Understanding Rhinoplasty Part III: The Tip of the Nose
7/15/2020
The tip of the nose is essential to both appearance and function of the nose. It may be the part of rhinoplasty surgery that is 
both the most subtle but has a profound effect on how the nose looks and works. There is no right or wrong way for a nose to look- there are infinite variations. Beauty truly is in the eye of the beholder. But a straight nose that is in ion to the other facial features, and allows for normal airflow, is generally considered preferable to bent, blocked nose that varies significantly from others in their community. Caring about appearance is not right or wrong, it is part of human nature. Caring too much or too little may be problematic.
The b
ottom third of the nose is made of two “C” shaped curved cartilages that start at the base of the nose and curve around the nostril rims, what plastic surgeons call the nasal ala. The cartilages are called the alar cartilages. The upper and outer portion support the nose rim for airflow and also control how wide the tip appears. We call this portion of the cartilage the “lower lateral cartilages”. The middle of the base of the nose is called the “columella”, and it looks like a column.
Many people who seek rhinoplasty surgery for appearance feel that the tip is too wide or “boxy”. The lower lateral cartilages can be trimmed and stitched towards the middle, causing a more slender and narrow tip. From the front view, surgeons often visualize an imaginary curved line that runs in a gentle arc from the brow, down the sides of the nose, and then curves out gradually to the tip. These lines are called the “dorsal aesthetic lines”. When the line shape curves in or out sharply or severely, it is usually noticeable, and often from previous injury. If the tip cartilages are very unequal in size and shape, they can be equalized with stitching and gentle sculpting to create a more even tip.
Plastic surgeons use a term for how far the nose tip points out, called “projection”. When someone’s nose appears hooked or curved, the tip is often less projected outward than the rest of the bridge of the nose. Increasing projection during surgery can help make the nose appear more straight from the side view. We can increase projection by surgery techniques such as adding cartilage ( septal extension, tip and strut grafts) or simply by sewing the tip cartilages together in a way that adds projection and strength... Other patients feel that that nose tip points out too far, and this is called “over projection”. Surgeons can set the tip back towards the case and make the nose tip more balanced with the rest of the nose. This is done with trimming of cartilage such as the medial footplastes at the base of the alar cartilages.
The columella from the side view should be visible, but not hanging to farr loafer than the tip- that condition is called a hanging columella and can be treated by trimming the bottom of the septum cartilage to help raise the columella. The nostril rims are difficult to control with surgery. When they are very wide, some skin can be excised to reduce the size of the nostrils, and the scars are hidden in the base of the nose or at the outer curve of the tip where it meets the cheek.
Surgeons study angles and geometry to understand variations in nose shape among different people and ethnicities. A normal nose for most people has a nostril size that is about 2/3 the length of the base of the nose to the tip. When the nostrils are overly large and this ratio is resorted, many people find that the nose has a more pleasing shape.
The angle from the lip to the tip, “the nasolabial angle” matters in rhinoplasty surgery. The angle in normal noses ranges from about 90-105 degrees. When the tip of the nose is elevated, it stands out, as does a tip that plunges too low. Breathing is also affected greatly by nostril shape. When the naso labial angle is normalized with surgery, the air flow goes properly to the back of the nose, and not toward the skin. Healthy nasal breathing is vital for good health, sleeping soundly and exercise capacity.
I hope this discussion of the nasal tip anatomy provides you with more understanding about how plastic surgeons think about rhinoplasty surgery in order to fix nasal deformities. Remember, there is no such thing as the best nose shape or the best rhinoplasty surgeon.
Our human variations contribute to beauty and being interesting. But if your nose does have some features that bother you, a skilled and caring surgeon would be glad to meet with you and help you learn more about what changes you can achieve.The above is an actual Dr. Suzman patient before and after photos showing increased tip projection, rotation and size balance.
Dr. Michael Suzman is a Plastic Surgeon in Greenwich CT and Westchester County NY, just north of Manhattan NYC. He is certified by the American Board of Plastic Surgeons and has performed thousands of plastic surgery procedures. On www.drsuzman.com, he blogs about the best in plastic surgery, reviews products and techniques, and strives to share his passion about plastic and reconstructive surgery.
