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COSMETIC

The Two Essential Elements for Planning TipSurgery in Primary and Secondary Rhinoplasty:Observations Based on Review of 100Consecutive Patients

Mark B. Constantian, M.D.Nashua and Hanover, N.H.

Nasal tip surgery has become significantly more complex since the introduction of tipgrafting and the many suture designs that followed the resurgence of open rhinoplasty.Independent of the surgeon’s technical approach, however, is the need to identify thecritical anatomical characteristics that will make nasal tip surgery successful. It is theauthor’s contention that only two such features require mandatory preoperative iden-tification: (1) whether the tip is adequately projecting and (2) whether the alar cartilagelateral crura are orthotopic or cephalically rotated (“malpositioned”). Data were gen-erated from a review of 100 consecutive primary rhinoplasty patients on whom theauthor had operated. The results indicate that only 33 percent of the entire group hadadequate preoperative tip projection and only 54 percent had orthotopic lateral crura(axes toward the lateral canthi). Forty-six percent of the patients had lateral crura thatwere cephalically rotated (axes toward the medial canthi). Both inadequate tip pro-jection and convex lateral crura were more common among patients with malposi-tioned lateral crura (78 percent and 61 percent) than in patients with orthotopic lateralcrura (57 percent and 20 percent, respectively). Tip projection can be reliably assessedby the relationship of the tip lobule to the septal angle. Malposition is characterized byabnormal lateral crural axes, long alar creases that extend to the nostril rims, alar wallhollows, frequent nostril deformities, and associated external valvular incompetence.The data suggest that the surgeon treating the average spectrum of primary rhinoplastypatientswill seeamajority(61percent)whoneedincreasedtipsupportandasignificantnumber (46 percent) with an anatomical variant (alar cartilage malposition) that placesthese patients at special risk for postoperative functional impairment. Correction ofexternal valvular incompetence doubles nasal airflow in most patients. As few as 23percent of primary rhinoplasty patients (the number with orthotopic, projecting alarcartilages in this series) may be proper candidates for reduction-only tip procedures.When tip projection and lateral crural orientation are accurately determined beforesurgery, nasal tip surgery can proceed successfully and secondary deformities can beavoided. (Plast. Reconstr. Surg. 114: 1571, 2004.)

The traditional aphorism, “as the tip goes, sogoes the rhinoplasty,” still applies, but itsimplications have become even more com-

plex since the introduction of tip grafting and thenumerous suturing techniques that followed theresurgence of open rhinoplasty. Against the back-drop of the currently available tip approaches

(closed, open, extended closed, or extendedopen) and techniques (reduction, resection,transposition, and/or suturing), any of which canbe used with grafts or struts, the permutationsquickly become overwhelming. I sympathize with

From the Departments of Surgery (Plastic Surgery), St. JosephHospital and Southern New Hampshire Medical Center, andDartmouth Medical School.Received for publication November 19, 2003; revised Feb-ruary 2, 2004.Presented at the Annual Meeting of the New England Societyof Plastic and Reconstructive Surgeons, Inc., in Manchester

Village, Vermont, June 2, 2002. Winner of the Founders’ Award,New England Society of Plastic and Reconstructive Surgeons, Inc.,2002.Reprinted and reformatted from the original article published withthe November 2004 issue (Plast Reconstr Surg. 2004;114:1571–1581).Copyright ©2012 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e3182507a92

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those surgeons who prefer the days when the onlyalar cartilage technique was reduction.

Independent of the surgeon’s technical ap-proach, however, is the need to identify the criticalanatomical characteristics that make nasal tip sur-gery successful. It is the author’s contention that onlytwo tip features need mandatory preoperative iden-tification, regardless of the surgeon’s technical plan:(1) whether the tip is adequately projecting and (2)whether the alar cartilage lateral crura are ortho-topic or cephalically rotated (“malpositioned”).1The degree of tip projection must be accuratelyassessed because a straight postoperative profilecannot be obtained without adequate projection.The lateral crural axis must be identified becausecephalically rotated lateral crura not only producecharacteristic tip configurations that may modifythe surgical plan but also provide insufficientstructural support to the external nasal valves. Thedegree of external valvular competence must beassessed preoperatively to avoid inadvertent injuryto the nasal airway.

The purpose of this article is to describe theincidence of these two alar cartilage characteristicsin 100 consecutive primary rhinoplasty patients onwhom the author operated, and to detail the prac-tical implications of tip projection and lateral cru-ral orientation for planning and performing pri-mary and secondary rhinoplasty.

