Positioning the Nasal Tip in Rhinoplasty | Journal CME Article-Journal CME Article: Positioning the Nasal Tip in Rhinoplasty (Article)

Journal CME Article: Positioning the Nasal Tip in Rhinoplasty (Article)

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This continuing medical education article comprehensively reviews nasal tip positioning in rhinoplasty, focusing on optimizing nasal tip projection, rotation, and symmetry. It emphasizes the importance of detailed anatomical analysis of the nasal tip, including key structures such as the lower lateral cartilages (LLCs), upper lateral cartilages (ULCs), suspensory ligament, caudal septum, and associated ligaments and muscles (e.g., depressor septi). Understanding these anatomical contributors is critical for achieving and maintaining long-term nasal tip stability.<br /><br />The article discusses the widely used Anderson tripod concept, which conceptualizes the nasal tip as a tripod formed by paired LLCs. Adjusting the lengths and orientations of the tripod’s legs influences tip position, but the concept has limitations, especially when domes are reconstructed in new locations.<br /><br />Assessment of the nasal tip involves evaluating projection, rotation, and deviation using standardized methods such as the Goode ratio and nasolabial angle, with attention to individualized patient factors like sex, ethnicity, and preferences. Ideal ranges and ratios are outlined but should not be universally applied.<br /><br />Various surgical techniques to modify the nasal tip are described, categorized into cartilage resections, cartilage modifications, structural cartilage grafts, suture techniques, and onlay grafts:<br /><br />- Cephalic rotation is commonly achieved through caudal septal resections, cephalic resections of LLCs, lateral crural overlay (LCO), lateral crural steal (LCS), and tongue-in-groove (TIG) sutures.<br /><br />- Caudal rotation, more typical in revision rhinoplasty, requires release of scar tissue and soft-tissue accommodation; structural grafts like extended spreader grafts (ESG) and septal extension grafts (SEG) provide long-term support.<br /><br />- Projection increases mainly rely on columellar struts, SEGs, and onlay tip grafts (preferably mastoid fascia), while deprojection is addressed via medial crural resection (MCR) combined with methods like LCS.<br /><br />- Tip straightening uses asymmetric overlays, resections, and sutures, often supplemented with grafting for support.<br /><br />Tables summarize the relative effects, pitfalls, and complications of each maneuver. The authors recommend a patient-centric, individualized approach over algorithmic protocols, integrating anatomical understanding with tailored surgical strategies to optimize outcomes in both primary and revision rhinoplasty.

Keywords

nasal tip positioning

rhinoplasty

nasal tip projection

nasal tip rotation

nasal tip symmetry

Anderson tripod concept

lower lateral cartilages

septal extension grafts

Goode ratio

cephalic rotation techniques