ORIGINAL ARTICLE

A 20-Year Review of the “New Domes” Technique

for Refining the Drooping Nasal Tip
Fernando Pedroza, MD

Objective: To describe in detail a technique to achieve patient that allows precise diagnosis and preoperative sur-
cephalic rotation, projection, and narrowing of the na- gical planning.
sal tip, the “new domes” technique.
Results: Thenewdomestechniquecreatesamoreprojected,
Design: Retrospective analysis of more than 3000 pri- cephalically rotated, narrowed nasal tip. The results are pre-
mary rhinoplasties performed during the last 20 years. dictable and stable over time, and patient satisfaction is high
becauseofthenatural-appearingresults.Complicationssuch
Setting: A private facial plastic surgery practice in Bogotá, as asymmetries, pinching, or retraction of the tip are rare.
Colombia.
Conclusion: The new domes technique is a conserva-
Intervention: Through an endonasal cartilage delivery tive, predictable, and stable technique especially appli-
approach to the nasal tip, we mold and reorient the alar cable for patients with drooped and wide nasal tips to
cartilages with transdomal and interdomal sutures. achieve a more projected, rotated, narrowed, and natu-
ral appearance.
Main Outcome Measures: Photographic analysis with
nasal and facial measurements taken directly from the Arch Facial Plast Surg. 2002;4:157-163

N
ASAL TIP surgery is con- nique, which places these new domes in a
sidered the most inter- position more lateral to the patient’s own
esting and difficult part domes. We suture the domes together, thus
of rhinoplasty. It obliges forming an aesthetic triangle that results in
the surgeon to perform a a natural-looking nasal tip. This technique
detailed presurgical analysis of each pa- is generally complemented with the resec-
tient, analyzing ethnic characteristics, skin tion of the vestibular skin of the membra-
thickness, cartilage strength, and nasal tip nous septum, the resection of the caudal sep-
shape and position. This analysis helps the tum and, if necessary, the placement of a
surgeon determine the patient’s nasal columellar strut and columellar-septal fixa-
anatomy and the precise changes that tion suture to secure the results. We be-
should be performed surgically. The goal lieve that this technique avoids the less pre-
is to obtain a natural-looking result that dictable healing consequences of the vertical
is proportional to the patient’s face and aes- dome division techniques.
thetically attractive as well as stable and
durable over time. REDISTRIBUTION OF
In this article, I describe the primary LOWER LATERAL CARTILAGE
rhinoplasty patient with a drooping nasal
tip and normal skin thickness and alar car- The medial and lateral crura, with the
tilage. For this patient, the nasal tip must domes being the most projecting part of
be cephalically rotated, projected, and nar- the lateral crura, constitute the tip carti-
rowed for aesthetic improvement. I de- lages. The shape, position, and strength of
scribe the postcartilaginous and precarti- these cartilages, as well as skin thickness,
laginous (marginal) incisions that allow determine the appearance of the nasal tip.
endonasal access for a cartilage delivery ap- While shape is influenced by cartilage di-
Dr Pedroza is in private proach, and a conservative, predictable, and mensions, strength, and orientation, the
practice in Bogotá, Colombia. stable technique—the “new domes” tech- position is influenced by dome location,

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 maintaining cartilage continuity, integrity, and sup-
port. It avoids using the vertical cartilage division, such
as the lateral crural flap, which can cause alar pinching
and inspiratory alar collapse, especially in patients with
very thin skin.

PREOPERATIVE ANALYSIS

The clinical history, findings from nasal and facial ex-

aminations, and a preliminary analysis of the options for
nasal and facial aesthetic improvement with frontal and
profile views are done during the patient’s first office visit.
Computer imaging helps the patient appreciate the nose
he or she wishes to have. The preoperative aesthetic analy-
sis at the second visit is crucial to the success of the rhi-
noplasty. In addition, appropriate laboratory investiga-
tions, medical assessment, sinus radiography, computer
imaging, and photographic analysis are performed.
The patient’s goals are determined and facial pro-
portions analyzed so that realistic results can be dis-
cussed and agreed on. These are traced on the profile pho-
tograph for the patient’s approval (Figure 1). This
pictorial appreciation of the expected results is of great
Figure 1. Presurgical aesthetic study. Right profile photograph analysis with psychological benefit for patients in accepting their new
patient measures and surgical planning marks on the tracing paper. postoperative appearance.