PATIENTS AND METHODSPatient Population

A chart review was performed of 100 consec-utive primary rhinoplasty patients (81 women, 19men) on whom the author had operated beforeFebruary of 2002 and in whom postoperative fol-low-up had been at least 12 months. The meanpatient age was 36 years (range, 14 to 72 years).

Surgical TechniqueAll reconstructive rhinoplasties were performed

endonasally. Inferior turbinectomy was not per-formed. I use Sheen and Sheen’s methods withvery few modifications.2–5 Only autogenous mate-rials were used for the nasal reconstructions; un-less specifically stated otherwise, all grafts werecreated from septal cartilage and bone. A brand ofexpanded polytetrafluoroethylene (1-mm Gore-Tex SAM facial implant; W. L. Gore and Associ-ates, Flagstaff, Ariz.) provided maxillary augmen-tation in some cases.

Cephalically rotated lateral crura that weresufficiently convex or malformed were exposedthrough incisions 2 to 3 mm above each alar rimand therefore caudal to the malpositioned lateralcrural edges. Each crus was separated by sharpdissection from its external and vestibular skinattachments, resected at the lateral genu, lightly

Fig. 1. Technique of resection and replacement of malpositioned lateral crura used in mostpatients. (Left) Resected lateral crus, divided at the lateral genu. (Right) Crus flattened,trimmed, and placed along the alar rim.

Volume 129, Number 5S • Tip Surgery in Rhinoplasty

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crushed, trimmed to the appropriate size, andreplaced along the alar rim, where it was immo-bilized by catching the edge of the graft in thewound closure with 6-0 chromic suture (Fig. 1).

Definition of Anatomic TermsThe anatomic characteristics being tabulated

were defined as follows: “adequate tip projection”

defined any tip that projected to or beyond thelevel of the anterior septal angle, whereas “inad-equate tip projection” defined any tip that did notproject to the level of the anterior septal angle.6Lateral crural orientation was defined by the axisof the crus lateral to the lateral genu. In patientswith orthotopic lateral crura, each axis ran towardthe lateral canthus of the ipsilateral eye (Fig. 2,

Fig. 2. (Above) Patient with orthotopic lateral crura and (below) patient with malpositioned lat-eral crura. Both patients have adequate tip projection. (Left) Preoperative views and (right) 2-yearpostoperative views. Note the surface contour conferred by the different lateral crural positions.

Plastic and Reconstructive Surgery • Spring 2012

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above and inset); in patients with cephalically ro-tated lateral crura, the axis ran toward the ipsilat-eral medial canthus (Fig. 2, below and inset). Forbrevity and because the original term 1 is familiarto most readers, “malpositioned” will be used inthis article to describe cephalically rotated lateralcrura.

Rhinomanometric Measurements andStatistical Methods

Inspired nasal airflow was measured preoper-atively and at postoperative intervals according toa protocol described previously, using anteriormask rhinomanometry in airways decongested bytopical 1% phenylephrine hydrochloride to min-imize the effects of mucosal factors and nasal cy-cling. Independent measurements were made ofeach nasal passage during a standard 14-secondtest. Geometric mean nasal airflow was calculatedas the square root of the product of the volumesinspired through each airway. The developmentand rationale of our methods have been docu-mented previously.7,8

RESULTSIn this group of 100 consecutive primary rhi-

noplasty patients, only 33 percent had adequatepreoperative tip projection; 67 percent had inad-equate tip projection. Fifty-four percent had or-thotopic alar cartilage lateral crura, whereas 46percent had malpositioned lateral crura (Table I).There was no overlap between this group andprevious series reported by the author.5,6

When the data were subdivided further (TableII), both tip projection and lateral crural convexitydiffered between those patients with malposi-tioned lateral crura and those with orthotopic lat-eral crura. Forty-three percent of the patients withorthotopic lateral crura had adequate tip projec-tion, and only 20 percent of the lateral crura wereconvex. In contrast, only 22 percent of the patientswith malpositioned lateral crura had adequate tipprojection (Fig. 3); 78 percent were inadequatelyprojecting (Fig. 4). Convex (“bossed”) lateral

crura were also considerably more common (Fig.5) than flat lateral crura (Fig. 4) in patients withmalposition.

