Archives of the Balkan Medical Union vol. 53, no. 4, pp.

568-572
Copyright © 2018 Balkan Medical Union December 2018

ORIGINAL PAPER

DIFFERENT TECHNIQUES IN TIP RHINOPLASTY

Amir ALSHEHARI1,2 , Serban Arghir POPESCU1, Ioan LASCĂR1
1
„Carol Davila“ University of Medicine and Pharmacy, Plastic Surgery and Reconstructive Microsurgery
Department, Clinical Emergency Hospital of Bucharest, Bucharest, Romania
2
Bombay Hospital, Plastic Surgery Department, Mumbai, India

Received 17 Sept, Corrections received 29 Oct 2018, Accepted 16 Nov 2018

https://doi.org/10.31688/ABMU.2018.53.4.13

ABSTRACT RÉSUMÉ

Background. Rhinoplasty is considered as one of the Techniques différentes de la rhinoplastie de la pointe

most challenging objectives in plastic surgery and tip nasale
rhinoplasty is arguably the greatest challenge for the
surgeon performing rhinoplasty. No routine tip pro- Introduction: La rhinoplastie est considérée comme
cedure is ever used and there are many ways to recon- l’un des objectifs les plus provocateurs dans la chirur-
struct and make nasal tips more attractive. gie plastique et la rhinoplastie de la pointe nasale le
Objective. The aim of this study was to evaluate the plus controversé défi face au chirurgien qui la pratique.
different correction techniques, in order to improve Il n’y a aucun procédé de routine utilisé et il existe
the outcomes in tip rhinoplasty. beaucoup de méthodes de reconstruction qui rendent
Methods. A prospective study was performed, includ- la pointe nasale plus attrayante.
ing all patients with nasal tip deformities who under- But: Le but de cette étude est l’évaluation des diffé-
went closed or open rhinoplasty between December rentes techniques de correction afin d’améliorer les
2015-August 2016 in Bombay Hospital, India. The pa- résultats dans la rhinoplastie de la pointe nasale.
tients were divided into two groups: group A – treated Méthodes: On a réalisé une étude prospective sur
with various types of tip sutures (12 cases), and group tous les patients avec des anomalies de la pointe nasale,
B – treated with combined tip sutures and grafts (18 soumis à une rhinoplastie fermée ou ouverte entre
cases). décembre 2015-aout 2016, à l’Hôpital de Bombay, de
Results. The study included 30 patients, 24 (80%) fe- l’Inde. Les patients ont été divisés en deux groupes : le
males and 6 (20%) males. 12 (40%) were patients with groupe A – ou les patients ont été traités par de divers
bulbous tips, 7 (23%) were patients with droopy tips, types de sutures (12 cas) et le groupe B dont les patients
5 (17%) were patients with boxy (broad) tips, 3 (10%) ont été traités par des sutures et des greffes de la pointe
were patients with wide tips, and 3 (10%) were patients nasale (18 cas).
with bifid tips. A total of 27 (90%) cases involved pri- Résultats: L’étude a compris 30 patients, 24 (80%)
mary rhinoplasties, and 3 (10%) cases involved revi- femelles et 6 (20%) mâles. Douze patients (40%) aux
sion. Patient’s and doctor’s satisfactions were recorded pointes nasales bulbeuses, 7(23%) patients aux pointes

Address for correspondence: Amir ALSHEHARI

Plastic Surgery& Reconstructive Microsurgery Department, Clinical
Emergency Hospital of Bucharest, Bucharest, Romania
Address: Calea Floreasca no.8, 014461, Bucharest, Romania
Email: Dr_Amir17@hotmail.com, phone 0754018744
 Archives of the Balkan Medical Union

by a score from 0 to 3, with 0 being the less satisfied by nasales retombées, 5 (17%) avec des pointes nasales
the result of surgery and 3 being the highest satisfied. grosses, 3 (10%) patients avec des pointes nasales élar-
Conclusion. Aesthetic outcome following the man- gies et 3 (10%) patients avec des pointes nasales bifides.
agement of nasal tips deformities with combined su- Un total de 27 (90%) cas a impliqué des rhinoplasties
ture techniques and grafts is more satisfactory than the primaires et 3 (10%) cas une révision. Les satisfactions
outcome that can be achieved following suture alone, du patient et du docteur ont été enregistrées par un
especially in certain cases. score de 0 à 3, 0 signifiant le résultat de l’opération le
moins satisfaisant et 3 une satisfaction au plus haut
Keywords: rhinoplasty, nasal tip, suture techniques, degré.
grafts. Conclusions: Le résultat esthétique après l’approche
chirurgicale des anomalies de la pointe nasale par des
techniques combinées de suture et de greffe est plus sa-
tisfaisant que celui obtenu par seule la suture, surtout
dans certains cas.

