Causes of the Bulbous Tip
The desire to create a more refined, elegant nasal tip is a common one. It is one of the most commonly requested changes that my patients bring up. There are a few common factors that can create tip bulbosity. The first is the nasal tip skin itself. Patients with thicker nasal skin tend to have more roundedness to the tip. In some patients the skin can be thinned conservatively. This is more common in non-caucasian noses where additional fibrofatty tissue can be removed. The second common cause is the tip cartilages themselves.
Bulbous Tip Misconceptions
There are many misconceptions about how to improve the appearance of a bulbous tip. One method that has been used involves merely trimming the nasal tip cartilages. I find that this can be a useful technique in some cases, but in many instances this maneuver will not provide the desired changes to the tip as the remaining tip cartilages that need to be left in place for adequate tip support tend to maintain some level of tip bulbosity.
The Aethetically Pleasing TipTo get a better understanding of how to improve tip bulbosity one needs to examine the anatomy of great looking nasal tips. When performing surgery on such noses one can see that a large component to the ideal aesthetics is having minimal to no convexity to the nasal tip cartilages (lower lateral cartilages). To improve this convexity one needs to be able to reorient the tip cartilages rather than just make them smaller.
Depending on the strength of the nasal tip cartilages suturing techniques (dome binding sutures) can be used to flatten convex tip cartilages. In many instances, however, this is not enough. In these cases a great way to flatten the cartilage is to place a cartilage graft underneath the cartilages called a lower lateral crural strut graft. The cartilage is usually carved from a patient's septal cartilage. It is then sutured to the underside of the tip cartilages where it is like placing an I-beam on the cartilage. As a result of this maneuver the cartilage flattens and takes on the straightness of the graft. A second benefit is that rather than destabilizing the nose, we now have even better tip support that better resists the healing process.
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