Bulbous Tip Nose Surgery in New York
Dr. Oleh Slupchynskj, MD
Bulbous: an adjective meaning round and swollen looking. Bulbous nose? You guessed it: a round and swollen looking nose.
Many patients come to see me for consultation about their bulbous nose. Some patients say the tip of their nose lacks definition or support; others say that their nasal tip needs to be more refined or less round. While the language used to explain this type of nose can vary, these descriptions all allude to the structural differences that result in a bulbous nose. Most common in African American, Asian and Hispanic patients, but found in all ethnicities, the right surgeon can successfully correct a bulbous nose.
What is it about the bulbous nose shape that may be aesthetically undesirable for some? To answer these questions we need to look at facial balance and symmetry. From the frontal view of the face, the nose should have 2 divergent, concave lines that extend from the medial brow to the nasal tip (like an hourglass shape). This is known as the brow-tip aesthetic line. See patient photos below. Excessive fullness in the nasal tip disrupts the balance of this line.
Before bulbous tip correction, on the
left, the brow-tip aesthetic line flares out with the tip of
her nose. After bulbous tip correction with Dr. Slupchynskyj,
her brow-tip line is balanced and symmetrically hourglass-shaped.
When looking at the bottom of the nose, balance, symmetry and shape again combine to affect the aesthetics. The nasal base, as this view is called, should be a triangular shape, with no notching or indentation as you move from the face towards the nasal tip.
What makes a bulbous nose? Structurally, the bulbous nose occurs when the nasal tip, or lower 1/3 of the nose (not including the nostrils), is amorphous and non-sculpted, creating a round, full appearance. This type of nasal tip contrasts with a defined nasal tip where the skin is thinner and the shape of the cartilage structures beneath skin are visible and prominent. In a nose that has not been surgically altered, the structures that can cause a bulbous nasal tip are: skin, subcutaneous tissue (including fat), and the shape, size and direction of the lower lateral cartilages. (McKinney, 2000) Take a look at the JP Gunter nasal anatomy diagrams below. You can see the lower lateral cartilages in both the nasal base and profile views. The lower lateral cartilages can be further broken down into their medial (towards the midline), lateral (away from the midline), and cephalic (closest to the top of the head) ends.
The lower lateral cartilages can be further broken down into their medial (towards the midline),
lateral (away from the midline) and cephalic (closest to the top of the head) ends.
We will discuss three general types of bulbous nose, as I define them. Not all bulbous noses fit easily into one of the three categories, but these basic divisions can provide a framework from which to discuss their causes and differences between each type of nose.
Type I: The Ethnic Bulbous Nose
The first type of bulbous nose that we will discuss is the Ethnic bulbous nose. Some ethnicities are prone to nasal features that contribute to this apperance. African American, Asian and Hispanic patients are some of the ethnicities in this group. These patients can sometimes have thicker, more sebaceous nasal skin. The sebaceous glands are microscopic glands in the skin that secrete an oily/waxy matter, called sebum, to lubricate and waterproof the skin. An increased occurrence of these glands can add to skin thickness and the appearance of bulbosity. However, even patients that do not have sebaceous skin can still have increased skin thickness—simply due to thicker epidermal and dermal layers. As we travel deeper below the surface of the skin, some individuals may have excessive subcutaneous tissue or fat. This excess fatty, fibrous tissue layer also adds to the rounded or swollen appearance. Another characteristic of the Ethnic bulbous nose is the weakness of the Lower Lateral Cartilage structures. The diagram above shows how the Lower Lateral Cartilages define and support the nasal tip. In some ethnic patients, these same structures are thin, soft and less supportive, leading to an amorphous, bulbous nasal tip.
Take a look at the figure below – it clearly illustrates two of the previously mentioned anatomical differences that can contribute to the Ethnic bulbous nose. Note the smaller, less prominent Lower Lateral Cartilages in the Ethnic patient to the right, in addition to the thicker layer of fat in the nasal tip. These factors, in combination with thicker and sometimes sebaceous skin create the Ethnic bulbous nasal tip.
Type II: Bulbous Nose Resulting from Overdeveloped Lower Lateral Cartilages
The second type of bulbous nose that we will discuss is one that results from over-developed, prominently sized or shaped Lower Lateral Cartilages. This type can occur in all ethnicities. The same Lower Lateral Cartilages that are small, flimsy and lacking support for the Ethnic bulbous tip are, in this case, strong, broad and shaped in a way that pushes out on the nasal skin, creating a rounded, prominent nasal tip.
