Pinched or Asymmetric Tip

A pinched or asymmetric nasal tip is another common issue for which patients consider a revision rhinoplasty consultation. The shape of the tip of the nose is primarily determined by the shape of the lower lateral cartilages, also called the tip cartilages. The asymmetry and pinching can certainly range in severity from mild to severe and the degree of each will determine what needs to be done during a revision rhinoplasty to correct the issues.

The lower lateral cartilages may naturally be too large, wide or round in shape, creating a bulbous or boxy tip for which patients often seek the procedure in the first place. When refining a nasal tip, it’s important that surgeons use techniques to reshape these cartilages that still respect the integrity and strength of the cartilages. If too much of the cartilage is removed, the remaining cartilages may not be strong enough to resist the force of contracture of the skin and soft tissue in the weeks or months after surgery. Dr. Mehta generally uses an open structural approach to modifying the shape of the tip. Conservative shaving of the cartilages combined with the use of permanent sutures to reshape the cartilage helps to maintain the strength of the tip cartilage framework.

Pinched Tip Nose JobIf patients present for a revision rhinoplasty consultation with a pinched or asymmetric tip, Dr. Mehta carefully examines the nose to determine the precise cause(s) of these issues. The septum is also carefully examined by pressing it with a Q-tip. This helps to determine if the septal cartilage has been removed or is still present. If the patient has very weak or flimsy nostrils, there may even be collapse of the sides of the nostrils with breathing in. Lifting the nostrils out with a Q-tip may improve breathing and suggest that strengthening the tip may help improve the function of the nose. In these cases, insurance coverage may help offset some of the cost of the surgery.

The most commonly used cartilage grafts to address a pinched or asymmetric tip are called lateral crural strut grafts. These are strong, straight pieces of cartilage taken from the septum, ear, or rib, and laid underneath the existing tip cartilages. This helps to support and strengthen the cartilages and reshapes them in a way which is symmetric with the opposite side. Another benefit is that these grafts prevent collapse of the cartilages while breathing in. The grafts are generally stitched in place using permanent sutures. Dr. Mehta’s preference is to use 5-0 prolene suture for this maneuver.

Other commonly used grafts for reshaping the tip include columellar struts, rim grafts, batten grafts, shield grafts, and caudal septal extension grafts. Suture techniques such as individual domal sutures, flattening sutures, septocolumellar sutures, and tongue-in-groove sutures may also be used.

If the asymmetry is minor and there is too much cartilage on one side, a simple shaving of the cartilage called a cephalic trim can be used. In some cases, a closed or endonasal approach may be possible. This is an option if the tip cartilages feel adequately strong during the consultation.

Asymmetric Nasal TipThe bottom line is that every nose is different and the revision rhinoplasty surgeon must be able to carry out a variety of techniques for addressing the tip of the nose. In general, it is advisable to begin with conservative techniques and proceed with more advanced maneuvers if required. Generally an open approach is required though in some cases an endonasal (closed rhinoplasty) can be used.

If you would like to seek a revision rhinoplasty consultation with Dr. Mehta, please contact us below.