Aesth Plast Surg (2013) 37:1621

DOI 10.1007/s00266-012-0020-1

ORIGINAL ARTICLE

AESTHETIC

Nasal Tip Plasty: The Delivery Approach Revisited

Rui Xavier

Received: 20 March 2012 / Accepted: 31 October 2012 / Published online: 4 January 2013
Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2013

Abstract The delivery approach, though very appropriate

for remodeling the tip of the nose, has been overlooked in
recent years and has often been passed over for the open
approach. One reason for this is the intercartilaginous
incision used for the delivery approach, which may cause
scarring at the nasal valve area, leading to postoperative
functional obstruction of the nose. The delivery of the alar
cartilages is another negative, as this maneuver will disrupt
the collagen fibers that attach the upper lateral cartilages to
the cephalic margin of the alar cartilages, leading to a
weakening of the tips support. We propose a modification
to the traditional delivery approach by using a transcartilaginous instead of an intercartilaginous incision to prevent
damage to the valve area. We also suggest taking advantage of the interference to the tips support caused by the
disruption of the collagen fibers of the scroll area. The
purpose of this article is to describe this modification of
the delivery approach and to emphasize the advantages that
this controlled interference to the tips support may have in
selected cases.
Level of Evidence V This journal requires that authors
assign a level of evidence to each article. For a full
description of these Evidence-Based Medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors www.springer.com/00266.
Keywords Delivery approach

Approaches for rhinoplasty
Rhinoplasty

R. Xavier
Hospital da Arrabida, Porto, Portugal
R. Xavier (&)
Rua Aristides Sousa Mendes 210, 4150-088 Porto, Portugal
e-mail: rjxavier@iol.pt

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Introduction
Every rhinoplasty begins with analysis of the patient. After
this evaluation a list of the surgical techniques necessary to
achieve functional and aesthetic improvements of the nose
is made and, according to this surgical planning, the surgical approach is selected. When selecting the approach to
be used on any given patient, the surgeon must weigh the
surgical trauma caused by the approach against the surgical
exposure afforded by the approach. The simplest approach
that allows the planned surgical techniques to be performed
without difficulty and cause the least disturbance to the
tips support should be selected [13]. Thus, the approach
should be as invasive as necessary, but, at the same time, as
noninvasive as possible.
A frequent goal of rhinoplasty is achieving an
improvement in tip definition. For this purpose it is often
advisable to trim the cephalic margin of the lateral crura of
the alar cartilages, sometimes combining this procedure
with other techniques such as single-dome or double-dome
sutures. The delivery approach, though very appropriate for
accomplishing these modifications to the nasal tip [1, 4],
has been overlooked in recent years and has often been
passed over for the open approach. One reason for this is
the intercartilaginous incision necessary for the delivery
approach, which may cause scarring at the nasal valve area
and lead to postoperative functional obstruction of the
nose. To prevent this potential danger, we have modified
the delivery approach by using a transcartilaginous incision
instead of the traditional intercartilaginous incision. This
precludes the potential danger of postoperative scarring at
the internal nasal valve. This modification of the delivery
approach has previously been described [5, 6]. The delivery of the alar cartilages is another negative of the delivery
approach, as this maneuver will disrupt the fibrous

Aesth Plast Surg (2013) 37:1621

17

ligaments of the scroll area, leading to weakening of tip

support. Every surgical approach and surgical technique
used in rhinoplasty will cause a certain degree of interference to one or several tip support mechanisms, however.
We believe that this disruption of the fibers at the scroll
area caused by the delivery approach may, in certain cases,
be desirable and may contribute to a good result of the
rhinoplasty, as long as the surgeon is fully aware of this
fact.
Fig. 2 The cephalic piece of the alar cartilage is dissected free and
resected

Surgical Technique
The modified delivery approach technique has been previously described [5, 6]. In brief, the intercartilaginous
incision traditionally used in the delivery approach is
avoided and instead a transcartilaginous incision is used on
each side of the nasal vestibule (Fig. 1). The position of
this incision must take into account that the exact amount
of cartilage to be resected may be difficult to assess at this
stage, so care must be taken to leave an appropriate amount
of cartilage caudal to the incision. The cephalic piece of the
alar cartilage is dissected free in the vestibular and nonvestibular sides and resected (Fig. 2). Then a marginal
incision is made (Fig. 3), and the remaining alar cartilage is
dissected in the nonvestibular side and easily delivered
(Fig. 4). After the same procedure is performed on the
opposite side, both alar cartilages are delivered. At this
stage of the procedure the size of the remaining alar cartilages is assessed; if necessary, further cephalic resection
is done to achieve perfect symmetry or the desired size of
the alar cartilages (Fig. 5).
The rhinoplasty may then proceed with other surgical
techniques used on the alar cartilages, which may be
grafted, sutured, or remodeled as necessary to achieve good
functional and aesthetic results. After addressing the upper
two thirds of the nose, at the end of surgery both the
transcartilaginous and marginal incisions are closed with
an absorbable suture material.
We have been using this modification of the standard
delivery approach for several years and we have had no

