A bulbous nasal tip refers to a tip that is too rounded or wide in relation to the remainder of the nose. Many rhinoplasty patients with a bulbous nasal tip present to the office complaining their nose looks too large at the end. Other rhinoplasty patients state their nasal tip has no definition or shape.
The adjacent photo example demonstrates what a bulbous, or rounded, nasal tip looks like. In this particular case, you can see that the nasal tip appears too wide for the nose. Ideally, her nasal tip would be more narrowed and defined to be in better proportion with the shape of her bridge and surrounding facial features.
A bulbous nasal tip is a direct result of the lower lateral cartilage of the nose. The lower lateral cartilage actually refers to a pair of structures that comprises the shape and position of the nasal tip. You can see this in the adjacent diagram where the lower lateral cartilage is shaded in red. When the lower lateral cartilage is properly shaped and positioned, the nasal tip will appear in balance with the remainder of the nose and will not draw unwanted attention to the area.
To explain how the lower lateral cartilage contributes to a bulbous nasal tip, it is easier to show this concept when looking from below the nose – called the basal view. When looking from underneath the nose you can better appreciate the general outline of the nasal tip. This is visually demonstrated in the adjacent diagram, which shows the shape of a normal nasal tip that is considered well-defined.
As you can see, the general outline forms what is called a soft triangle – meaning a triangle without sharp angles. This is because the lower lateral cartilage on each side creates a relatively tight angulation as it extends out from the center of the tip. This is represented by the two red lines forming an angle at what is called the dome region (indicated by the star). On each side of the nasal tip the lower lateral cartilage should form a well-defined angle with two relatively symmetric domes. This translates into an appropriately narrowed, shapely nasal tip when seen on front view.
The adjacent diagram is shown for comparison sake to contrast the normal nose with a bulbous nasal tip. As you can see, the lower lateral cartilage in a bulbous nasal tip is much broader and has a more open angulation as it extends out from the dome region on each side. This is precisely why the lower lateral cartilage is wider and contributes to a less defined nasal tip. Some rhinoplasty surgeons even describe this type of nasal tip as being trapezoidal or boxy because it almost appears flat across the front of the nose. Regardless of how it is described, the nasal tip cartilage is simply too large for the nose.
The adjacent is an intraoperative photograph of the actual patient shown above with a bulbous nasal tip. As would be predicted, the patient’s lower lateral cartilage is quite wide, similar to the diagram just discussed. For instance, note how wide the angle is on each side as the lower lateral cartilage extends from the dome region in the midline. This translates into an excessively broad shape and directly contributes to the nasal tip appearing bulbous, or excessively wide.
On frontal view of the nose, the lower lateral cartilage also appears too broad in the bulbous nasal tip. Granted, this can be a bit more difficult to appreciate for the untrained eye. But take my word for it, the bulbous lower lateral cartilage simply looks too wide from side to side as shown in the adjacent intraoperative photograph (same patient shown above). In fact, each lower lateral cartilage appears to be just flat across. In a sense, that is precisely how the cartilage is shaped – as shown in the diagrammed basal view above. Combined, the pair of poorly shaped lower lateral cartilages create an excessively wide nasal tip as seen from this frontal view.
Rhinoplasty for a Bulbous Nose
Rhinoplasty surgery to correct a bulbous, or wide, nasal tip requires reshaping of the lower lateral cartilage. But how do you take broad, rounded, and wide lower lateral cartilage and create a narrow, triangulated, more refined nasal tip? As in many other rhinoplasty deformities, there are several options available to the experienced rhinoplasty surgeon when it comes to reshaping a bulbous nasal tip.
Cephalic Trim Technique
One option is to reduce the size of the lower lateral cartilage on each side to create a smaller, less bulbous nasal tip. This specific rhinoplasty technique is referred to as a cephalic trim maneuver. The cephalic edge is the upper margin of the lower lateral cartilage and is shown in the adjacent diagram by the arrows. This particular area of the lower lateral cartilage is what mainly contributes to the nasal tip looking too broad as it transitions to the bridge. If one were to trim, or remove, the cephalic margin (as indicated by the blue shaded area), this would effectively make the lower lateral cartilage much smaller. As the nasal skin shrinks down after surgery, this would translate into a less bulbous, more refined nasal tip. It should be noted, however, that caution must be exercised when performing cephalic trim for the bulbous nasal tip. This is because the rhinoplasty surgeon must preserve a certain amount of lower lateral cartilage to maintain adequate support for the nasal tip. If one were to perform overly aggressive cephalic trim, there will be insufficient remaining lower lateral cartilage to keep the nostril sidewall open. The end result could be unwanted collapse of the nostril with obvious pinching of the nasal tip region – a telltale sign of prior unsuccessful rhinoplasty. In my opinion, you should leave behind at least a 9-12 mm wide segment of lower lateral cartilage when performing cephalic trim. In doing so, there should be ample cartilage remaining to keep proper support and shape for the nasal tip.
