Tip support

What repeats

Five findings that hold across the literature.

The tripod is the model most surgeons were taught, and the anatomy behind it was re-measured

Janeke and Wright described four areas of anatomic support in 1971. The plan of tip surgery that became the tripod concept was published in 1962, and the M-arch model later read the same cartilage as one continuous arch whose overall length sets projection, rotation and nasal length. Dissection of 24 fresh cadavers confirmed five structures: the interdomal, intercrural, Pitanguy midline and pyriform ligaments and a scroll ligament complex. Two ligaments in common textbook use were not found, one at the medial crural footplate and one at the pyriform aperture.

Rests on: Janeke and Wright, studies on the support of the nasal tip · Anderson, a plan of nasal tip surgery · Adamson et al., the M-Arch model · Daniel and Palhazi, the nasal ligaments · Rohrich et al., beyond the tripod concept.

The septum does not hold the domes up directly

In the same dissections the domes sat a mean of 5.7 mm above the anterior septal angle, range 2.2 to 9.6 mm, and a mean of 5.5 mm caudal to it, range 2.9 to 9.5 mm. What holds the tip forward is the cartilage and the ligaments, or a graft the surgeon puts there.

Rests on: Daniel and Palhazi · Mattos et al., positioning the nasal tip.

Taking cartilage away costs support, so current practice keeps it

Trimming the upper edge of the lateral crus narrows the tip and weakens what is left, and the published algorithm for it is written around avoiding that. The current lateral crura algorithm states the same rule for the whole cartilage: preserve and restore rather than excise, and manage by repositioning and reinforcement. Its own series of 50 patients, 80% primary, reported 90% satisfied on both aesthetic and functional scores and 4% needing revision. The cost was measured early. Cephalic border resection, alone, with vertical dome division, and with dome division plus suture reapproximation of the medial crura, produced a measurable loss of projection in all but one case of the series that compared the three. Serial measurement of 51 primary rhinoplasties before surgery, on the table and at 6 months reached the same finding: projection falls unless the medial crural segment is lengthened or strengthened.

Rests on: Rich et al., lower lateral cartilage excision · Petroff et al., quantitative changes · Nagarkar et al., role of the cephalic trim · Tanvar and Basu, lateral crura algorithm · and the bulbous tip.

A strut supports in proportion to its size and how it is fixed

A finite element model of the nose was loaded with columellar struts from 15 by 4 by 1 mm up to 25 by 8 by 1 mm. Reaction force at the tip rose with strut volume. Struts sutured along their whole length or at the front end resisted load like a fixed graft, while struts sutured only at the back behaved like a strut that was not attached at all. Support has also been read off a gauge on the patient. Tip strain averaged 0.158 in 30 people with normal recoil and ran 35% higher in 30 people with a ptotic tip. A year after surgery in 40 patients, a columellar strut had cut tip strain by 43% and a caudal extension graft by 74%.

Rests on: Gandy et al., strut dimensions · Atighechi et al., tip recoilometry · Patel et al., medial crura · and tip sutures.

A graft anchored to the septum outperforms one floating in the columella

Across 133 primary rhinoplasties, projection loss at a year was 4.7% with a columellar strut and 0.2% with a septal extension graft, and rotation loss 4.9 degrees against 1.3 degrees. In secondary cleft rhinoplasty, where support is weakest, thirty-three patients were divided between the two and the strut group lost projection progressively while the septal extension graft group did not. The graft was described in 1997, after 20 patients at risk of losing projection were reviewed and only the one whose strut had been fixed to the caudal septum held it. Three-dimensional photogrammetry of 106 later patients put rotation change at 1.01% with the septal extension graft against 5.08% with the strut, with projection falling in both.

Rests on: Byrd et al., septal extension grafts · Bellamy and Rohrich, long-term stability · Sawh-Martinez et al., three-dimensional comparison · Acil et al., cleft tip support · and tip rotation and projection.

By what carries the load

Four structures, each with its own repair.

The medial crura and the columella

The paired legs inside the columella carry the tip forward. Their shape decides how much projection survives simply lifting the skin, and they are reinforced with a strut or by fixing them to the septum. Where the caudal septum and the nasal spine have been over-resected, a wide-based strut is built from rib or septum: 32 patients, 11 of them revisions, with one mini-revision for a visible graft over 12 to 24 months.

Rests on: Patel et al. · Soylu et al., wide-based strut · and rib cartilage grafts.

The lateral crura and the sidewall

The outer arms hold the sidewall open and hold the alar rim in place. Weakening them by excision is the documented route to alar retraction and external valve collapse, which is why reinforcement replaced excision.

