Nasal Tip Rhinoplasty

Nasal tip projection and rotation: profile harmony features

Nasal tip sculpture is both an intricate and complex aspect of rhinoplasty. However, it is of fundamental importance in determining also the harmony of profile. Patients seek the opinion of a rhinoplasty specialist due to a falling, globular or asymmetric tip. The cosmetic and functional aspects of the nose are intimately intertwined. This principle applies to the septum, turbinates, nasal tip, the “wings” of the lower lateral cartilages, and the columella, i.e. the lower portion of the nose.

Any alteration of shape and size of the external nose also affects its internal space. Altering nasal tip structure can significantly improve nose aesthetics, but requires thorough planning and precise execution to avoid respiratory issues, such as the collapse of the tip cartilages, which can severely damage breathing. The harmony of the profile and frontal views and the function of respiration depend on the concurrence of a series of elements, including the shape of nasal dorsum, wings, and tip.

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Determinants of harmony/disharmony of the shape of the nasal tip

Which elements determine the shape of the nose? The appearance of the tip of the nose depends on the shape, size, and firmness of the wing cartilages. However, nose surgery considers many other aspects including tip size, tip definition, width of the domes, nasal wings outline, nostrils edges, wing groove, and columella. Furthermore, an aesthetically pleasant nasal tip is devoid of post-surgical defects, such as pinching, asymmetries or other deformities.

The tip contributes to the harmony of the profile and the frontal views: a nose with a scarcely projected, drooping, flattened, globular or asymmetrical tip could benefit from targeted surgery. Similar to the surgical correction of the nasal hump, the remodeling of the tip requires a careful balancing of many anatomical components (cartilage, skin thickness, ligaments, muscles) that interact in defining its shape and function. The balance of all the components of the nose with each other and with the other aesthetic units of the face is the foundation of harmony.

Defects of the nasal tip and surgical correction

For simplicity, we can subdivide the main anatomical features of the nasal tip deformities into a series of general categories: globular tip, asymmetric tip, deviated tip, tip with defective projection or rotation (too projected or slightly projected). These variations all require a targeted rhinoplasty. The surgeon will assess the general conditions of the patient during a careful pre-operative analysis to establish the most indicated strategy.

  1. Globular tip rhinoplasty
  2. A globular tip is an unattractive tip with variable shape, namely: squared, trapezoid, bulging (ball-shaped) or bifid (visually separated into two parts by a central groove). The cartilages of the tip, or wing cartilages, are generally too bulky or “bulbous”, sometimes with unbalanced external convexity. The rhinoplasty of the bulbous tip usually begins with the selective removal of the redundant cartilage, avoiding dangerous excesses of resection. Then, the surgeon corrects the convexity and harmonize the globose tip by reshaping the outline of the wings with specific sutures or thin grafts, generally taken from the nasal septum of the same patient.

  3. Asymmetric tip rhinoplasty
  4. Countless variations of asymmetric nasal tip are due to the shape and position of the alar cartilages and their three constituents – lateral crus, medial crus, and dome. Also malposition of the caudal septum may cause tip asymmetry. Surgical results depend on a series of variables (including skin thickness) and are different from case to case. The experienced surgeon can obtain a satisfying symmetry by combining targeted cartilage resections, sutures, and grafts.

  5. Deviated tip rhinoplasty
  6. Nasal tip deviation is a frequent example of nasal disharmony. Two anatomical structures play a prominent role in the alignment of the nasal tip: the septum and the anterior-inferior nasal spine. The alignment of a deflected nasal tip often requires a septoplasty, followed by the correction of the nasal spine. The rhinoplasty expert can achieve the best possible result in each specific case by combining different technical options (including cartilaginous micro-excisions, grafts, and sutures). A perfect tip alignment is rare in nature and even after surgery. This is a salutary lesson for patients and novice surgeons.

