REVIEW

Aesthetic Rhinoplasty of the Asian Nasal Tip: A Brief Review

Guang-Yu Mao Æ Song-Lin Yang Æ Jiang-Hong Zheng ÆQing-Yang Liu

Published online: 24 January 2008

� Springer Science+Business Media, LLC 2008

Abstract Tip surgery, the most important part of the

rhinoplasty procedure, has entered a new era in the past

few decades. Various treatment protocols have been

attempted. To date, however, opinions on the management

of the Asian tip have not been solidified. To generalize and

provide appropriate guidelines for the treatment of typical

Asian tips, an English literature search from 1977 to March

2007 was conducted. Finally, a total of 26 papers were

selected for review. The full text of each paper was read

carefully, and data were extracted. Then all extracted

information was imported into Microsoft Excel. Nine

articles treating 11 groups of patients described the suitable

techniques for Asian nasal tips, with 81.8% of the groups

advocating that the protocol include a grafting technique,

64% reporting use of the grafting technique alone, and 9%

applying cartilage reduction and a suturing technique. Of

the 11 (18%) groups, 2 attempted more than one technique.

Because of the Asian nasal tip’s innate qualities, success

with nasal tip plasty for Asians depends on the combined

application of appropriate suturing, grafting, and defatting,

with grafting techniques contributing the most.

Keywords Asian � Grafting � Nasal tip plasty �Rhinoplasty � Suturing

Currently, rhinoplasty is one of the most popular aesthetic

surgical procedures, particularly in China and South Korea.

However, the results of simple augmentation rhinoplasty

often have failed to satisfy the high expectations of

patients. Therefore, many procedures have been developed

to improve the appearance of the nasal projection and nasal

tip.

Nasal tip surgery was first introduced at the end of the

19th century by John O. Roe. At that time, aggressive

techniques involving alar cartilage resection were used.

Recently, more conservative techniques have become

increasingly recognized including suture techniques, tip

grafting, and subcutaneous tissue resection. However, the

characteristics of the Asian nasal tip including the bulbous

appearance, flared nostrils, and restriction of the nasal tip

attributable to an underdeveloped medial crus of the alar

cartilage and a short columella have made such procedures

difficult.

Metaanalyses are becoming an increasingly accepted

means for achieving evidence-based conclusions, helping

surgeons to make rational decisions in choosing methods.

The lack of adequate trials and publications comparing the

efficacy of varied methods for performing Asian nasal tip

plasty spurred us to perform an analysis of the literature on

this subject. In this evidence-based review, the current

literature was examined to determine whether any signifi-

cant scientific evidence existed to support a standard

method for the Asian nasal tip.

Materials and Methods

Search Criteria

A relevant literature search was performed by using

Medline (through Pubmed, from 1977 to March 2007). The

search strings and the number of hits are given in Table 1.

The search was performed with limiting factors of

G.-Y. Mao � S.-L. Yang (&) � J.-H. Zheng � Q.-Y. Liu

Department of Plastic Surgery, Shanghai No.6 People’s Hospital,

Shanghai Jiao Tong University, 600 Yi Shan Road, Shanghai

200233, China

e-mail: yangsonglin@hotmail.com

123

Aesth Plast Surg (2008) 32:632–637

DOI 10.1007/s00266-008-9114-1

‘‘human’’ and ‘‘English language.’’ Additional articles

identified from these references that contained relevant

supporting information then were included.

Inclusion and Exclusion Criteria

• After excluding identical papers, we selected peer-

reviewed articles that met the following criteria:

• Articles about other fields except for ‘‘the aesthetic

nasal tip plasty’’ were excluded.

• Literature that focused on the treatment of aesthetic

nasal tip plasty was selected regardless of the number

of patients.

• Additional articles identified from the references that

contained relevant supporting information then were

included.

After all the abstracts had been read, 19 papers about the

treatment were selected for review. The full text of each

paper was read carefully, and data extraction was per-

formed. Finally, all extracted information was imported

into Microsoft Excel.

Data Extraction

The techniques described in the articles were divided into

three types: suturing, grafting, and cartilage reduction. The

respective number of patients treated using each technique

was calculated. Cases with no complications were con-

sidered as demonstrating a good result whether the patient

was satisfied with the outcome or not. Any treatment that

lengthened the columella (e.g., columellar strut use) was

considered as a type of grafting.

Results

Classification

According to common knowledge, the typical Asian nose is

characterized by its bulbous appearance, flared nostrils, and

restriction of the nasal tip. With the development of the

management for the Asian nose since the year 2000, plastic

surgeons have paid more attention to the classification of

the Asian nose/nasal tip.