Mots-clefs: rhinoplastie, pointe nasale, techniques

de suture, greffes.

INTRODUCTION MATERIAL AND METHODS

The nasal tip is the most challenging part of rhi- We performed a prospective study on 30 pa-
noplasty, because it plays a very significant role in tients admitted for rhinoplasty to Bombay Hospital,
the achievement of a functional, aesthetically pleas- India, between December 2015 and August 2016. We
ing, and natural result1. Rhinoplasty is challenging, included all patients who underwent aesthetic rhino-
due to the complex relationship of nasal anatomic plasty with nasal tip deformity. All the patients with-
structures and the variety of techniques available to out nasal tip surgery or less than 18 years old were
excluded from this study. Written informed consent
alter them2.
was obtained from all patients. The study has been
The length, width, strength, shape, and position
approved from ethics committee of the hospital.
of the lower lateral cartilages and the ligamentous
In this study, patients were divided according to
attachments between these paired structures are tip intervention into two groups. Patients in Group
critical in supporting the nasal tip. The upper lateral A were treated with various types of tip sutures, and
cartilages, nasal septum, nasal base, and pyriform patients in Group B were treated with combined tip
aperture provide additional stability and support to sutures and grafts.
the nasal tip through their soft- tissue attachments3. All patients underwent the preoperative evalua-
Due to anatomical variations and complexity of the tion in the form of history taking, physical examina-
nasal tip deformities, no single technique is adequate tion, complete laboratory investigations, psychiatric
to correct the anatomical presentations of the nasal evaluation, and photographic evaluation and docu-
tip. Therefore, preoperative planning is the basis of mentation. Standard medical photography of patients
rhinoplasty. The surgeon must have the technical was performed preoperatively and postoperatively.
skills required and the experience to take advantage The surgical outcome was assessed in this study
of them to achieve the best aesthetic and functional by a subjective method that evaluated the patient’s
result1,4-8. and the doctor’s satisfaction through a questionnaire.
A successful outcome is predicted by appropri- A four points score was used for both the patient and
the surgeon to document their satisfaction with the
ate patient selection. Time spent developing a good
final results of surgery as follows:
relation with the patient and listening to his con-
0, Bad: results are not accepted and revision surgery
cerns during this visit is time well spent. Although is needed.
an operation may be perceived as a technical success 1, Fair: results are acceptable (mild improvement).
by the surgeon, it may not satisfy the patient who 2, Good: results are satisfactory with reservations
is the ultimate judge. Full disclosure of the physical 3, Excellent: results are satisfactory without reserva-
and psychological motivations of the patient and the tions.
limitations perceived by the surgeon are essential to Statistical analysis: data were analyzed using
avoid confusion, misgivings, and dissatisfaction4,9-12. SPSS version 24. Categorical variables are expressed as

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Different techniques in tip rhinoplasty – ALSHEHARI et al

Table 1. Postoperative outcomes in all patients –

degree of satisfaction.
Variable Mean ± SD / No. (%)
Bad 2 (6.7%)
Satisfaction Fair 3 (10%)
of the pa-
tients Good 9 (30%)
Excellent 16 (53.3%)
Bad 2 (6.7%)
Satisfaction Fair 1 (3.3%)
of the doctor Good 16 (53.3%)
Fig. 1. The percentage of different types of nasal tip
deformity in patients included in the study. Excellent 11 (36.7%)

Table 2. Comparison of post-operative satisfaction between operation groups.