DISCUSSIONThe rhinoplasty literature has devoted exhaus-

tive and justifiable attention to the small, pared alarcartilages. Their morphology has been detailed,9,10

and seemingly countless techniques describe meth-ods of improving alar cartilage contour.11–16 The in-creasing interest in open rhinoplasty has itself gen-erated significant innovations for modifying tipshape with sutures or grafts,17–23 in turn amplifyingthe augmentation methods that had been describedpreviously for the endonasal approach.3,24–30 Evenfor the experienced surgeon, it is easy to get over-whelmed by the options and become distracted fromthe primary issue in planning tip surgery, that ofmaking the correct diagnosis.

If the goals of any rhinoplasty are reduced totheir simplest elements (creating a straight dor-sum and maintaining or increasing the size of theairway), the alar cartilages participate in both ob-jectives by controlling tip projection and externalvalvular support. Even without considering thenuances of tip angularity, lobular size, nostril pro-portion, and other factors, the surgeon who canaccurately assess tip projection and external val-vular support is already prepared to devise an op-erative plan that will safely achieve the two goals ofa straight dorsum and optimal airway. Conversely,if tip strength and anatomy are not accuratelyidentified before surgery, other details becomeless relevant because an unfavorable outcome islikely.6

Each segment of the alar cartilage crura servesa different primary purpose: the medial crura sup-port the columella; the middle crura26 determinetip projection and contour; and the lateral crurasupport external valvular function.6–8 Although itcould reasonably be argued that the medial crura,intranasal ligaments, and dorsal height also pro-vide tip support, the majority of tip projection andexternal valvular support derive from middle andlateral crural volume, substance, and position.

“Tip projection” has been used to connotedifferent things by different authors, but for thepurposes of this article and in my own practice Ihave found that the most valuable indicator ofmiddle crural strength is the position of the tiprelative to the septal angle.4,6,31,32 Other surgeonshave assessed tip projection by measuring the dis-tance of the most projecting point of the tip fromsome facial parameter,22,33–35 but such criteria do

Table I. Alar Cartilage Orientation and Projection in100 Consecutive Primary Rhinoplasty Patients

Patients

Lateral crural positionOrthotopic 54%Malpositioned (cephalically rotated) 46%

Tip projectionAdequate (tip supported to septal angle) 33%Inadequate (tip not supported to septal angle) 67%


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Table II. Relationship of Lateral Crural Orientation to Tip Projection/Configuration in 100 Consecutive PrimaryRhinoplasty Patients

Lateral Crural Orientation

Comparative Relative Frequency of Occurrence

Adequate Projection Inadequate Projection Bossed (Excessively Convex)

Orthotopic (n � 54) 43% 57% 20%Malpositioned (cephalically rotated)(n � 46) 22% 78% 61%

Fig. 3. Patient with convoluted, malpositioned lateral crura and adequate tip projection.(Left) Preoperative views. (Right) Twenty-four-month postoperative views after lateral cruralresection and replacement, nasal shortening, and radix, spreader, and tip grafts. Geometricmean nasal airflow increased 12 times over preoperative measurements.


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not easily apply to patients with large nasal bases(Figs. 3, 4, 6, and 7). In such patients, tip projec-tion may be inaccurately assessed as “adequate” bythe relative distribution of lower nasal skin, butthat judgment is not the same as determining thatthe alar cartilages can support the tip indepen-dent of dorsal height, one critical prerequisite for

a straight profile line. The patients in Figures 4and 5 have short, poorly projecting middle crura;the patient in Figures 6 and 7 has had the majorityof her alar cartilages removed. In all three women,skin surface measurements would indicate ade-quate tip projection, though that is clearly not thecase. The data generated from this study indicate

Fig. 4. Patient with bilateral, flat, malpositioned lateral crura and inadequate tip projection(Left) Preoperative views. (Right) One-year postoperative views after resection and relocationof the lateral crura, minimal dorsal reduction, nasal shortening, and radix, spreader, and tipgrafts. Note the apparent diminution in nasal base size achieved by tip rotation and elevationof the radix. Postoperative airflow doubled over preoperative measurements.