In this review, all classifications were based on the

internal anatomic structures (skin and alar cartilages) or on

their external reflections. According to the detailed dis-

tinctness, the different treatment programs listed in

Table 2, were used.

Management Indication

After screening of the abstracts, 9 articles describing

treatment for 11 groups of patients were selected for

techniques suitable for Asian nasal tips. The detailed data

are listed in Table 3. Most clinical studies advocated a

multiple choice for the Asian tip. Of the 11 groups, 9

(81.8%) included a grafting technique with the protocol, 7

(64%) reported the use of grafting techniques only, and 1

(9%) respectively underwent cartilage reduction and

suturing techniques. Two (18%) of the 11 groups attempted

more than one technique (Fig. 1).

Discussion

Nasal tip procedures have undergone a significant change

in the past few years. Previous techniques resected or

vertically divided the alar cartilage, resulting in altered

structural integrity and stability. In contrast, the new phi-

losophy of tip surgery focuses on preserving and

reorienting the nasal tip structures, thus maintaining their

integrity instead of destroying it.

It is speculated that for Asian noses, sufficient tip pro-

jection cannot be attained by either the domal suture

technique or onlay grafting alone because of weak alar

cartilage, thick skin, and abundant subcutaneous tissue.

Therefore, clinicians need to be familiar with suturing and

grafting techniques and to combine them properly.

Grafting and Implanting

Many Asian plastic surgeons believe that an alloplastic

implant [1], especially a silicone graft, is the correct material

for three reasons. First, for most Asians, harvesting of

autologous cartilage or bone may be difficult to accept for

traditional or religious reasons. Second, for the Asian nose, a

moderate amount of augmentation is indicated for preser-

vation of the racial type. Finally, although many Western

supporters of biologic nasal augmentation argue that silicone

is a foreign body that is not incorporated into the patient’s

Table 1 Search strings and number of hits

Search strings Medline

‘‘Nasal tip’’ and ‘‘Asian’’ 30

‘‘Nasal tip’’ and ‘‘Oriental’’ 28

‘‘Cartilage reduction’’ and ‘‘nasal tip’’ 41

‘‘Cartilage cutting’’ and ‘‘nasal tip’’ 6

‘‘Suturing’’ and ‘‘nasal tip’’ 30

‘‘Cartilage graft’’ and ‘‘nasal tip’’ 131

Aesth Plast Surg (2008) 32:632–637 633

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tissue, and thus will become infected or extruded, this may

not be completely true because the nasal soft tissue of Asians

is thicker and less extensible than that of Caucasians.

However, not all Asian noses can be treated adequately

using simple implant insertion alone. Wu [27] thinks that

for thick bulbous tipped noses, a simple implant placement

can produce a trilobed appearance of the tip, which is made

up of the implant tip and the displaced domes of the alar

cartilages or lower lateral cartilages that lie on either side

of the implant tip. In his opinion, the smallest, sharpest tips

can be attained only with autogenous materials. Wu prefers

to use a silastic implant only for the dorsum, terminating

the implant in the supratip region. The tip of the nose then

is given more projection by resecting the upper two-thirds

of the lower lateral cartilages and using these as supporting

grafts for the columella and tip.

The availability of increasingly varied alloplastic

materials has evolved in response to techniques for nasal

augmentation. The best implant for nasal augmentation,

however, remains controversial. Three factors must be

considered: biocompatibility, the patient’s selection, and

long-term results.

Table 2 Classification of Asian nose/tip

Author Description Treatment

Aung et al. [3] 2000 A. A very prominent alar lobule forming a full and rounded nasal tip No mention

B. A less prominent alar lobule forming a more defined nasal tip

C. The least prominent alar lobule forming a relatively

straight slope from the tip to the base

Shirakabe et al.

