Tip Points: Defining the Tip

Steven Burres, M.D.

Los Angeles, California, USA

Abstract. At the center of the tip, the tip points (TPs) are thesingle most defining feature of a nose. In a random survey (N4 146; females, 76; males, 70), TPs were 8.9 ± 1.6 mm apart.TP quality was graded into four categories based on the criteriaof presence, interdomal crease, base width, and distinction. Thedistributions of TPs according to TPG were as follows: I, 12%;II, 50%; III, 30%; and IV, 8%. The TPG system was applied toa collection of photographs of female Caucasian magazinemodels, which had a distribution similar to that of the Cauca-sian females in the study population, demonstrating the effec-tiveness of grading. Surgical guidelines for the preservation andgeneration of TPs are presented, especially the geometric con-sequence of various surgical maneuvers, e.g., dome divisionand tip graft.

Key words: Nose—Rhinoplasty—Cartilage—Nasal measure-ments

At the junction of the medial and lateral crura of eachlower lateral nasal cartilage, a thick condensation of car-tilage is often found that creates a sharp, localized im-pression in the skin of the nasal tip lobule. From thislocation at the apex of the tip lobule, these cartilaginousbeads, the so-called ‘‘tip points’’ (TPs) or ‘‘tip definingpoints,’’ can be of paramount significance as a cosmeticstructure because they draw attention to the nasal tip byboth their influence on nasal shape and light reflectionand their contribution to the tip projection at this criticalspot (Fig. 1).

Anthropomorphic studies avoid points of unpredict-able occurrence and so Farkas and co-workers justifiablyincluded the apex of the nasal complex, known as thepronasale, as the only point of measurement in the tip

lobule and excluded the TPs [1,2]. Many surgeons havecreated nasal measurement systems to analyze tip pro-jection and rotation utilizing the same pronasale land-mark but have, instead, labeled it the tip defining point,omitting the term pronasale [3–6]. This substitution innomenclature is accurate only in the lateral projectionand only if the tip defining point is equal to or lateral tothe pronasale in the coronal plane, but often this is notthe case. Tardy and others precisely reserve the designa-tion of the tip defining points for the dual impressions ofthe domes, which are found at a location that is distinctfrom the pronasale [7–9]. Frequently the term TP is re-placed by dome or dome segment, which refers to awider, ill-defined section of the central arch that includesany TP formation that may or may not be present. Sheenand Sheen referred to the intercrural distance (ICD) andused an imaginary line connecting the domes or ‘‘defi-nition points’’ as the base for two idealized, equilateraltriangles between the columellar–lobular and the tip–dorsal junctions [10].

Beyond the issue of tip terminology, neither the ana-tomic variations in the TPs nor their significance hasbeen systematically investigated. For instance, Bernsteinoutlined the deviated, wide, sharp, protrusive, bifid and

Correspondence to author at 465 North Roxbury Drive, Suite1012, Beverly Hills, CA 90210, USA Fig. 1. TPGs. I, poor, II, fair, III, good, IV, excellent.

Aesth. Plast. Surg. 23:113–118, 1999

© 1999 Springer-Verlag New York Inc.

asymmetric tip types and listed four variations in under-lying dome patterns, without elaborating on the contri-bution of the TPs to these categories [11,12]. Similar tipgroupings are commonplace references and help sur-geons to compare cases by providing familiar images,but none are correlated with actual measurements of thetip lobule except for variations in projection, and the TPsremain a secondary detail. Demonstrating the classifica-tion potential of nasal measurements, Farkas et al. cat-egorized nostril types from the basal view [2].

Rhinoplasty surgery frequently includes reshaping thecrura and domes to correct imbalances in symmetry, ro-tation, bulk, and projection, often without regard for thesecondary, deleterious consequences these manueversmay have on the natural TPs and their topographic rep-resentation. The establishment of the desired lateral pro-file is not a complete measure of anthropomorphic oraesthetic success and the details of the tip lobule deserveadditional priority. Some natural and artificial tip im-plants have a specific TP component and most efforts atdome reconstruction attempt to return or preserve tipbifidity in a natural manner, but the preferable surgicaldetails of the TPs have not been specifically described[13–16].

