The bulbous tip

What repeats

Five findings that hold across the literature.

Cartilage and skin are separate causes, and each is treated on its own

Choosing the manoeuvre starts with the type of tip, the strength of the cartilage and the quality of the skin. Where the skin is the limiting layer, reshaping the frame underneath will not deliver the change on its own, which is why the thick-skin literature is a separate body of work.

Rests on: Nagarkar et al., role of the cephalic trim · Cobo et al., management of thick skin.

Cutting the cephalic strip away is the old answer and it costs support

Removing the upper edge of the lower lateral cartilage narrows the tip, and the standing criticisms are alar retraction and a weakened internal valve. The current lateral crura algorithm states the principle directly: preserve and restore rather than excise. The working rule once sutures took over was to leave a lateral crus about 6 mm wide. Where even that risks a retracted rim, the cephalic strip is slipped under the remaining crus as a strut instead: in 14 primary patients with borderline alar and columellar relationships, the mean alar-nostril axis was 1.48 mm before surgery and 1.71 mm after, and 13 of the 14 showed no significant change in that relationship from 11 months onward.

Rests on: Gruber and Friedman, the four-suture algorithm · Gruber et al., preserving the lateral crus · Generalow et al., scroll preservation · Tanvar and Basu, lateral crura algorithm · and alar retraction.

Folding or turning the strip in keeps the cartilage and the width

The cephalic strip can be turned into a pocket under the remaining crus instead of being discarded. In 24 patients with lateral crura wider than 12 mm the turned-in flap reshaped the crus and kept the scroll area intact. An angulated version of the same idea was used in 138 bulbous tips with no revision related to the technique and no narrowing of the internal valve. In a two-arm comparison of thirty patients, a mid-down flap scored better than cephalic excision on a questionnaire about tip aesthetics and valve function, where the excision arm scored worse than before surgery. One institution reviewed 120 turn-in flap patients operated over 10 years, mean age 23, followed a mean of two years, and six went on to revision surgery.

Rests on: Apaydin, turn-in flap · Generalow et al. · Kaderi et al., mid-down flap · Alkarzae and Bafaqeeh, ten years of turn-in flaps.

Narrowing the dome too hard trades one deformity for another

Two dome stitches were compared on basal-view photographs of 112 patients. The binding version gave a satisfactory contour in 22.7%, the hemitransdomal version in 93.3%. The wide tip is easy to narrow and hard to narrow without pinching it. The hemitransdomal stitch exists for that reason: the classic transdomal suture reduces tip width and can leave a concave alar rim and an inverted lateral crus, and the modification, reported in 12 cases, everts the crus instead. Once a tip is pinched, the repair is a lateral crural strut graft, with repositioning of the crus where it also sits in the wrong place.

Rests on: Dosanjh et al., the hemitransdomal suture · Casanueva and Gerecci · Daniel, open tip sutures · Hyman et al., correction of nasal pinching · and the pinched tip.

Cartilage that sits in the wrong place makes a round tip that no stitch fixes

Cephalic malposition means the lateral crura run toward the inner corner of the eye rather than toward the alar base, defined as diverging less than 30 degrees from the midline. It produces a ball-shaped tip with parenthesis lines and a weak external valve, and the correction is to move the crus, not to narrow it.

Rests on: Nassar and Naba, cephalic malposition review · Tanvar and Basu.

By what is making the tip wide

Four causes, four different operations.

The lateral crura bow outward

A convex crus pushes the skin out on each side of the tip. It is flattened with a mattress stitch, turned in as a flap, or overlapped. The cruciate overlap technique reduced mean tip width from 22.7 to 18.2 mm and tip angle from 101.0 to 87.7 degrees in 43 patients, while raising mean tip protrusion from 14.3 to 16.7 mm. Graded on a lateral wall insufficiency score, overlay and lateral crural strut graft methods improved the internal valve zone, while cephalic trimming and turn-in flaps left it unchanged. Cosmetic scores improved in every group.

Rests on: Yin et al., cruciate overlap · Daniel · Abdelwahab et al., lateral crural procedures and wall stability.

The lateral crura sit too high

The cephalically malposed crus is repositioned into a pocket that runs toward the alar base, with a strut graft under it. The review groups the published answers into flaps, grafts, transection and suture methods, and notes that long-term data on stability are thin.

Rests on: Nassar and Naba · and the pinched tip.

The domes are too far apart

Where the two tip points sit wide of each other the tip reads as broad or boxy. Interdomal and dome stitches bring them together, and the dome stitch chosen decides whether the alar lobule follows. Where a stitch is not enough, the arch is divided at the dome and rebuilt. In 41 patients vertical lobule division lowered projection in 34, narrowed a wide or boxy tip in 25 and corrected knuckling or bossae in 20, with one patient returning for revision. A derotation suture that pulls the lateral crus caudally was used instead in 50 patients, improving tip bulbosity in 96%, with tip drooping in 4%.