[25] 2003

A. An unprojected dorsum and tip Dorsum augmentation with or without

tip augmentation

B. Prominent dorsum and diminutive tip Tip augmentation and dorsum reduction

C. Adequate dorsum height and diminutive tip Tip augmentation only

D. Prominent dorsum and adequate projected tip Dorsum reduction only

Ahn [1] 2006 A. Thin skin and strong cartilages Interdomal suturing/columellar strut/shield graft

B. Thick skin and strong cartilages Cartilage onlay grafts/alloplastic implants

C. Thick skin and weak cartilages B + A/premaxillary grafts

Table 3 Publications on the management of the Asian nasal tip

Author Tip morphology Technique

Suturing Cartilage reduction Grafting Defatting

Shin & Lee [24] 1994 Flat nasal tip - - Columella lengthening -

Deva et al. [7] 1998 No mention - - Silicon implant -

McKinney [20] 2000 Bulbous nose - Resection of the cephalic or

middle portion of the lateral crura

- -

Lam & Kim [16] 2003 No mention - - ‘‘Bird’’ -

Silicon implant

Shirakabe et al. [25] 2003 Diminutive tip - - Conchal cartilage -

+

Silicon

Lee et al. [18] 2004 Deviated nose - Alar cartilage resection Columella strut +

Broad nose Septal cartilage graft

Flat nose

Lin et al. [19] 2006 Bulbous nose - - Lateral crura flap -

Saddle tip Silastic tip implant

Hodgkinson [13] 2007 Flat tip - - Conchal graft -

Bone graft

Jang et al. [14] 2007 No mention - - Onlay graft -

+ - - -

+ - Onlay graft -

634 Aesth Plast Surg (2008) 32:632–637

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Generally, implants can be divided into biologic and

alloplastic types. Biologic materials include cartilage,

bone, and fascia [17]. Alloplastic materials comprise sili-

cone, Supramid, Vicryl, Proplast, Mersilene, Medpore,

polytetrafluoroethylene, and ivory. Each has its advantages

and disadvantages [1, 7]. Alloplastic implants are straight

or curved sheets for augmentation of the dorsum, and

sometimes for augmentation of the tip as well. They are

readily available and easy to fashion and shape, but they

may incur some serious complications (e.g., resorption,

infection, extrusion, and foreign body reaction), which can

be avoided with the application of autogenous implants.

Nevertheless, autogenous implants also have some disad-

vantages such as insufficient supply, longer procedure time,

high cost, and donor-site morbidity.

Konig [8] was the first to use autogenous cartilaginous

grafts for humans. The earliest clinical application of septal

grafts in the nose was reported by Metzenbaum [8]. One of

the two most commonly used techniques is the shield-

shaped (sometimes triangular) graft proposed by Sheen and

Sheen [23]. The first technique places the shield graft in the

lobule to accentuate the middle crura–columella angle and

to provide tip projection. The second technique positions

the rectangular onlay graft over the domes, as proposed by

Peck and Peck [22]. Some widely used biologic grafts are

listed in Table 4, and a few donor sites are listed in

Table 5.

In addition, actual lengthening of the columella would

increase nasal tip projection. The medial crura of the alar

cartilages are the primary components of the columella and

provide tip support. Footplates of the medial crus vary in

size, shape, and angulation. To solve this problem, Oguz

Cetinkale et al. [5] used cartilage grafts in both the tip and

the labiocolumellar junction at the same time, whereas

Shin and Lee [24] used V-Y advancement or an earlobe

composite graft in the columella base to lengthen the

columella.

Suturing

Rhinoplasty in the 20th century places more emphasis on

surgery of the nose for aesthetic reasons than ever before.

The period ranging from 1930 to the early 1980s was

Fig. 1 Distribution of patients undergoing different techniques

Table 4 Overview of tip grafts [5, 6, 9–10, 12, 15, 21–23]

Description Graft pocket (envelope) Application

Anchor graft Shaft is sutured to the caudal margin of the medial crura Improve tip support and/or project and collapse or

deform the lateral cruraTransverse components replacing the lateral crura or

lying over their remnants and sutured to them

Cap graft Between the tip-defining points and the middle crura Refine, soften, and fill in clefts of the nasal tip in

patients with thin skin to enhance tip projection

minimally and occasionally to refine the infratip

lobule area

Columella strut (floating/fixed-

floating)

Between the medial crura through a small incision

caudal to the feet of the medial crura

Maintain tip support and increase tip projection and

aid in shaping the columella-lobular angle

Columellar strut (fixed) Fixed to the nasal spine or premaxilla Increase tip projection and perhaps aid in

lengthening the nose

Extended columella strut tip

graft (extended shield graft)

In the precrural space or by placed caudal to or between

the medial crura and sutured in place to the crura

Provide tip support, projection, definition, and

fullness caudal to the medial crura to aid in

shaping the columella

Onlay tip graft Placed horizontally over the alar domes Minimally increase tip projection but mainly to

camouflage tip irregularities

Shield graft (Sheen or

infralobular graft)

