Correction of intrinsic nasal tip asymmetries in primary rhinoplasty

Preoperative nasal analysis for the rhinoplasty patient is not complete without recognition and characterization of asymmetries. A simplified classification of columellar and intrinsic nasal tip asymmetries has evolved from 15 years' experience with rhinoplasty. Nasal tip asymmetries have vertical and horizontal dimensions. The vertical, or cephalocaudal, causes of tip asymmetry are primarily extrinsic factors. Elements that contribute to tip asymmetry and are extrinsic to the lower lateral cartilages are the bony and cartilaginous septum, the nasal bones, the upper lateral cartilages, and the maxilla. Horizontal or side-to-side asymmetries can be the result of intrinsic lower lateral cartilage abnormalities. The importance of this distinction is to differentiate the patient with a deviated nose and concomitant tip asymmetry from the patient with an isolated, intrinsic deformity of the nasal tip cartilages. A simplified classification system for nasal tip asymmetries is presented along with proposed methods for surgical correction. Case examples are analyzed also. A description of nondestructive suturing techniques and cartilage grafts to restore nasal tip symmetry is provided for each deformity. An open rhinoplasty approach is advocated in all cases.