip asymmetry may be developed.
225
224
ASIANRHINOPLASTY
Fig.6-127
Correctionoftip&columellaasymmetryduetodeviatedimplant
a, b: Long implant that was inserted up to the nasal tip is distorted causing
asymmetrical tip and columella.
c: The implant end is pressing the right alar cartilage.
d:Thedistortedalarcartilagedoesn’trecoverregardlessofimplantremoval.
e:correctionofdeformedalarcartilageusingcolumellastrutgraft withseptal
cartilage,
f, g: Corrected look of the asymmetrical tip and columella after the surgeryg
e
c
a
f
d
b
Fig.6-128 Deviatedconchalcartilageonlaygraft
a b

3.Pinchedtip
1) The causes of pinched tip
(1) Inadequate closure of inframarginal incision
In a rhinoplasty, suturing the incision is the final process; however, it is also an important procedure. For
suture, symmetry should always be achieved without tension. If such conditions are not satisfied, pinched tip
may occur (Fig. 6-132).
(2) Inadequate transdomal or spanning suture of lateral crus
In case of too tight/strong or deep trandomal suture or spanning suture of lateral crus for the correction of the
bulbous tip, it may cause pinched tip (Fig. 6-133).
(3) Distruption of lateral crus
In case of disrupted lateral crus, this area becomes depressed causing pinched tip, and sometimes it
accompanies internal valve or external valve insufficiency (Fig. 6-134).
(4) Overresection of cephalic portion of lateral crus
In case of overresection of the cephalic portion of the lateral crus to correct bulbous tip, the remained lateral
crus becomes weak causing buckling. Such phenomenon generates pinched tip (Fig. 6-135).
(5) Inadequate tip projection with implant
Among Asians, excessive projection of the nasal tip only with an implant alone or excessive tip on-lay graft
sometimes causes pinched tip (Fig. 6-136).
2) The solutions for the pinched tip
(1) Cartilage or dermal graft on pinched soft tissue
In cases without abnormal alignment or position of the alar cartilage but having narrow pinching of the soft
227
226
ASIANRHINOPLASTY
Fig.6-129 Correctionoftip&columellaasymmetryduetodeformedalarcartilage
a, b: preop view of deviated tip and nostril asymmetry, c: twisted medial crus due to previous asymmetric work-up of suture technique,
d: correction of asymmetric alar cartilage with columella strut, e,f: postop. View
Fig.6-130 Correctionofdeviatedanddeformedalarcartilage
a: preop, b: deformed alar cartilage due to asymmetric cartilage work-up, c: alar cartilage realignment with columella strut graft, d: postop
c
a
d
b
a b c
d e f
Fig.6-131 Deviatedcolumellastrut

tissue due to asymmetry occurred during skin suture, cartilage or dermal graft can be applied at the depressd area
for correction (Fig. 6-137)
(2) Alar contour graft
This is a good technique to achieve favorable results not only for pinching caused by abonormal lateral crus,
but also for various cases (Fig. 6-138).
(3) Lateral crural onlay graft
It is possible to correct ala collapse caused by buckling and discontinuity of the lateral crus as well as pinched
tip (Fig. 6-139).
(4) Lateral crural strut graft
It is effective for ala collapse caused by buckling or discontinuity of the lateral crus and especially, it is
excellent correction of internal valve collapse (Fig. 6-140).
(5) Umbrella graft
It recovers discontinuity of the lateral crus or dome and is possible to correct a narrow nasal tip by widening
the space between the domes (Fig. 6-141).
(6) Alar spreader graft
For pinched tip caused by excessively tight lateral crural spanning suture, alar spreader graft provides space
between the lateral crus and dome (Fig. 6-142).
(7) Caused by implant or tip on-lay graft
It is necessary to perform tip plasty that lifts the height of the dome itself after removal of the implant or on-lay
graft on the dome
229
228
ASIANRHINOPLASTY
Fig.6-132 Pinchedtipontheleftsideduetoinappropriateclosureofinframarginalincision
Fig.6-133 Pinchedtipdevelopedafterbulboustipcorrection
Left:beforeoperation,Right:afteroperation(Tootightandstrongtransdomal
&spanningsutureoflateralcrusisthemaincauseofthepinchedtip.)
Fig.6-134 Disruptionoflateralcrus
Fig.6-135 Pinchedtipduetobucklingoflateralcrus
a b
Fig.6-136 Pinchedtipduetotipprojectionwithimplant
a b
Gore Tex

231
230
ASIANRHINOPLASTY
Fig.6-137 Pinchedtipcorrection(dermalgraft)
c
a
d
b
Fig.6-138 Pinchedtipcorrection(alarcontourgraft) a : preop. view, b : postop. view
a b
Fig.6-140 Correctionofinternalvalvecollapse(lateralcruralstrutgraft) a: pinched tip appearance, b: internal valve is nearly closed due to the
collapse of lateral crus, c,d: postop. view (Pinched tip appearance is corrected and internal valve angle is increased.)
c
a
d
b
Fig.6-139 Pinchedtipcorrection
(lateralcruralonlaygraft)
a: preop. view,
b,c: intraop. view of lateral crural onlay
graft with conchal cartilage,
d: postop. viewc
a
d
b

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Fig.6-141 Umbrellagraft
Fig.6-142 Alarspreadergraft
a b
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