Placed adjacent to the caudal edges of the anterior

middle crura, extending into the tip

Increase tip projection, define the tip, and improve

contour of the infratip-lobule

Subdomal graft Placed under the domes Correct dome asymmetry by controlling the

horizontal and vertical orientation of the domes

Correct the pinched nasal tip deformity

Umbrella graft Transverse component placed in a small tight pocket or

sutured to the domes of the lateral crura

Increasing both tip projection and support

Aesth Plast Surg (2008) 32:632–637 635

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marked by two parallel developments. On the one hand, the

increased use of cartilage excision techniques in aesthetic

rhinoplasty often resulted in disruption of the nasal tip

components, with inconsistent outcomes. Thus, sutures

served to hold the disrupted tip components and then

reposition them in place. On the other hand, a concurrent

evolution was taking place in the field of cleft nose surgery.

The ensuing two decades leading to the 21st century were

marked by a rapid transition from disruptive cartilage-

altering techniques to procedures that made use of preci-

sion suture placement for reshaping of the nasal tip

cartilages without serious disruption of the components.

In this innovative field, it is not surprising that many

techniques have developed in tandem but with varying

nomenclature. Invariably, this creates confusion for the

novice and the experienced surgeon alike. It is of great

importance to extend credit to the pioneers of tip rhino-

plasty techniques. Surgical results are more predictable

with increased reliance on sutures placed with precision

and with an understanding of the dynamic that they induce

when used singly or in combination. Currently, instead of

excising and repositioning of the tip cartilages, the focus is

on lateral crus preservation and tip cartilage modification

through precise suture placement and tension control

(Table 6).

Assistant Technique

To some extent, the characteristic of an Asian nasal tip is

its bulbous nature. It is different from the tip of Western

noses, which is characterized by a strong nasal cartilage.

Five soft tissue layers overlying the osseocartilaginous

framework are identified: the skin, the subcutaneous are-

olar plane, the vascular-fibromuscular layer, the deep

areolar plane, and the perichondrium/periosteum. The

cartilaginous framework provides projection, support, and

shape to the dorsum and tip of the nose. The skin of the

nose is specialized, capable of retaining its shape even after

dissection due to an arrangement of elastin fibers in the

upper dermis and the subcutaneous areolar plane that

confers elasticity to the skin, especially in the region of the

alar lobule, which is a skin and fibromuscular sandwich

[28]. To ‘‘thin’’ out the tip, most surgeons thin the

Table 5 Indications for donor

cartilage related to the area to be

reconstructed [2]

Donor site Advantages Disadvantages

Septum Easy harvest May be deficient

No separate donor-site morbidity

Auricle Easy harvest Separate donor site

Relatively abundant Curved (less desirable

for some purposes)

Curved nature ideal for certain purposes

Rib Large volume (abundant, even for significant augmentation) Donor-site morbidity

Distant donor site (2-team approach possible) Warping possible

Reliable

Table 6 Evolution of suture placement in the nasal tip [4, 11, 26]

Surgeon Technique

Joseph 1931 Orthopedic suture: columella septal suture (interdomal and medial crura anchor sutures)

Goldman 1954 Lateral crura divided just lateral to domes, medial crura sutured together (medial crural, middle crura,

and interdomal sutures)

McIndoe and Rees 1959 Cleft nose repair: alar cartilage repositioned with medial crural and lateral crural sutures (medial crura

anchor and medial crural sutures)

McCollough and English 1985 Double-dome unit: morselization of domes; horizontal mattress through both medial and lateral crura

under domes (early transdomal and interdomal sutures)

Tardy and Cheng 1987 Transdomal suture: horizontal mattress through both domes with knot placed interdomally

Daniel 1987 Domal creation sutures: an individual horizontal mattress suture placed across each dome

Kridel et al. 1989 Lateral crural steal technique

Tebbetts 1989,1994 Systematic nondestructive approach: specific sequence of suture placement; medial crura anchor

suture, medial crura footplate suture, medial crura suture, lateral crura suture, tip rotation sutures

Gruber 1997 Lateral crura convexity control suture

Guyuron 1998 Medial crura footplate suture refinement

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undersurface of the raised skin flap, then excise and discard

the fibrofatty areolar tissue over the tip and between the

lower lateral cartilages. This latter tissue is in fact a useful

source of interpositional tissue between implant and skin,

which also can be used to mold the tip [27].

Conclusion

In summary, because of the Asian nasal tip’s innate qual-

ities, including weak cartilages and abundant subcutaneous

tissue, success with nasal tip procedures for Asians

depends on the combined application of appropriate

suturing, grafting, and defatting, with grafting techniques

contributing the most.

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