Operation Group
Group 1 Group 2
Variable P. value
Suture (No. = 12) Suture and Graft (No. =18)
No. (%) No. (%)
Bad 1(8.3%) 1(5.6%)
Satisfaction of the Fair 2 (16.7%) 1 (5.6%) 0.671
patient Good 4 (33.3%) 5 (27.8%) NS
Excellent 5 (41.7%) 11 (61.1%)
Bad 2 (16.7%) 0 (0.0%)
Fair 0 (0.0%) 1 (5.6%)
Satisfaction of the 0.135
Good 7 (58.3%) 9 (50%)
doctor NS
Excellent 3 (25%) 8 (44.4%)
No 12 (100%) 16 (88.9%)
NS = non-significant statistically

number and percentage and continuous variables ex- columellar area and only one case of hemorrhage),
pressed as mean and standard deviation. Comparison quickly resolved without consequences in the early
of categorical variables between groups was done us- postoperative period.
ing Chi Square (X2) test and between continuous vari- In this study, we assessed the degree of satisfac-
ables using independent sample T- test. P. value less tion of the surgical outcome, by the patient’s and the
than 0.05 was considered statistically significant. surgeon’s impression. The level of patient satisfaction
in all patients, regardless of operation group, was
RESULTS excellent in 16 patients (53.3%), good in 9 patients
(30%), fair in 3 patients (10%) and bad in 2 patients
The study included a total of 30 patients, 24 (6.7%) (Table 1). The level of doctor’s satisfaction in
(80%) females and 6 (20%) males, with mean age all patients, regardless of operation group, was ex-
of 29.07 ± 5.04 years. In the current study, for the cellent in 11 patients (36.7%), good in 16 patients
purpose of analysis of the deformities, the patients (53.3%), fair in 1 patient (3.3%) and bad in 2 patients
were classified into two groups: Group A included 12 (6.7%) (Table 1). There was no significant difference
(40%) patients who undergone tip suture only, Group in patient’s satisfaction or in doctor’s satisfaction be-
B included 18 (60%) patients who had undergone tip tween both groups, as shown in Table 2.
sutures and graft. Regarding the nasal tip deformity,
the most common deformity in this study was bul- DISCUSSION
bous tip in 40% cases, followed by droopy tip in 23%
cases, then boxy tip in 17% cases, wide tip in 10% Successful rhinoplasty begins with the careful
cases, and bifid tip in 10% (Fig. 1). All patients were preoperative preparation to understand the patient’s
operated in this study by the same plastic surgeon. expectation; planning and communication with the
Minor complications were rarely observed (two patients are extremely important to identify any un-
cases of minor infection around stitches in the realistic expectations5, 13-16.

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Kuran et al and others evaluated the long-term relationship of the tip with the rest of the nose, as
effects of tip sutures and tip cartilage grafts, and sug- well as face. During rhinoplasty, all anatomic struc-
gested that cartilage grafts should be considered as tures and the relationships between them should be
cases in which dimensional changes are a priority. protected. If we cannot protect them, we should re-
If minor dimensional changes with more rotational construct again. Also, repair of nasal ligaments allows
alterations are planned, tip-suture techniques that surgeons to control tip rotation, enhance projection,
provide sculpting the nasal tip with a long-lasting sat- and emphasize a supratip break. The management
isfactory aesthetic outcome should be preferred6, 17-19. of nasal tip deformities with various suturing tech-
A columellar strut graft can affect tip rotation niques helps to control nasal tip dynamics. However,
and projection. In a study of its effect on nasal tip the aesthetic outcome following a combination of
position, Rohrich et al concluded that the columel- both techniques was more satisfactory than the out-
lar strut cartilage graft does not necessarily imply an come achieved using either one of them, and also cer-
increase in tip projection, but rather serves to unify tain cases, including thick skin, posttraumatic, and a
the nasal tip and helps to control the final position weak lower lateral cartilage usually require combined
of the tip5, 20-23. techniques to provide the optimum cosmetic results.
In this study, we tried to protect all anatomi-
cal structures and the relationships between them.
If we couldn’t protect them, we should reconstruct Compliance with Ethics Requirements:
them again. The nasal tip is anatomically supported „The authors declare no conflict of interest regarding
over the anterior septum and suspended by ligamen- this article“
tous attachments such as Pitanguy’s ligament, scroll „The authors declare that all the procedures and ex-
ligaments, and cephalic attachments to the pyriform periments of this study respect the ethical standards in the
aperture10,24, 25. Çakır et al advocate delicate dissec- Helsinki Declaration of 1975, as revised in 2008(5), as
tion, preservation, and repair of Pitanguy’s midline well as the national law. Informed consent was obtained
ligament, which enables the surgeon to control tip from all the patients included in the study“
rotation, enhance projection, and emphasize a su- „No funding for this study“
pratip break by ligamentous manipulation of the
nose. Rhinoplasty dissection by the open approach
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