Below is a rhinoplasty patient example of cephalic trim for a bulbous nasal tip. This particular patient with a more rounded nasal tip is featured above. She underwent an open rhinoplasty where the lower lateral cartilage was fully exposed. The cephalic margin was then trimmed on both sides to reduce the volume of cartilage in this area. Some additional work was then done on her bridge to further refine her nose. If you look specifically at her nasal tip, you can appreciate how much improvement was made using careful cephalic trim technique to reshape her bulbous tip. You can also see how natural her nose looks despite having undergone surgical alteration.
Suture Reshaping Technique
Another rhinoplasty technique that can be used for a bulbous nasal tip involves suture reshaping. In some rhinoplasty patients who have more favorable anatomy, sutures alone can help address the excessively wide, rounded nasal tip without having to trim the cartilage. In most rhinoplasty cases where this technique is feasible, it is preferred since it does not compromise the structural support of the nasal tip. Suture reshaping for a bulbous nose involves placement of permanent sutures through the dome region of the nasal tip on both sides – called ‘dome binding’ sutures. These dome binding sutures are strategically positioned so that they narrow the lower lateral cartilage, thus making the nasal tip less bulbous and more refined. When used in the right setting with proper surgical technique, dome binding sutures can be incredibly effective at improving the overall shape of the nasal tip.
An example of suture reshaping of the bulbous nasal tip is shown below. This is a rhinoplasty patient from San Diego who presented with complaints of a bulbous nasal tip that appeared too rounded. He simply desired to have his nasal tip narrowed to be in better balance with his surrounding facial features. As you can see from his preoperative rhinoplasty photographs his nasal tip is excessively wide with poor definition. When looking at the nasal tip from the oblique (45 degree angle) view, you can see how it looks rounded as it transitions from the nasal bridge. We performed cosmetic rhinoplasty on him and used dome binding suture technique to narrow his tip. This allowed us to preserve his native cartilage structure without compromising support of the nasal tip. By careful placement of permanent sutures, his nasal tip was refined and the bulbous appearance was taken away. On frontal view of the nose you can now see improved domal highlights (the light reflexes on the nasal tip showing definition) with a more proportional nasal tip. On the oblique view of the nose you can now see that the rounded appearance of the tip has been markedly improved to provide him with a nasal tip that no longer draws unwanted attention.
Cartilage Grafting of the Nasal Tip
An alternative technique for managing the bulbous nasal tip involves use of cartilage grafting to reshape the lower lateral cartilage. In some rhinoplasty patients, the rounded nasal tip cartilage is so stiff that it requires more sophisticated surgical technique beyond cephalic trimming and suture reshaping. Grafting in rhinoplasty implies that a segment of the patient’s own cartilage is harvested from one area and used to reshape the nose in another area. This cartilage is commonly taken from the patient’s own septum, but ear cartilage and rib cartilage are also frequently used in rhinoplasty for grafting purposes. In terms of a bulbous nose, the cartilage that is harvested is used to make the nasal tip more defined. This method of refining the nasal tip is also referred to as a lateral crural underlay technique.
The lateral crura is the winged portion of the lower lateral cartilage that extends out from the nasal tip around the nostril rim on each side and is what is largely responsible for the bulbous contour. This is shown in the adjacent rhinoplasty diagram when looking from below the nose. If a relatively stiff piece of cartilage is placed under the lateral crura (thus the term crural underlay) and the lateral crura is sewn down onto this graft, the nasal tip can be narrowed. This is indicated by the red arrows in the diagram that show how the bulbous lateral crura can be essentially straightened out by sewing them onto the lateral crural underlay graft. The end result is a nose that looks less rounded and more defined.
Below is a patient example of the lateral crural underlay technique to correct a bulbous nasal tip. This rhinoplasty patient from San Diego is a very attractive female who was unhappy with the tip of her nose. As the preoperative photo shows, her nasal tip was bulbous and more rounded than desired. She elected to undergo cosmetic nose reshaping and the lateral crural underlay technique was utilized to reshape the tip. Using a segment of septal cartilage, the curved, bulbous lower lateral cartilage was straightened out to create a more defined nasal tip. This is readily seen on her frontal view following rhinoplasty. Notice how her nasal tip was refined without creating a pinched or surgically altered look. On base view of the nose, you can also appreciate how her nose went from being more rounded and broad to being more like a soft triangle. Overall, you can see how her nose is now much more balanced with her remaining facial features.
Combined Techniques for a Bulbous Tip
In many rhinoplasty patients we choose to combine the above mentioned individual techniques to define a bulbous nasal tip. For instance, in cases where the lower lateral cartilage is too stiff to reshape with suture technique, a conservative cephalic trim maneuver may also be needed to achieve the desired rhinoplasty outcome. In other cases, suture tip reshaping may be combined with the lateral crural underlay technique to bring out proper nasal tip definition. At the end of the day, the most important consideration is finding a rhinoplasty expert who is versed in the various techniques involved in reshaping the bulbous nasal tip.