To overcome these deficiencies in TP nomenclature,classification, and surgical design, the TPs in normalsubjects were surveyed and graded. An aesthetic sub-group, female Caucasian magazine models, was then as-sessed by the newly devised standard. Appropriate sur-gical guidelines and the predictable effect of dome re-configuration on the TPs were then deduced from theseobservations.

Method

Patient Evaluation

Linear Measurement.Random, nonsurgical adults resid-ing in the Los Angeles area were surveyed over a3-month period, regardless of race or gender. All dis-tances were measured with a hand-held, rotary-style,stainless-steel caliber. When TPs were not evident, theauthor gave a best measurable approximation of the cen-ter of the dome region.

Tip Point Grade (TPG) (Figs. 1 and 2).TPs were alsograded by the author, according to the following proto-col.

I. Poor: No TPs present, or minimal appreciableTPs; no columellar crease present in the tip re-gion.

II. Fair: TPs appreciable but blunt; minor bifurcationbetween the TPs.

III. Good: TPs obvious with a distinct base but inter-mediate in diameter; clear bifurcation. IV.

IV. Excellent: TPs distinct, sharp, and small with adiscreet base; deep columellar crease.

Since the TPG is a registry of the TP detail, the size ofthe tip lobule should not be a determinat, so that the factthat a small tip lobule may be poorly defined or a largetip lobule may have obvious, distinct points did not alterthe assigned TPG. Furthermore, tip asymmetry in eitherthe horizontal or the vertical plane was irrelevant to theirgrade. Both the columellar crease and the peak of the softtriangle can guide the surgeon in TP identification andappraisal.

Magazine Survey

Color facial photographs of female, Caucasian modelsfrom full-page, promotional advertisements in high-profile beauty magazines, e.g.,CosmopolitanandAllure,were randomly reviewed by the author. Photos were re-jected if the TPs could not be visualized because of poorcamera focus, shading, camera angle, and/or small size.

Anatomy

A consensus agrees that the outermost, tip lobule bound-aries are the alar crease, columella, and bridge, whereasthe supratip or ‘‘weak triangle’’ region, a soft spot thatresults from the absence of skin support from the caudalend of the cartilaginous bridge to the lateral crus, may bevariably included within the lobule domain [7,17]. Be-tween the medial crura lies the columellar crease, a ver-tical, midline sulcus that may extend superiorly to dividethe TPs (Fig. 3).

The TP is firmest along the inferior edge of the lowerlateral cartilage, where the angulation of the rim is itsmost extreme. The caudal borders of the crura typicallymeet at a 30° angle, but TPs tend to be more noticeablewhen the angle is more acute, and vice versa [10,18]. Onthe nasal exterior, the TPs form the peak of the softtriangle, a superomedial area of the alar rim lacking car-tilaginous support. In most noses, the pronasale spot cor-responds to a midline skin point tented between the TPs.

In profile, the tip rarely displays a single, sharp pointbut is more often rounded or characterized by a ‘‘doublebreak point,’’ in which the outer edge of the bridge andthe columella each form separate sharp angles in the tipregion [24]. In the latter case, the upper angle representsthe TP junction and the lower angle indicates a bend inthe columella, demarcating a central cartilage segmentthat has been named the middle crus by Sheen.

TPs may be anatomically absent or undetectable ex-ternally when thick, sebaceous skin of the tip lobule,padded by underlying fibrofatty tissue, resists the TPimpression or if postoperative or postinflammatory scar-ring in the dome region blunts their impact (Fig. 4).Crural weakness can reduce the apical pressure that a TPwould apply to the overlying skin and asymmetric cruraltension may eccentrically displaced TPs. The platyrrhinenose, with a small septum and soft alar cartilages, oftenhas stunted TP development.

