The nasal tip is the most complex and most noticeable part of the nose. From the front it defines the character of the nose; in profile, its length and its angle with the lip. Many patients are unhappy not with the bridge but only with the tip: a drooping, wide or asymmetric tip. On this page I describe the structures that shape the tip, how problems are corrected, and when tip surgery alone is enough.
Structures that shape the tip
The shape of the tip is a combination of three elements:
- The lower lateral (alar) cartilages: the two wing cartilages that determine the width, symmetry and definition of the tip. Wide and soft cartilages create a rounded tip.
- The front of the septum and tip support: these determine how far forward and upward the tip sits; weak support leads to drooping with age.
- Skin and subcutaneous tissue: thick skin hides the detail of the cartilage; thin skin shows every irregularity.
Common tip problems
- Drooping tip: the tip points downward and the nose looks long in profile; further drooping when smiling is typical.
- Wide or rounded (bulbous) tip: the tip lacks definition because the cartilages are wide and far apart, or because of thick skin.
- Asymmetric tip: a difference in shape or size between the two cartilages; the nostrils may also look different.
- Over-rotated tip: usually the result of a previous operation; the nostrils are too visible from the front.
- Weak tip support: the tip collapses easily when pressed; the sidewalls may be drawn inward when breathing.
When is tip surgery alone enough?
If the bridge is straight, there is no hump and the complaint concerns only the tip, an operation limited to the tip (tip plasty) can be performed. It is a more limited procedure: the bony vault is not touched, and swelling and bruising are usually less. However, the tip must be assessed together with the bridge: when the tip is lifted or reduced, a small hump not noticed before may become apparent. For this reason I make the decision by looking at the whole profile, not only at the tip. If a hump, deviation or breathing problem is present, a full rhinoplasty is planned.
Techniques used
In modern tip surgery the principle is to reshape cartilage rather than cut it away:
- Suture techniques: the alar cartilages are brought together, narrowed and made symmetric with special sutures. Because tissue is preserved, support is maintained in the long term.
- Support grafts: a strut prepared from septal cartilage prevents the tip from drooping; small grafts may be used to define the tip under thick skin.
- Limited cartilage trimming: if needed, only the excess part of the cartilage is removed; structural integrity is preserved.
- Nostril refinement: wide nostrils can be narrowed with small incisions at the base of the alae.
Tip surgery is usually performed with the open technique, because symmetry needs to be adjusted under direct vision. For limited corrections the closed technique may also be suitable.
Examination, expectations and outcome
During the examination the firmness and shape of the cartilages are assessed by hand, skin thickness is measured and tip support is tested. Patients with thick skin are told clearly that refinement of the tip may remain limited; for them the aim is not a "thin tip" but a "defined and balanced tip". The tip is the last area where swelling subsides after rhinoplasty: in the first months it looks larger and rounder than it will be, and the final shape keeps settling for up to a year. Patience and follow-up matter during this period.
This page is for general information; which procedure is appropriate is decided during examination. For bridge and hump problems see Dorsal Hump, for the principles of a natural result Natural Rhinoplasty, for other topics Rhinoplasty: Overview; to arrange an appointment please use the contact page.