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that 67 percent of 100 consecutive primary rhi-noplasty patients had inadequate tip projection.Inadequate projection was similarly present in 80percent of the patients in my previous series of 150consecutive secondary and tertiary rhinoplasties8

and in 78 percent of a current review of suchpatients seen in consultation36; therefore, unrec-ognized inadequate tip projection is one of themost common reasons for an unfavorable postop-erative result.8

Fig. 5. Patient with malpositioned, convex lateral crura and inadequate tip projection (themost commonly observed phenotype in this 100-patient series). (Left) Preoperative views.(Right) Twenty-month postoperative views after resection and relocation of the lateral crura,dorsal reduction, and radix, spreader, and tip grafts. Note the ablation of the alar wall hollowsand the alteration in alar rim contour following lateral crural relocation. Postoperative nasalairflow increased four times over preoperative measurements.


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Fig. 6. Secondary rhinoplasty patient in whom lateral crural malposition was present(inset, left) preoperatively; the patient was treated before the entity was described. (Left)Preoperative views. Note the deepening of the alar grooves and nostril distortion afterloss of external valvular support. The middle vault collapse and maxillary retrusion are theconsequence of a coexistent septal collapse. (Right) Fifteen-month postoperative viewsafter resection and relocation of the alar cartilage lateral crura, Gore-Tex maxillary aug-mentation, and dorsal, spreader, and tip grafts. Coronally oriented composite grafts wereplaced to complete the nostril reconstruction. Airflow increased 11 times over preoper-ative measurements.


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When Sheen described alar cartilage malpo-sition in 1979,1 he considered this anatomical vari-ation to be an uncommon phenotype that im-parted a broad shape to the nasal tip and createdcharacteristic “parentheses” on frontal view. Sheen’sobservations37 and my own6,8 since then, however,indicate that malposition is not rare. Nearly half(46 percent) of the patients in the current seriesof primary patients had lateral crural malposition.The high incidence of secondary deformities andairway obstructions attributable to this normal an-atomical variant (84 percent in a current review of50 consecutive secondary and tertiary patientsseen in consultation)36 suggests that the majorityof surgeons are not diagnosing malpositionpreoperatively.6

Malposition is not only an aesthetic problembut also a technical and functional one. The ab-normal position of the lateral crura places themat special risk for intracartilaginous incisions,36

which transect the malpositioned lateral crura in-stead of only splitting the intended cephalic por-tions. When the lateral crura are removed or weak-ened, the alar wall deformities are characteristic(Figs. 6 and 7). It is important to recognize thatthese same identifying characteristics also exist inthe primary patient: long alar creases that extendto the alar rims (Figs. 2, above, right, and below, left,3, and 5), alar wall hollows (Figs. 3 through 5),and/or eversion of the nostril rims (Fig. 3). Many

patients with external valvular incompetence un-consciously flare their nostrils to avoid inspiratorycollapse and airway obstruction (Fig. 3), an ob-servation that I made in earlier publications7,38 andthat remains one of the most frequent character-istics of secondary rhinoplasty patients.36 Not everymalposition patient has obvious “parentheses”(Fig. 2, below, left, and 5 through 7), but all haveabnormal alar cartilage axes and long alar creasesand most share the other common phenotypicaltraits just enumerated.

The axes of malpositioned lateral crura cannotprovide adequate external valvular support. Ourprevious reports7,8 have indicated that approxi-mately 50 percent of patients presenting with air-way obstruction at the external nasal valves havealar cartilage malposition. Adequate treatment ofthis anatomical variant requires resection and re-placement of the lateral crura39,40 or, at the veryleast, augmentation of external valvular supportwith autogenous grafts.7,38 In secondary cases andin most primary patients, I have found that resec-tion, light crushing, and replacement of an ap-propriately sized graft (Fig. 1) is the most depend-able method of relocating the lateral crus. I havetried simple mobilization, caudal or cephalic trim-ming, and scoring of the concave surface, andeach method works sometimes, but secondary de-formities are common. In secondary patients, lat-eral crural replacement with conchal cartilage or

Fig. 7. Same patient as shown in Figure 6. (Left) Preoperative view. (Right) Fifteenmonthpostoperative view. Note the change in alar base configuration conferred by lateral cruralrelocation. Alar notches disappear.


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even composite grafts may be necessary (Figs. 6and 7), depending on the degree of scarring andthe extent of soft-tissue contraction following theprevious surgeries. In fact, a preexisting malposi-tion is one of the most common indications forcomposite grafting in my practice.5 Even in pri-mary cases, however, the salutary effect of reposi-tioning the lateral crus upon alar rim contour isobvious (Figs. 3, 5, and 7).