In the patient photo example above, the Lower Lateral Cartilages are shown
superimposed over their approximate location. You can see
how these structures are directly responsible for the bulbous
shape of her nasal tip. Imagine, stiff, boxy cartilage
structures pushing out on the nasal skin, causing the rounded tip shape.
Type III: The Iatrogenic Bulbous Nose
Iatrongenic literally means “originating from a physician”. The broader definition is an inadvertent adverse effect or complication resulting from medical treatment. In my description, this type of bulbous nose is one that has arisen from a previous surgical intervention, usually a Primary Rhinoplasty procedure.
In my practice, I regularly see Rhinoplasty Revision candidates whose complaints include, among other things, undefined and rounded nasal tips. In many cases, these patients may have had bulbous noses (Type I or Type II) prior to their first, failed Rhinoplasty. Unfortunately, rather than properly correcting the issue, the operating surgeon’s attempts to reduce the bulbosity either didn’t work at all or may have even exacerbated the bulbosity. In some cases, the previous surgeon tried to refine the nasal tip with the insertion of excessive alloplastic (non-biologic) material, like an L-shaped silicone implant, or with cartilage grafts. When done incorrectly, the insertion of these materials will actually add fullness to the nasal tip, instead of refining the shape, as intended. In fact, the bulbous tip that results from the addition of inappropriately shaped/sized implant material can be further worsened by poor surgical technique that can create scar tissue within the nasal tip. That unfortunate circumstance is demonstrated in the patient photos below.
Figure Patient is shown Before and 3 Weeks After Revision Surgery with
Dr. Slupchynskyj. The upside down Pre-formed Silicone implant that was
removed by Dr. Slupchynskyj is shown in anatomical position in
the After image. The improper placement and migration of this
implant actually increased the patient's chief concerns,
her wide dorsum and bulbous nasal tip.
On the left, this patient is shown before her Rhinoplasty Revision with me. In her two previous Rhinoplasty procedures with another surgeon, an improperly sized and positioned pre-formed silicone implant was placed upside down. On the right, the patient is shown about 3 weeks after I performed her revision. The removed implant is resting in its approximate anatomical position. The previous implant had migrated towards the nasal tip, actually increasing the patient’s chief concerns- her wide bridge and bulbous nasal tip. Scar tissue buildup from her two previous procedures also exacerbated the bulbous tip that was already worsened by poor implant selection and placement.
Surgically correcting or refining a bulbous nose is one of the more challenging nasal procedures that I perform. In all cases we need to determine the source of the bulbous appearance. If the patient had an implant improperly placed previously, the clear solution is to remove it. If excessive scar tissue resulted from poor surgical technique in a previous primary procedure, then the excess scar tissue must be addressed and removed. Grafts will likely be needed to further refine and support the nasal nasal tip.
In many cases though, there are two common and very important components to address. First, the nasal tip may need to be de-fatted. One feature that most bulbous noses have in common is the presence of excess fatty fibrous tissue. This extra fatty tissue gives the nose its swollen appearance. In the photo below, you can see the nasal tip before and after I have removed the excess fatty fibrous tissue.
"Defatting" of the tip as well as the weak, "flimsy" cartilage.
The tip of the bulbous nose is often weak and flimsy. The second step involves adding support to the nose with cartilage grafts. Taken from the nasal septum or ear, I use cartilage grafts to bolster the nose, much like the frame of a house supports the roof, or tent poles hold up a tent. I typically achieve this using two different types of grafts, the shield graft and the strut graft. The shield graft, named for its shape, is custom-carved out of cartilage and provides much of the framework for the nasal tip. The strut graft contributes additional support and reinforces the structure of the nose.
Patients often wonder how I access the internal parts of the nose. They ask whether bulbous nose correction can be performed as "Closed" Rhinoplasty, where the nose is left relatively intact and the inside of the nose is accessed only through the nostrils. In my opinion, this procedure is best performed as "Open" Rhinoplasty. That is the only real way to address both essential components: the excess of fat in the nasal tip and the lack of cartilage support. In this situation, a closed approach would greatly limit the surgeon's ability to properly reach and correct the source of the patient's concerns. Though it may sound like an unusual or scary technique, Open Rhinoplasty doesn't drastically affect the surgery experience or recuperation for the patient. In this case, it is the best way to achieve the desired result.
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