Rests on: Tanvar and Basu · Nagarkar et al. · and alar retraction.

The ligaments and the scroll

The interdomal, intercrural, Pitanguy midline, pyriform and scroll ligaments were confirmed on dissection, and preserving or repairing them is now used as a way to control tip position rather than only as anatomy to cut through.

Rests on: Daniel and Palhazi · Schertzer et al., tip tensioning · and preservation rhinoplasty.

The caudal septum

The septum is the fixed point everything else is tied back to. It is also the donor site, so a nose that has given up cartilage once has less to tie to the second time.

Rests on: Bellamy and Rohrich · Soylu et al. · and revision rhinoplasty.

What to ask about tip support

Questions the evidence supports asking.

What are you taking out, and what replaces it

Ask which cartilage is being cut and what goes back. The current algorithms are written around keeping the lateral crus and reinforcing it rather than trimming it away.

Rests on: Tanvar and Basu · Nagarkar et al..

Will the graft be fixed to the septum or left floating

The two behave differently under load and at one year. Ask which one the surgeon plans, and how it is sutured, because fixation at the front of a strut matters as much as its size.

Rests on: Gandy et al. · Bellamy and Rohrich.

How firm will my tip be afterwards

A tip anchored to the septum is stiffer to the touch than a tip supported by a floating strut. Ask what the surgeon expects, and ask to feel the difference described before choosing.

Rests on: Schertzer et al. · Acil et al..

Is there enough cartilage left in my nose

In a revision nose or a nose with a weak caudal septum, the septum may not supply the graft. Ask where the cartilage will come from and what the donor site costs.

Rests on: Soylu et al. · and rib cartilage grafts.

The terms, defined

The words used about what holds the tip up.

• Tip support: the resistance of the tip to being pushed back toward the face. [29365051]
• Tripod concept: the tip modelled as three legs, two lateral crura and the joined medial crura. [35877943]
• M-arch model: the same cartilage read as one continuous arch from footplate to footplate, whose overall length sets the tip parameters. [16415443]
• Tip recoil: how far the tip moves when it is pressed and how fully it returns, measured as tip strain. [28234154]
• Anterior septal angle: the forward corner of the septum, close to but not touching the domes. [29365051]
• Pitanguy midline ligament: the fibrous band running down the midline of the nose to the tip. [29365051]
• Scroll ligament complex: the attachment between the lateral crus and the upper lateral cartilage. [29365051]
• Columellar strut: cartilage set between the medial crura, floating or fixed. [26868130]
• Septal extension graft: cartilage fixed to the caudal septum that the tip is set on. [36728586]
• Cephalic trim: removal of the upper strip of the lateral crus. [26710011]

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 the tip framework is altered. 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 the chapter that sets out the M-arch model and two chapters on supporting and contouring the tip.

• Supporting the Nasal Tip
• Nasal Tip Surgery, The M-Arch Model
• Nasal Tip Contour and Support Management

The reference summary

Rhinoplasty Tip-Shaping Surgery in StatPearls gives the tip anatomy and the named grafts in full text on the National Library of Medicine's Bookshelf.

The societies

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

The trials in progress

• Measurement of Age and Sex Related Changes in Nasal Tip Support Using Digital Newton Meter, completed, 159 participants.

What is not settled

• The tripod is being written about as a limited model while it is still taught as the main one, and nothing measured has replaced it. [35877943] [40996913]
• The ligament anatomy rests on 24 cadavers from one pair of anatomists, including the two ligaments they could not find. [29365051]
• Strut mechanics come from a computer model of one nose. Reaction force in a simulation is not the same thing as a tip a patient can push on years later. [26868130]
• The graft comparisons are retrospective apart from the cleft study, and the cleft study enrolled thirty-three patients. [36728586] [37567945]
• The preservation algorithms report their own 50 patients at a mean of 14.2 months, which is short for a claim about long-term support. [42624495]
• The support mechanisms every textbook lists were described in 1971 and 1962 and have not been re-measured as a set. The ligament study tested the anatomy, not the mechanics. [5554881] [14012866] [29365051]
• Tip recoil has a measurement, and one group has published it: 30 people with normal recoil, 30 with a ptotic tip and 40 operated patients. [28234154]
• The cost of cephalic resection was measured on photographs in two 1991 series and is still cited as the reason to preserve cartilage. [1986762] [1863446]
• The three-dimensional comparison of strut against septal extension graft found rotation held better by the graft and projection falling in both, in 106 patients from one centre. [31373990]