For the same reasons that TPs are absent, clinical

114 Tip Points

variations in their location are the norm when they arepresent. A domineering lateral crus deflects the TP junc-tion medially and creates bulbosity by filling the tip lob-ule, whereas a prominent medial crus causes lateralsplaying of the TPs. TP projecting force may be modifiedby alterations in the curvature, length, and stiffness of thecrura, buckling and deformity of the cartilage created byfibrous attachments, or postsurgical laxity from deliber-ate cartilage effacement.

Results

Table 1 contains the ICD results by TPG, gender, andrace. TPs were plainly evident in 88% of our survey,considering those subjects in Grades II–IV.

Based on the analysis of variance of ICDs, the popu-

lations of each clinical grade were independent. Since theICD was significantly different in each TPG, this singlemeasurement functioned as an objective correlate for thesubjective visual grading and, likewise, demonstratedthat the individual grades followed an objective, measur-able pattern. The ICD decreased with increasing grade,indicating that the visual perception of well-defined tippoints correlated with their proximity.

There was no significant difference in the ICD ofmales and females or among the various racial groups.Although a trend toward high ICDs in Blacks and Asiansand lower ICDs in Middle Easterners and Hispanics waspresent, there was no statistically significant differencesin the study populations.

TPGs in two populations of Caucasian females, thosein our random population and those found in the maga-zine survey, were found to be statistically indistinguish-

Fig. 2. Examples of TPGs.A Poor.BFair. C Good.D Excellent.

115S. Burres

able. Of the 35 Caucasian females in our survey, theTPGs were 0% I, 46% II, 36% III, and 17% IV, whichstatistically matched the magazine model population (N4 130): 0% I, 35% II, 52% III, and 13% IV.

Surgical Principles of TP Management

Although individual preference may supersede generalguidelines in selected cosmetic cases, the following prin-ciples were assembled based on the results of measure-ments and grading and the author’s own surgical obser-vations.

(1) TPs should be preserved when the following apply.

A. They are clearly present and distinct.B. They are in good relationship to each other.

(i) They are a natural or desirable distance apart,typically between 6 and 10 mm.

(ii) They are horizontally aligned.C. They establish the desired projection of the tip lob-

ule.

Since they are difficult to recreate accurately, the sur-geon should allow minor variations in the location ofwell-formed tips. Any surgical intervention in the tip cancreate subcutaneous scarring that may blunt TPs.

Sacrificing TPs to reduce projection is common andunderstandable, since overprojection is disfiguring at anydistance, whereas TP problems may go unnoticed evenunder close inspection.

(2) In some circumstances, it might not be desirable tocreate TPs. In the Black or Asian nose, Westernizationby the addition of TPs may be unharmonious with theface, particularly since these groups have a naturally lowincidence of TPs.

(3) Crural modification may rectify TP misalignmentwithout TP destruction so that alar rim and cartilageasymmetry is frequently associated with TP asymmetry[2]. Division of the lateral crus may move the tip pointscloser by reducing the tethering of the low arching lateralcrus. Medial crus devision may also allow approximationof the tip points by removing the outward bow of a stiff

medial crus. In either case, division of a crus can weakenthe pressure of the points against the lobule skin, therebyreducing definition.

(4) Central division with removal or scoring of thedome segment eliminates the native TPs and may reducesupport of the tip lobule skin, resulting in blunting of theskin and local scarring [19,20]. The remaining, fresh cru-ral edges may simulate TPs.

(5) TPs draw an observer’s attention to that spot, sothey must join the adjacent alar cartilage and supratipspace naturally, especially if the crura have also beenreshaped. Misshaped TPs or cartilage edges in the tiplobule can create a distracting deformity and is a sine quanon of surgical intervention. Compacted or multilayeredcartilage on the edge, with an irresistible foundation, isrequired to create an impression or defining point in theskin. Crushed cartilage, shield- or umbrella-style grafts,and some plastic prosthesis have specific TP simulationpoints. Cartilage overlapping techniques tend to rein-force dome cartilage. Crural division and rotation of cru-ral edges, e.g., Goldman tip, will bury the natural TPsand form new points of definition.

(6) Bossa are false, lateral tip points resulting fromconcave bunching along the alar rim.

(7) Sometimes TPs cannot be created because of thickskin, subcutaneous fibrofatty tissue, etc., and should beabandoned as a consideration.