  7. Defects of Tip projection
  8. Imagine drawing a vertical line between the most prominent point of the forehead and the most prominent point of the chin: this is the vertical plane of the face. To simplify, we can subdivide nose projection defects into two categories, according to the protrusion of the tip from this imaginary line: if it is excessive, the tip is over-projected; if it is insufficient, the tip is under-projected. The rhinoplasty specialist measures the projection of each nose with numerical and angular parameters. An excessively or poorly projected tip of the nose can be modified through many different techniques.

    4.1 Over-projected tip rhinoplasty

    In over-projection, the imbalance of the tip is often associated with a high dorsum and tethered upper lip. The correction of a tip that is too forward may require the modification of nasal dorsum (frequently associated with a nasal hump), septum, spine, and wings. The mutual proportions of the anatomical components will determine the naturalness and harmony of the rhinoplasty results, in careful consideration of all the aforementioned individual variables.

    4.2 Falling or under-projected tip rhinoplasty

    The correction of a poorly projected tip, especially when it is also curved and descending requires lift and support. Usually the surgeon reinforces the columella or the final portion of the septum with grafts of cartilage taken from the septum (columellar strut or septal extension graft). Other surgical options include special suturing techniques. The tongue-in-groove suture is a powerful tool to maintain tip position but it requires specific technical abilities.

As we have seen, surgical correction of an irregular nasal tip may involve several different techniques, some of which are quite elaborate. The experienced rhinoplasty specialist chooses the technique according to the particular case and applies the selected procedure with precision and versatility.

The objective is to create a support that remains stable over time for the raised, shortened, or lengthened tip. The new position of the nasal tip must indeed remain adequate while smiling and adapt to the individual features.

Is it possible to lift the tip of the nose without full rhinoplasty? Although the patient may only request changes of the tip, surgery may also involve other parts of the nose, or the face, as the tip cannot be considered in isolation. A harmonious tip must fit with its surrounding structures naturally and seamlessly.

Nasal tip surgical correction: open or closed approach

The surgeon combines different methods to modify the shape and position of the nasal tip. Limited cartilage resections, autologous grafts (i.e., taken from the same subject, when possible from the nasal septum), and various types of sutures are the most common techniques used by rhinoplasty surgeons. Tip sculpture should be designed and implemented without surgical excesses, which can lead to severe complications.

There are no universally valid techniques for nasal tip plasty. The surgeon can opt for open rhinoplasty, which offers an opencast view of anatomy, or for closed rhinoplasty, which in experienced hands can also give natural and refined results, while minimizing surgery and healing times.

Dr. Pietro Palma has developed a method that combines the main advantages of the two traditional approaches (open and closed rhinoplasty). Highly versatile, his Hybrid Rhinoplastyincreases the chances of success in rhinoplasty thanks to careful pre-operative assessment and targeted surgery. Reconstituting normal anatomy is the strongest foundation for a tailor-made rhinoplasty of the tip.

Nasal tip plasty with Dr. Pietro Palma in Milan

Dr. Pietro Palma is available for evaluating the opportunity to correct an unattractive nasal tip with a targeted rhinoplasty. More than 25 years of experience and exclusive dedication to nasal surgery have allowed Dr. Palma to master this sophisticated craft. His super-specialization sets the scene for treating the most complex cases – including critical revisions.

Considered one of the leading experts in rhinoplasty in Europe, Dr. Palma is available for consultation at Clinica del Viso or Casa di Cura La Madonnina, both in Milan, and easily accessible from all over Italy and abroad. From subtle aesthetic changes to major reconstructions, from humpectomies to tip sculptures, every case deserves and receives the undivided attention of the specialist. For more information about nasal tip surgery and the costs of rhinoplasty procedure, please contact Clinica del Viso (Piazza Repubblica, 21 – Milan – Tel +390263611932 – info@youniquerhinoplasty.com) or Casa di Cura “LA MADONNINA” (Via Quadronno, 29 / 31 – Milan – Tel +390258395555 – cup.cclm@grupposandonato.it).


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