Can I Get A Pointy Tip To My Nose With A Rib Graft Rhinoplasty?

Q: Dr. Eppley, when using diced cartilage graft for nose augmentation do you overgraft to compensate for potential resorption?  Did you use a columellar strut on your nasal augmentations and do you do anything for wide and flared nostrils? In some rib graft rhinoplasty results, the nose looks pinched. I have read that some doctors place two extra grafts on each side of  the nose giving the frontal view a very nice look to it. What are these grafts and how are they done? While I love the idea of diced cartilage mainly because there is less chance of warping, I am concerned that there would not be enough build up to achieve the height that I desire with this. In addition, my rib graft rhinoplasties that I see have a tip that is bulbous and not sharp. I would like a much pointier and defined tip. I feel like this is one of the biggest flaws I keep seeing over and over in the before and after results that I have seen on asian ethnicity patients. It seems as if the surgeons augmented the bridge and completely forgot the tip.

A: In answer to your questions:

1) In looking/suspecting the degree of augmentation that you want from your rhinoplasty, I would ‘overgraft’ as much as possible. The limiting factor in any augmentation rhinoplasty is what the skin will accomodate (how much can it be stretched) and how much recoil (deformational elastic limit) the skin will do. The thicker the skin, the greater the elastic recoil will be. (push back) This is what leads to resorption of cartilage more than any other factor.

2) Columellar struts are used in every augmentation rhinoplasty. The length of the columellar strut and its stiffness (thickness) depends on how much nasal tip lengthening is needed. Most non-Caucasian rhinoplasties need and get nostril narrowing as part of their rhinoplasty.

3) There is no question that whole rib grafts are going to give more of a push on the skin and resist recoil than any diced cartilage graft. Given the result you are showing, a whole rib graft would need to be used as that is pushing it to the limits of what the skin can tolerate. What you are referring to as ‘side grafts’ are known as lower alar rim grafts, sometimes called batten grafts. (although this is not technically correct) They are placed obliquely to the rib graft at the nasal tip. This adds expansion/fullness to the lower alar cartilages so that when the tip gets significcantly elevated, it is not like a tent pole sticking out of the top of the tent. (pinched look)

4) What you are seeing in the tip is more often a conservative approach to tip projection/stress, rather than ignoring the refinement of the tip area. You have to remember that when you significantly push the tip up in an open rhinoplasty, the tip skin over the graft has very little blood supply. There is a real risk of tip skin necrosis after surgery, a disastrous event in rhinoplasty. There are well documented cases of it happening and I have seen it with a bone graft many years ago. In your type of nose, the columella is very short. Once you push up the tip area with rib grafting, the open rhinoplasty incision must be closed. If the rib graft is too high, one can not close the columellar incision. Pulling the tip skin down pushes the partially devascularized nasal tip skin tight over the graft. This is where the risk of tip skin death is and the blood supply may get cut off. This is an important issue to recognize during surgery as a sharp point on the end of the rib graft, if the skin is too tight, will cause this problem to occur. It is far better to have a more rounded end of the rib graft and not too tight of columellar skin closure over it to avoid this nightmare of a problem. This is the likely biologic explanation for some of the nasal tip results you are seeing.

Dr. Barry Eppley

Indianapolis, Indiana