Fig. 3 A marginal incision is made on each side

Fig. 4 The remaining alar cartilage is delivered

Fig. 5 Further cephalic resection may be done

Fig. 1 A transcartilaginous incision is made on each side

complications. None of the patients in whom this modified

approach was used complained of postoperative nasal
obstruction. Therefore, even though no functional studies
were conducted in these patients, significant scarring
of the internal nasal valve leading to symptomatic nasal
obstruction probably did not occur.

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Aesth Plast Surg (2013) 37:1621

17

ligaments of the scroll area, leading to weakening of tip

support. Every surgical approach and surgical technique
used in rhinoplasty will cause a certain degree of interference to one or several tip support mechanisms, however.
We believe that this disruption of the fibers at the scroll
area caused by the delivery approach may, in certain cases,
be desirable and may contribute to a good result of the
rhinoplasty, as long as the surgeon is fully aware of this
fact.
Fig. 2 The cephalic piece of the alar cartilage is dissected free and
resected

Surgical Technique
The modified delivery approach technique has been previously described [5, 6]. In brief, the intercartilaginous
incision traditionally used in the delivery approach is
avoided and instead a transcartilaginous incision is used on
each side of the nasal vestibule (Fig. 1). The position of
this incision must take into account that the exact amount
of cartilage to be resected may be difficult to assess at this
stage, so care must be taken to leave an appropriate amount
of cartilage caudal to the incision. The cephalic piece of the
alar cartilage is dissected free in the vestibular and nonvestibular sides and resected (Fig. 2). Then a marginal
incision is made (Fig. 3), and the remaining alar cartilage is
dissected in the nonvestibular side and easily delivered
(Fig. 4). After the same procedure is performed on the
opposite side, both alar cartilages are delivered. At this
stage of the procedure the size of the remaining alar cartilages is assessed; if necessary, further cephalic resection
is done to achieve perfect symmetry or the desired size of
the alar cartilages (Fig. 5).
The rhinoplasty may then proceed with other surgical
techniques used on the alar cartilages, which may be
grafted, sutured, or remodeled as necessary to achieve good
functional and aesthetic results. After addressing the upper
two thirds of the nose, at the end of surgery both the
transcartilaginous and marginal incisions are closed with
an absorbable suture material.
We have been using this modification of the standard
delivery approach for several years and we have had no

Fig. 3 A marginal incision is made on each side

Fig. 4 The remaining alar cartilage is delivered

Fig. 5 Further cephalic resection may be done

Fig. 1 A transcartilaginous incision is made on each side

complications. None of the patients in whom this modified

approach was used complained of postoperative nasal
obstruction. Therefore, even though no functional studies
were conducted in these patients, significant scarring
of the internal nasal valve leading to symptomatic nasal
obstruction probably did not occur.

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Aesth Plast Surg (2013) 37:1621

Clinical Cases
Two patients who had this modified delivery approach are
presented. Patient 1 is a 27-year-old woman with a tension
nose and a septal deviation to the right side. Her nasal tip is
overprojected and overrotated, boxy, and bifid. The nasolabial angle is undefined and there is a convexity to the
nasal dorsum (Fig. 6ad).
The delivery approach was chosen for this patient, as it
would provide the possibility to perform cephalic resection
of the alar cartilages and bilateral single-dome and doubledome suturing, approximate the two tip-defining points,
narrow the nasal tip, and improve tip definition. The
delivery of the alar cartilages of course would break the
fibrous ligaments of the scroll area which would weaken
this tip support element, thus decreasing tip projection and
rotation. These changes of the tip, however, were one of
the goals for this patient, so this breaking of the fibers at the
scroll area was an anticipated advantage. A complete
transfixion incision of the nasal septum was also used and
the anterior nasal spine was partially resected; both these
maneuvers were used to promote further weakening of tip
support and to decrease tip projection and rotation. A
transcartilaginous incision was used in this patient instead
of an intercartilaginous incision, to prevent postoperative
scarring at the internal nasal valve, as previously described.
After the rhinoplasty, tip projection and rotation were
improved and the nasolabial angle had better definition.
The tip lost its bifid and boxy appearance and an
improvement in tip definition was achieved. The nasal
dorsum was lowered to be in balance with the tip. An
improvement in nasal aesthetics as well as in nasal functioning was achieved by rhinoplasty. Preoperative
(Fig. 6ad) and postoperative (Fig. 7ad) photographs of
this patient are provided.