Geometric mean nasal airflow typically doublesafter external valvular reconstruction.7,8,38 Thehigher airflow improvements seen in the pa-tients reported here are not unusual, however.The majority of these patients had severely com-promised airways preoperatively, which allowsdramatic postsurgical changes. Furthermore,many patients with external valvular incompe-tence have coexistent internal and/or septal ob-structions, and the improvements from correc-tions at each site are additive.8 Note also that thesecondary patient in Figures 6 and 7, who hadundergone a previous septoplasty, had an air-flow improvement similar in magnitude to thatof the primary patients, once again underscor-ing the relative importance of valvular functionin the hierarchy of possible causes of nasal air-way obstruction.4,8

The data also indicate an association betweenlateral crural position and tip projection (TableII). Although the incidence of inadequate tip pro-jection was higher than that for adequate projec-tion in either lateral crural configuration, 78 per-cent of patients with cephalically rotated lateralcrura had inadequate projection, in contrast to 57percent of those with orthotopic lateral crura. Theeffect of lateral crural position on middle crurallength (and therefore tip projection) is charac-teristic and evidenced by a comparison of the pa-tients shown in Figures 4 and 5 (who have inad-equate projection) with the patient in Figure 3(who has adequate projection).

Lateral crural axis was also associated with anapparent difference in lateral crural contour: 61 per-cent of the cephalically rotated lateral crura wereexcessively convex (as shown in the patient in Figure5), as opposed to only 20 percent of the orthotopiclateral crura. Although malpositioned lateral cruraare characteristically identified by the “parentheses”that they confer on tip lobular shape, their relation-ship to the “ball” and “box” tip is also strong and isthe subject of a forthcoming publication.36

In view of the popularity of open rhinoplasty,the reader should recognize that both tip projec-tion and lateral crural position must be diagnosedpreoperatively rather than intraoperatively once

surgery has begun. The creation of an infracarti-laginous incision and separation of the dense soft-tissue attachments to the medial crura each createartifacts that make it easy for the surgeon to losehis or her landmarks. Unless the position of thelateral crus relative to the alar rim and to the medialand lateral canthi is determined beforehand, ce-phalic rotation may look erroneously orthotopiconce the nose has been opened. Not all malposi-tioned lateral crura need repositioning, but almostall have functional ramifications: Either the externalvalves are already incompetent or valvular support ispotentially threatened by the surgeon’s intraopera-tive maneuvers.

Despite the referral nature of my rhinoplastypractice, which is currently 80 percent secondaryand tertiary cases, it is likely that the primary casessurveyed in this report represent a spectrum thatis characteristic of most plastic surgeons’ practices.If that assumption is true, the data presented in-dicate that a relatively small percentage of primaryrhinoplasty patients (Fig. 2, above) are suitablecandidates for straightforward alar cartilage re-duction techniques. Only 54 percent of patients inthis study had orthotopic lateral crura, of whichonly 43 percent (23 of the 100 patients in theentire study) also had adequate tip projection.The data suggest that the surgeon treating theaverage spectrum of primary rhinoplasty patientswill see a majority (67 percent) who need in-creased tip support, a significant number (46 per-cent) of patients with an anatomical variation (ce-phalic rotation of the lateral crura) that puts themat special risk for postoperative functional impair-ment, and a minority (23 percent) who can betreated by alar cartilage reduction alone. Asidefrom the technical approach and the specifics ofany individual case, accurate assessment of tip pro-jection and recognition of alar cartilage malposi-tion are the two essential elements in successfulpreoperative tip rhinoplasty planning.

Mark B. Constantian, M.D.19 Tyler Street, Suite 302Nashua, N.H. 03060-2979

[email protected]

ACKNOWLEDGMENTSThe author gratefully acknowledges the research as-

sistance of Janis Silver, M.A., and the expert technicalassistance of Donna Mayo, L.P.N., Anita Serian, andCharlotte Constantian.

REFERENCES1. Sheen, J. H. Aesthetic Rhinoplasty, 1st Ed. St. Louis: Mosby,

1978. Pp. 432–462.


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2. Sheen, J. H., and Sheen, A. P. Aesthetic Rhinoplasty, 2nd Ed.St. Louis: Mosby, 1987.

3. Constantian, M. B. Elaboration of an alternative, segmental,cartilage-sparing tip graft technique: Experience in 405cases. Plast. Reconstr. Surg. 103: 237, 1999.

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