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Nasal tip asymmetry
Nasal tip asymmetry can be defined as any noticeable difference between sides in the shape, size, or
orientation of the nasal tip. While the nasal tip can certainly demonstrate natural asymmetry, prominent tip
asymmetries are typically due to previous rhinoplasty. When performing revision rhinoplasty for tip
asymmetry, it is common to find that the causes of such asymmetries were irregularly shaped or placed
grafts, asymmetric and unequal cartilage excisions, and unbalanced suture correction of the lower lateral
cartilages. Scar contracture and thin skin can also reveal asymmetries that were not readily apparent at the
time of surgery. Sutures can also create unequal tension that will result in asymmetry, not necessarily
intraoperatively, but months to years after surgery.

It is estimated that as many as 29% of patients seeking revision rhinoplasty note tip asymmetry as a major
motivator for seeking secondary surgery . Patients who have undergone revision rhinoplasty are more
[4]
likely to be perceived as having an asymmetric nose compared to those who have only undergone primary
[5]
rhinoplasty . This finding illustrates the necessity of careful planning and the level of complexity faced
when approaching nasal asymmetry correction with revision rhinoplasty.

Prevention
Given that various seemingly minor variations in technique can cause noticeable tip asymmetries, it is
essential to carefully plan and meticulously perform all maneuvers that will affect nasal tip shape.

Any graft used in correction or support of the nasal tip can potentially contribute to nasal asymmetry if not
properly placed or shaped. Correct placement and careful consideration of smoothing cartilage edges,
especially in patients with thin skin, can help prevent nasal tip asymmetries. Shield grafts are sometimes
used to help project and contour the nasal tip, but irregularly shaped shield grafts can cause a noticeable
asymmetry in the nasal tip. Lateral crural grafts can help to smooth the edges of a shield graft, making them
less noticeable. Using a curved piece of cartilage for the shield graft can help to preserve the infratip lobule .
[6]

Various materials and grafts can be used to help mask the firm, irregular edges of cartilage grafting that may
contribute to nasal tip asymmetry. Perichondrium from either the ear or rib can be used to cover cartilage
grafts to help smooth sharp edges and fill up empty spaces from previous rhinoplasty. In a case series of 62
patients, Boccieri et al. demonstrated the successful use of perichondrial graft harvested together with
[7]
conchal cartilage to be used during revision rhinoplasty for the correction of nasal tip asymmetries . Other
autologous grafting material can also be used depending on surgeon or patient preference to cover and
[8,9]
camouflage nasal tip reconstructions such as postauricular soft tissue, temporalis fascia, or fascia lata .
AlloDerm (AbbVie - North Chicago, Illinois, USA) has been used in the past for smoothing out the edges of
cartilage grafts to prevent asymmetries, but the resorption rate has been found to be significant, and this has
fallen out of favor .
[10]

Correction
Tip asymmetries can be due to an unwanted tip shape such as a boxy or overly rounded tip. In patients
undergoing revision rhinoplasty, these tip abnormalities are more frequently caused by malpositioned,
rather than orthotopic, lower lateral crura. Consequently, these tip asymmetries can be addressed via lateral
crural repositioning or reconstruction with or without lateral crural strut grafts .
[11]

One strategy to reduce the delayed appearance of cartilage graft edges and asymmetries after postoperative
edema has resolved, is to create a soft, moldable cartilage graft. This has been achieved through a diversity
of described techniques, which include dicing, or finely mincing cartilage and then wrapping it in fascia or