Rests on: Gruber and Friedman · Daniel · Casanueva and Gerecci · Funk et al., vertical lobule division · Kim and Suh, derotation suture · and tip sutures.

The skin is thick

Thick, inelastic skin holds its own shape over whatever frame is built. The systematic review of twenty-eight studies on thick-skinned noses sets out a plan across the pre-operative, operative and post-operative phases rather than a single manoeuvre.

Rests on: Vahidi et al., thick-skinned noses · Cobo et al. · and recovery.

What to ask about a bulbous tip

Questions the evidence supports asking.

Is my tip wide because of cartilage or because of skin

The answer changes the operation and the timescale. Ask the surgeon to say which layer they think is responsible in your nose, and what they expect if it is the skin.

Rests on: Nagarkar et al. · Vahidi et al..

Will you cut the cephalic edge away or fold it in

Ask by name. The preservation techniques were designed because the classical trim is followed by alar retraction and valve narrowing, and the comparative study found the excision arm worse than baseline on tip and valve questions.

Rests on: Kaderi et al. · Apaydin · and tip support.

How will you avoid a pinched tip

The stitch that narrows the dome is the stitch that can pinch it. Ask which one the surgeon uses and to see their own basal view photographs at a year.

Rests on: Casanueva and Gerecci · and the pinched tip.

Where do my lateral crura point

Cephalic malposition is found by examination before surgery, and it is the reason some round tips do not respond to narrowing. Ask whether it is present and what the plan is if it is.

Rests on: Nassar and Naba · Tanvar and Basu.

The terms, defined

The words used about a wide tip.

• Bulbous tip: a tip that is wide and round in the frontal view with no defined tip point. [26710011]
• Lower lateral cartilage: the paired cartilage of the tip, with a medial and a lateral crus. [40469545]
• Lateral crus: the outer arm of that cartilage, running toward the cheek. [22006234]
• Cephalic trim: removal of the upper strip of the lateral crus to narrow the tip. [26710011]
• Turn-in flap: the same strip folded under the remaining crus instead of removed. [22006234]
• Cephalic malposition: lateral crura pointing toward the inner eye rather than the alar base. [40469545]
• Parenthesis deformity: the curved shadows a malposed crus casts on each side of the tip. [40469545]
• Scroll area: the join between the lateral crus and the upper lateral cartilage. [39965762]
• Skin soft tissue envelope: the skin and the layers under it that cover the tip frame. [37369866]
• Vertical lobule division: cutting the cartilage arch at or beside the dome and rebuilding it, to reset projection, rotation and width. [19289685]
• Lateral crural strut graft: cartilage set under the lateral crus to hold it flat and hold the alar rim down. [31587767]
• Lateral wall insufficiency: a graded score for how far the sidewall falls in at the internal and external valves. [33459395]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology guideline on nasal form and function after rhinoplasty sets what should be assessed and recorded before a tip is narrowed. Its plain language summary is written for patients.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries three chapters covering the wide tip and the cartilage shapes behind it.

• Rhinoplasty in Small Bulbous Asian Noses
• Seeing through the Envelope: The Cartilage Shape Requirements for an Aesthetically Pleasing Nasal Tip
• Lateral Crural Flap Technique

The reference summary

Rhinoplasty Tip-Shaping Surgery in StatPearls, on the National Library of Medicine's Bookshelf, sets out the tip anatomy and the named manoeuvres.

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.

The trials in progress

• A New Concept in the Tip Plasty of Asian Rhinoplasty, completed, 161 participants.

What is not settled

• The comparison of a preservation flap against cephalic excision enrolled thirty patients in one centre, and the two techniques were equal on the general outcome score. Only the tip-specific questionnaire separated them. [40394313]
• Preservation series are reported by the surgeons who designed them, 138 patients in one case and 24 in another, with no independent replication. [39965762] [22006234]
• The cephalic malposition review states plainly that long-term data on complications and structural stability are limited across all the techniques it compares. [40469545]
• The thick-skin evidence is weak by its own grading. Of the twenty-eight included studies, most were the two lowest levels of evidence, 39% and 32%. [37369866]
• The lateral crura classification and algorithm reports 50 patients followed for a mean of 14.2 months by the authors who wrote it. [42624495]
• The 6 mm rule for how much lateral crus to leave is a working figure from a suture algorithm, not a measured threshold. [12447060] [20375762]
• Dome division outcomes are counted as indications met rather than measured on photographs. The vertical lobule division series reports 41 patients from one practice. [19289685]
• The largest turn-in flap series, 120 patients over 10 years, reports complications and revisions but no photographic measurement of tip width. [32051804]
• The lateral wall score that separates the techniques on valve function is graded by the surgeons who performed them. [33459395]