Abstract
The bulbous and boxy tips are two common morphologies encountered in rhinoplasty. The management algorithms for both tips share various techniques. These techniques include but are not limited to cephalic trim, lateral crural turnover flaps, transdomal sutures, and interdomal sutures. A graduated approach to managing the bulbous and boxy tips will help in achieving consistent results. New concepts applied to the management include supporting alar rims with alar contour grafts, closing dead space through a series of techniques, and managing the soft tissue envelope.
18 The Bulbous versus Boxy Tip
Key Points
Nasal tip reshaping is an important aspect of rhinoplasty.
Two common tip morphologies are the bulbous and the boxy tip.
Detailed preoperative analysis and intraoperative assessment aid in understanding the anatomic cause of the nasal tip morphology.
A graduated approach to the tip with appropriate technique selection will provide consistent results in tip reshaping and minimize the risk of secondary deformity.
18.1 Preoperative Steps
A detailed analysis of the nose is a critical prerequisite for understanding the anatomic framework underlying the shape abnormalities (Fig. 18.1a, b).
Bulbous tip:
The bulbous tip is described as having a wide, poorly defined shape.
The underlying anatomic causes include large lateral crura, dysmorphology of the lateral crura, and cephalically malpositioned lower lateral cartilages (LLCs).
The lateral crus may have one of the three morphologies:
Type I: Flat.
Type II: Convex.
Type III: Concave.
The cartilage may be strong or weak, which will also influence surgical technique.
Patients with bulbous nasal tips may often have external causes contributing to the tip volume, namely, thick, sebaceous skin.
Boxy tip:
The boxy tip is best assessed from the basal view.
It is described as having a squared off shape.
Rohrich et al described a classification system based on intercrural angle of divergence and domal arch width (Fig. 18.2a–c):
Type I: Intercrural angle >30 degrees with normal domal arch width (4mm).
Type II: Intercrural angle <30 degrees with wide domal arch width (>4mm).
Type III: Intercrural angle >30 degrees with wide domal arch width (>4mm).
Fig. 18.1 (a–c) Morphology of normal, bulbous, and boxy tips. (Reproduced with permission from Rohrich R, Adams W, Ahmad J, et al, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. Thieme; 2014.) 
Fig. 18.2 (a–c) Classification of boxy tip based on domal arch width and interdomal angle of divergence. (Reproduced with permission from Rohrich R, Adams W, Ahmad J, et al, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. Thieme; 2014.)
18.2 Operative Steps
See Video 18.1.
18.2.1 Management
The fundamental principles governing tip reshaping include cartilage preservation and suture techniques.
Rohrich et al described a management algorithm that incorporates the techniques below for both classification systems for the boxy and bulbous tips.
Managing lower lateral cartilage cephalic excess:
Cephalic trim:
Separate the LLCs from the upper lateral cartilages at the scroll area.
LLC cephalic portion is undermined and excised to maintain at least 6 mm of LLC width to avoid excessive weakening of the lateral crura.
Cephalic trim may be applied to the lateral and/or middle crus depending on the tip morphology (see Algorithm Applied) (Fig. 18.3).
Lateral crural turnover flap:
Lateral crus is partially incised, maintaining a 6-mm strip of cartilage caudally.
The cephalic cartilage is turned over and sutured to the caudal lateral crura.
This strengthens the lateral crura while reducing concavity.
Tip sutures:
Transdomal suture:
The transdomal suture is a horizontal mattress suture placed through the medial and lateral aspects of the dome.
End points of this suture include (1) well-defined tip, (2) narrowing of the domal arch, (3) everted inferior margin of the lateral crus, and (4) straight and flat lateral crus.
The entry and exit points of this mattress suture dictate these end points.
Interdomal suture:
Horizontal mattress suture placed between the middle crura of the LLC.
The interdomal suture narrows the angle of domal divergence, narrows distance between tip-defining points, increases tip projection, and provides camouflage to the columellar strut or septal extension grafts.
Current concepts for improved outcomes:
Septal extension graft (SEG):
In the bulbous or boxy tip, the SEG provides a stable point of fixation at the tip complex to aid in correcting lateral crural concavities. It allows superior control for change in projection and rotation.
Technical details of the SEG are discussed in Chapters 13 and 22.
Supporting alar rims with extended alar contour grafts (ACGs) and dual ACG:
Patients with bulbous or boxy tips often have weak alar rims.
Cephalic trim techniques inherently weaken the LLC.
To provide improved shape and structural support to the alar rims, nonanatomic extended alar contour grafts are placed in pockets created along the alar margin.
15 × 2 mm beveled cartilage grafts (septal or costal cartilage) are fashioned and placed in pretunneled pockets at the inferior alar margin.
After placement of extended ACG, any focal notching or contour irregularity along the inferior alar rim can be addressed by placing a dual ACG.
A small stab incision inferior to the irregularity is created with a #11 blade and a short 5-mm graft is placed in retrograde fashion to obliterate the residual notching.
Dead space closure:
Dead space secondary to excess soft tissue envelope in a reduced framework needs to be addressed. This is most notable at the tip.
The infratip lobular butterfly graft provides additional infratip lobule definition with filling of the soft tissue triangles bilaterally. This helps in preventing soft tissue triangle scarring and retraction.
The soft tissue triangles may also be packed with crushed cartilage.
Splinting the soft tissue triangle can be done with Surgicel® coated with antibiotic ointment. These small antibiotic-covered pledgets are packed into the soft triangle to ensure tissue apposition and dead space closure.
Horizontal mattress sutures of 5–0 chromic gut at the columella and caudal septum at the end of rhinoplasty provide additional dead space closure and internal splinting.
Meticulous closure of the transcolumellar incision and infracartilaginous incisions additionally aids in reducing dead space.
Skin management: In patients with thick nasal tip skin, incremental defatting of the skin envelope is performed with reassessment.
Fig. 18.3 Incremental approach to cephalic trim. (a) Shows limited cephalic trim. (b) Shows middle and lateral crural cephalic trim. (Reproduced with permission from Rohrich R, Ahmad J, eds. The Dallas Rhinoplasty and Dallas Cosmetic Surgery Dissection Guide. 1st ed. Thieme, 2018.)
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