Fig. 6 ad Preoperative photos of clinical case 1

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Fig. 7 ad Postoperative photos of clinical case 1

Patient 2 is a 31-year-old woman with convexity of the

nasal dorsum and a septal deviation to the left side. There
is an overprojection and a slight overrotation of the tip
and a lack of tip definition as well, with the two tipdefining points too far apart and a trapezoidal nasal base
(Fig. 8ad).
The delivery approach was chosen for this patient as it
would provide the possibility to perform cephalic resection
of the alar cartilages and double-dome suturing, decrease
the interdomal distance, narrow the nasal tip, and improve
tip definition. The delivery of the alar cartilages would
break the fibrous ligaments of the scroll area which would
weaken this tip support element, thus decreasing tip projection and rotation. These changes to the tip were one of
the aesthetic goals of this patient so this disruption of the
fibers at the scroll area was an anticipated advantage. A
complete transfixion incision of the nasal septum was also
used to promote further weakening of the tips support and

Fig. 8 ad Preoperative photos of clinical case 2

Aesth Plast Surg (2013) 37:1621

decrease tip projection and rotation. A transcartilaginous

incision was used instead of an intercartilaginous incision
to prevent postoperative scarring at the internal nasal valve,
as previously described.
After the rhinoplasty, tip projection and rotation were
improved. An improvement in tip definition was achieved,
with the two tip-defining points closer and a more triangular shape to the nasal base. The nasal dorsum was lowered to be in balance with the tip. An improvement in nasal
aesthetics as well as in nasal functioning was achieved by
the rhinoplasty. Preoperative (Fig. 8ad) and postoperative
(Fig. 9ad) photographs of this patient are provided.

Discussion
The three standard approaches for rhinoplasty are the
nondelivery approach, the delivery approach, and the open
approach.
The open approach affords an unparalleled exposure of
the nasal framework, thus facilitating the diagnosis of the
deformities whenever the preoperative analysis of the nose
has not allowed a complete understanding of the deformities of the nasal pyramid [2, 3, 7]. The enhanced exposure
offered by the open approach also facilitates the correction
of the nasal deformities by remodeling or grafting the nasal
framework and allows the surgeon to promptly assess the
effect of these modifications. Therefore, the open approach
is the preferred approach whenever major reconstruction of
the nose is planned or major modifications to the nose are
anticipated to be necessary [810].
In most patients, however, the nose will not need major
reconstruction but will benefit from slight modifications in
tip rotation or projection, correction of a bifid or boxy tip,
improvement of tip definition, or conservative hump
removal. These modifications will improve the aesthetic

Fig. 9 ad Postoperative photos of clinical case 2

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appearance of the nose and its balance to the face and may
often be accomplished through an endonasal approach.
The nondelivery approach is an endonasal approach
very suitable for achieving minor modifications of the nasal
tip such as a moderate increase in tip rotation or an
improvement in tip definition [1, 4, 11]. The nondelivery
approach is particularly suitable for patients with reasonable tip symmetry, normal domal angles, and normal
interdomal distances [1], as this approach does not allow
any modification of the domal angles or a narrowing of the
interdomal distance.
The delivery approach is another endonasal approach.
This elegant approach allows the surgeon to modify the tip
of the nose by remodeling the alar cartilages. Besides
providing access to the upper two thirds of the nose, the
delivery approach may be used to correct bifidity or
asymmetry of the tip, achieve extra tip rotation, or change
tip projection [2, 4]. With the delivery approach, precise
excision of cartilage is possible under direct visual control
of the alar cartilages, and it is possible to introduce and
fixate cartilaginous grafts. It is also possible to interrupt the
continuity of the alar cartilages to change nasal tip projection and rotation, or to enhance tip projection by using a
lateral crura steal technique [4]. The delivery approach
allows excellent exposure of the alar cartilages, which may
be remodeled as needed. This approach is particularly
useful in patients with a nontriangular tip (on basal view),
wide domal angles, and large interdomal distances [1, 11],
as both the interdomal distance and the domal angles may
easily be changed through this approach.
The surgical approach selected for every rhinoplasty
case should afford adequate exposure of the nasal structures that are to be addressed by surgery and allow the
various surgical techniques to be easily executed, but it
should also be as noninvasive as possible. For providing
adequate exposure, however, every approach has to divide
or elevate nasal cartilaginous and soft tissue structures,
which may interfere, to a certain degree, with the natural
mechanisms of tip support and strength. Several nasal
structures are unanimously recognized as contributing to
tip support. The structures influencing this support are
usually classified as major and minor tip support mechanisms. The major tip support mechanisms are the size,
shape, thickness, and resilience of the alar cartilages, the
upper lateral cartilages attachment to the cephalic margin
of the alar cartilages, and the attachment of the medial
crura footplates to the caudal septum. The minor tip support mechanisms are the ligamentous sling spanning the
domes of the alar cartilages, the membranous septum, the
cartilaginous septal dorsum, the nasal spine, the sesamoid
complex extending the support of the lateral crura to the
piriform aperture, and the attachment of the alar cartilages
to the overlying skin and musculature [1, 12].

