Bulbous Nasal Tip: How Tension Might Prolong Your Longevity

When it comes to surgery for the wide and bulbous nasal tip, using a load-bearing wall constructed out of autologous cartilage can balance the tension within the existing tip complex to produce durable functional and aesthetic results, a rhinoplasty expert said during an invited presentation at the Triological Society Combined Sections Meeting.

Richard Davis, MD, clinical professor of facial plastic and reconstructive surgery at the University of Miami and Western Section Guest of Honor at the meeting, described the main feature of his approach, a septal extension graft (SEG), used as a “central support tower,” analogous to a suspension bridge with a tower in the middle and suspension cables extending from both sides. “If you use it as an adjunct to skeletal support, a SEG can provide an anatomic tent pole, if you will, from which to suspend the lower nasal side walls,” he said.

Bulbous nasal tips can bring about not just aesthetic problems, but also functional issues, since bulbous cupping of the tip cartilages also causes recurvature.

The “age-old workhorse” of tip refinement—the cephalic trim approach—often produces functional and even aesthetic morbidity, Dr. Davis said, because it destabilizes the skeletal structures of the nose, causing nasal distortion and collapse. “Soft tissue healing forces, which can take decades to complete, will frequently exacerbate progressive deformities such as pinching, retraction, and over-rotation, and often all three will occur in the same patient,” he said.

Tip sutures, another common approach, can pinch off the airway even if there are aesthetic improvements.

You have to individualize. … It’s not a cookbook and you have to think it through, but it works. —Richard Davis, MD

With his “tensioning” approach, Dr. Davis said, the first principle is to keep as much natural skeletal tissue as possible, which will mean more strength and stability over time. The surgeon must then augment naturally deficient or iatrogenically weak noses with structural grafts that are securely suture-fixated to the existing skeletal components, he added. “We’re trying to re-engineer tip dynamics so as to reduce dependence upon bulky and cumbersome grafts that often obstruct the nasal airway.”

The septal extension graft, which serves as a load-bearing wall and central support tower hidden within the central compartment, “will bear the structural load and balance forces in the tip to maintain strength and tone in the side walls.” Tensioning the side wall is a way of creating a “taut, flat, and attractive lateral crus” that will increase resistance to inspiratory collapse without the need for sidewall grafts, he said.