Fig. 3. Anatomic landmarks related to TPs.

Fig. 4. Examples of TP problems.A Normal. B Dominantlateral crus.C Dominant medial crus.D Thick skin.E Subcu-taneous tissue.F Tip cartilage resection.G Lateral dome divi-sion.H Medial dome divisions.I Weak crura.J Tip graft.

116 Tip Points

Discussion

The concept of tip definition refers to architectural dis-tinctions that attract the viewer’s attention, of which theTPs are often an important component. Since they are apurely aesthetic site, taste and philosophy may influencethe desirability of TPs, and so patients and their surgeonmay have conflicting, but equally valid, viewpoints. Oursurvey demonstrates wide variations in the natural con-figuration, and so, in the absence of an absolute ideal, anunbiased choice between the natural and an artificial de-sign can be made.

Patients as laymen may be influenced by society’sselection of nasal types in the media, and ethnic prefer-ence may add to partiality for either a native or a non-native pattern. The fact that 65% of Caucasian females inour survey of beauty magazines had TPG III or IV sup-ports the contention that the Caucasian nose should haveTPs, and the more distinct, the better, at least as a mar-keting tool. Yet our random survey demonstrated that themajority of people (62%) had minimal or fair TPs, indi-cating that good TPs are not a part of the natural con-figuration. So within Western society, TPs are a some-what exceptional quality that should be preferred.

More so than patients, surgeons tend to be guided bythe optimal or platonic ideal, which would appear tofavor TPs in our society. Most authors would agree thatTPs are desirable to give the nose some attention, com-pared to the more colorful eyes and sensual lips, andcreate facial balance by generating an aesthetic centerbased on attractive architecture. Some authors have at-tempted to define what is desirable by analyzing thecollected opinions from other surgeons but this form ofexpert analysis may be inaccurate if the only true mea-sure of individual success in a cosmetic case is patientsatisfaction [7,16].

Collecting objective data on a point that is variablypresent can be an elusive process [21–23]. Experienceteaches that measuring facial distances is not the verysimple, reproducible process that one would anticipate.Interobserver variability in measurements commonlystems from the exact choice of point placement and isamplified by the fact that the measurements are linear

approximations of a curved skin surface [23]. Further-more, the real surgical applicability of precise measure-ments may be limited [24].

Innumerable factors bias every population sample, nomatter how randomly subjects were admitted into theprotocol. For instance, Ofodile et al. surveyed 201 BlackAmerican noses and grouped them into three broad cat-egories of African, Afro-Indian, and Afro-Caucasian,thus showing that many distinctions may be resolvedfrom subgroups when they are throughly scrutinized[25]. In addition, since they considered the tip bulbous in100% of African-type noses, a TP population improperlyrepresented by this racial group would be imbalanced,and so a survey must properly reflect the investigator’sintention.

Despite these barriers to absolute accuracy, our studyestablished a grading system for TPs based on measur-able differences in the ICD and tip form and showed thatthese categories had statistical independence to supporttheir validity on an objective basis. By then testing thesystem on a collection of photographs of models in cos-metic advertisement, an indication of the social signifi-cance of TPs were derived. Proper TP management canenhance the likelihood of a natural surgical result.

References

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Table 1. Intercrural distance (ICD) in the random study population

ICD (mm)

TPG I II III IV Overall

9.7 ± 1.3 9.2 ± 1.5 7.8 ± 1.4 7.4 ± 1.5 8.9 ± 1.6(N 4 17; 12%) (N 4 73; 50%) (N 4 44; 30%) (N 4 12; 8%)

Gender Male Female8.9 ± 1.6 8.5 ± 1.5(N 4 70; 48%) (N 4 76; 52%)

Race Caucasian Black Asian Middle East Hispanic8.8 ± 1.7 9.3 ± 2.0 9.0 ± 1.1 8.1 ± 1.8 8.4 ± 1.6(N 4 77; 53%) (N 4 5; 3%) (N 4 22; 15%) (N 4 14; 10%) (N 4 28; 19%)

117S. Burres

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