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Recent studies have underscored the role of the attachment of the upper lateral cartilage to the cephalic margin of
the alar cartilages to maintain strong tip support [13, 14]. It
has been demonstrated that this attachment is made of
fibrous tissue consisting of dense collagen fibers, all oriented in one direction, thus fulfilling the criteria of a true
ligament [13]. Another study demonstrated that the most
efficient way to release the tip so it can be freely moved is
severing these fibrous attachments between the upper lateral and the alar cartilages [14], thus highlighting the role
of this ligament in tip support.
Despite some criticism that has surrounded the delivery
approach, this is an elegant approach that allows the surgeon to modify the tip of the nose by remodeling the alar
cartilages. Two incisions usually are made in this approach:
an intercartilaginous incision and a marginal incision. One
criticism of the delivery approach is the intercartilaginous
incision. This incision is made close to the internal nasal
valve, which may cause postoperative scarring at the valve
area [4, 8], leading to postoperative nasal functional
obstruction.
The delivery of the alar cartilages is another negative
point of the delivery approach, as this maneuver will
inevitably provoke breaking of the fibrous connections
between these cartilages and the triangular cartilages, at the
scroll area, and thus promote weakening of this major tip
support mechanism [8, 15].
We suggest that a transcartilaginous incision replaces
the intercartilaginous incision usually used for the delivery
approach. The purpose of this modification is avoidance of
the scarring close to the internal nasal valve that may result
from the intercartilaginous incision. In this modified
approach, the delivery of each alar cartilage is performed in
two stages. In the first stage, after the transcartilaginous
incision is made, a cephalic piece of the cartilage is
resected. In the second stage, after a marginal incision is
made, the remaining alar cartilage is delivered. The exact
amount of cartilage to be resected may be difficult to assess
during the first stage, so it is crucial to leave an appropriate
amount of cartilage caudal to the transcartilaginous incision. During the second stage, after delivery of the
remaining alar cartilages on both sides, they are assessed
and compared. Further cephalic resection of the alar cartilages may be performed at this stage of the procedure to
achieve perfect symmetry or the desired cartilage size.
By using a transcartilaginous incision instead of an
intercartilaginous incision, this modified delivery approach
moves the incision away from the internal nasal valve, thus
precluding the danger of possible postoperative scarring at
the internal nasal valve and subsequent nasal obstruction.
Another criticism of the delivery approach is the damage
done by the delivery of the alar cartilages to the collagen
fibers connecting the upper lateral cartilages to the cephalic

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Aesth Plast Surg (2013) 37:1621

border of the alar cartilages. The importance of the

attachment between these cartilages is well recognized and
considered a major tip-support mechanism [1, 12].
Recently, this attachment has been described as a true
ligament because it is made of dense collagen fibers
organized in one direction [13]. It has been shown that
dividing this fibrous tissue has much more of an effect on
releasing tip structures than dividing any other soft tissue
important to the tip-support mechanisms [14], emphasizing
the importance of keeping this tissue to maintain strong tip
support.
Every surgical approach and surgical technique used
for rhinoplasty interferes to a certain degree with one or
several of the tip-support mechanisms. The damage to the
collagen fibers at the scroll area caused by the delivery
approach is something that the surgeon should be aware
of. However, it is also something that the surgeon can
take advantage of in selected cases, such as when some
loss of tip support is advisable as in the patients presented
above.
We believe that by modifying the delivery approach and
using a transcartilaginous incision instead of an intercartilaginous incision, the possibility of postoperative scarring
at the internal nasal valve is precluded. Some interference
of tip support will inevitably occur due to the disruption of
the fibrous ligament at the scroll area, but this may be in the
interest of the surgery if some loss of tip support is helpful
to achieve an improvement of the nasal tip.
By using this modification of the approach and taking
advantage of the interference to one of the tip-support
mechanisms when appropriate, we believe that the surgeon
may wish to include the delivery approach in his or her
armamentarium of rhinoplasty approaches.
Conflict of interest
disclose.

The author has no conflicts of interest to

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