Surgical techniques for broad, boxy, and ball tips

Abstract

Some of the most challenging rhinoplasties involve correction of broad, boxy or ball tips (the three Bs of tip surgery). A review of the literature indicates significant variations in diagnosis and treatment. This article will deal with analysis and correction of the “three Bs.” The broad tip is most easily diagnosed on oblique view where the sheer volume of the alar cartilages is readily apparent, as is the lack of tip definition. Anatomically, the domal segment is flat and continues into a broad convex lateral crura. The surgical goal is to decrease volume, increase domal definition, and decrease lateral crural convexity — all amenable to open tip suture techniques. The boxy tip is most easily diagnosed on basilar view where the basal perimeter is square. The tip itself may be underprojected and require caudal septal support. Aesthetically, one appreciates Tardy's triad of strong convex alar cartilages, weak alar bases, and collapsible side walls. The choice of sutures or grafts is often dictated by the rigidity and malleability of the alar cartilages. Alar rim grafts are recommended to overcome the inherent weakness of the alar rims. The ball tip is most easily identified on anterior view by the convex lateral crura whose lateral borders give the tip a circular appearance. Aesthetically, the tip overwhelms the rest of the nose and one must carefully assess both projection and skin quality. Anatomically, the major axis of the lateral crura is now vertical rather than transverse, and the highest projecting point on the alar cartilages is the lateral crura rather than the dome. Surgically, the problem is that the alar cartilages are too large and too ill-defined for subtle changes. In most cases, the need to decrease intrinsic projection by 4 to 8 mm favors an open structure tip graft.