A common request during cosmetic rhinoplasty is to remove or refine a bulbous or rounded nasal tip.

What causes a bulbous or rounded nasal tip?

A bulbous nasal tip can be caused by the shape and thickness of the nasal tip skin or by the shape and orientation of the tip cartilages underneath the skin. A number of different techniques may be necessary to reshape the tip.

Thick nasal skin

Nasal tip skin is the thickest skin on the nose and can vary significantly in different racial groups. Mediterranean ethnicity tends to be equated with thicker tip skin.

The nasal tip skin can be thinned conservatively by removing fibro fatty tissue and muscle tissue that sits just underneath the skin. This is an advanced rhinoplasty technique that needs to be done very carefully. If the skin is thinned too much irregularities can occur in the skin post-operatively giving it an unnatural appearance.

Alar cartilage shape

Alar cartilages can be too wide, too large or too curved. All of these scenarios can lead to a bulbous rounded tip.

It is often misconstrued that in order to reshape a bulbous tip you need to remove large amounts of tissue from the tip but sometimes this can result in destabilisation, pinching and an unnatural appearance. In some cases it is more important to move the curved lower lateral alar crura rather than remove this tissue.

How will I know what is causing my tip to be rounded?

Thick skin can usually be evaluated by it’s appearance and feel. Sometimes it is difficult to appreciate the shape and orientation of the alar cartilages until they have been exposed at the time of surgery. Decisions can then be made as to the best way to refine them in a more aesthetically pleasing manner. Sometimes one conservative technique is performed during surgery (such as stitches into the cartilage) however these do not produce the desired result. The surgeon may then go on to perform further techniques to achieve the desired outcome.

What techniques are used to refine a rounded nasal tip?

If the nasal skin is thick, it is usually conservatively thinned. A number of other techniques may also be used.

Cephalic trim Dr Roth rhinoplasty

Cephalic trim

The Cephalic Trim Technique

The cephalic trim technique has been in use for many years now for treating bulbous nasal tips. Surgeons used to remove a significant portion of the lower lateral cartilage leaving only a small amount. Unfortunately over time the nose would sometimes heal with too much upward rotation or pinching. This is still a very useful technique but it must be done conservatively.

Dome Binding Stitches

Dome binding sutures Dr Roth rhinoplasty

Dome binding sutures

This process involves placing a stitch above and below the tip defining point in order to cinch the cartilage, leading to a more defined tip. Sometimes when these are placed the outer alar cartilage has a tendency to curve inwards which may require further reshaping with a strut graft. As the cartilage is turned inwards it is important to monitor the size of the internal airway so that breathing is not affected.

Lower Lateral Crural Strut Graft

Lateral crural strut graft Dr Roth rhinoplasty

Lateral crural strut graft

This is a very effective and powerful way of reshaping a bulbous nasal tip. Strut grafts help to straighten the lateral crura so that the tip can be made more pointy. They have the potential to cause significant changes in nostril shape and position so the technique must be performed very carefully.

Refining a bulbous nasal tip is a very common reason for rhinoplasty surgery. Careful pre-surgical assessment and planning will ensure a good result. The rhinoplasty surgeon must be comfortable with a range of advanced techniques in case these are needed to achieve the desired outcome.