crural length, and the adjacent structures. In 1960, Fo- SURGICAL PROCEDURE
mon1 described the use of interdomal and transdomal su-
tures for narrowing and projecting the nasal tip. To change The new domes technique for nasal tip rotation, projec-
the position of the nasal tip and obtain cephalic rotation tion, and narrowing consists of the following 5 steps: (1)
of the tip, we can change the position of the domes and marking the new domes; (2) making the necessary post-
the length of the lateral and medial crura through direct cartilaginous and precartilaginous (marginal) incisions;
techniques on the cartilage and/or the modification of ad- (3) obtaining endonasal access with the delivery ap-
jacent structures (ie, by using indirect techniques to proach; (4) creating and fixing the new domes; and (5)
change the position of the nasal tip). To further explain performing any necessary complementary techniques. A
the dynamics of these direct techniques, Anderson2 pro- detailed description of these steps follows.
posed a very useful concept of a structural tripod. The
cartilaginous structure of the nasal tip is considered a tri- Marking the New Domes
pod in which 2 limbs are the lateral crura, the third limb
is the 2 conjoined medial crura, and the apex of the tri- Using violet dye, we draw 2 dots on the nasal skin to de-
pod, the nasal domes. marcate the location of the patient’s own domes
In a drooped nasal tip, considering the lower lat- (Figure 2A) and vertical lines to identify the level of
eral cartilage, the domes are drooped (ie, counter- the new domes (Figure 2C). To aid in defining the level
rotated and underprojected) owing to long lateral crura of the new domes, we press on the inferior nasal tip with
and short medial crura. In other words, the distribution the index finger, rotating it cephalically to the desired
of the lower lateral cartilage corresponds to a longer lat- position. This action causes the lower lateral cartilage to
eral crus and a shorter medial crus than desired. What redistribute itself, and through the skin it is possible to
we do with the new domes technique is redistribute the see the new dome, located more lateral to the patient’s
lower lateral cartilage by moving the dome position to a own dome, which corresponds to the apex of the new
more lateral location, which creates a shorter lateral crus arch formed by the cartilage as the index finger presses
and a longer medial crus. down on it (Figure 2B). In addition, the edges of the lower
In our technique we create new domes by placing lateral cartilages are outlined with violet dye also to show
transfixion sutures 3 mm or more lateral to the position the techniques to be performed on them as described by
of the patient’s own domes such that the lateral crura are Webster et al.4 This includes the cephalic cartilage re-
shortened and the medial crura are lengthened. This in- section, which generally accompanies the use of the new
creases nasal tip projection and rotation, resolving the domes technique, hump removal, osteotomies, and any
problem of the droopy tip. Relating this to the tripod con- other desired procedures (Figure 2D and E).
cept, the longer lateral limbs are shortened and the shorter
central limbs are lengthened, changing the position of Incisions
their apex as described.
This conservational technique, which I first re- The postcartilaginous incision, described in 1978,5 is made
ported in 1985,3 provides the desired aesthetic result while at the cephalic border of the lower lateral cartilage as fol-

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 A B

C D

Figure 2. Intrasurgical marking of the rhinoplasty planning. A, The patient’s own domes (2 dots); B, pressing on the nasal tip with the thumb or index finger and
rotating it cephalically to the desired position; and C and D, marking completed.

lows: It is begun 3 mm from the valvular edge at the pos- cutaneous tissues adjoined to the nasal skin. Dissection
terior aspect of the lower lateral cartilage and is contin- is continued above the domes and the caudal edge of the
ued anteriorly until reaching the cephalic border of the medial crura. We dissect between the domes and the me-
medial crus. An incision is then made at the cephalic mar- dial crura until the cartilage is well released between the
gin of the medial crus and is connected, from the poste- precartilaginous (marginal) and postcartilaginous inci-
riorly to anteriorly, to the first incision at a right angle sions, leaving only the distal ends of the lateral and me-
in the apex of the vestibular vault (Figure 3A). The tis- dial crura undissected. This creates a bipedicled chon-
sue is dissected through the incision, and the flap is held drocutaneous alar flap because the tip cartilages are almost
toward the lateral part using mosquito forceps, thereby totally released; only their feet remain connected to the
providing ample access for the septal and the nasal dor- underlying tissues. The vestibular skin remains con-
sum surgery. nected to the cartilage. Using a single hook in the ves-
The precartilaginous (marginal) incision1,2,4,6-10 is made tibular vault, the cartilage is pulled outside of the nasal
at the caudal border of the lower lateral cartilage (Fig- cavity, providing a direct view of the cartilage and al-
ure 3B) and is performed as follows: The double hook is lowing application of the techniques for redistribution
placed at the edge of the naris while putting pressure with of the lower lateral cartilage (Figure 4).
the finger on the alar cartilage, thereby everting and vi-
sualizing the vestibular skin. The caudal border of the The New Domes
lower lateral cartilage is identified and an incision made
in the skin. The incision is made posteriorly to anteri- The area for the new domes was initially marked out us-
orly following along the lateral crus, and then anteriorly ing violet dye by drawing vertical lines on the skin of the
along the caudal medial crus. nasal tip. By placing the single hook at the correspond-
ing level in the vestibular vault, the cartilages are deliv-
Cartilage Delivery ered and we are able to observe and corroborate the place
to locate the new dome, usually several millimeters lat-
By visualizing the marginal incision with the help of the eral to the patient’s own dome.
10-mm double hook and external pressure with the middle
finger over the alar cartilage and using sharp curved iris Cephalic Resection of the Alar Cartilage. Several au-
scissors, the caudal border of the cartilage is dissected. thors have described this procedure.1,2,4,6-10 We measure
One should dissect superiorly as close as possible to the the width of the cartilage at the level planned for the new
cartilage of the lateral crus, preserving the fat and sub- dome. If the width is greater than 5 mm, we perform a

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 A Postcartilaginous Incision

Everted Lower
Lateral Cartilage
Lateral Crus
1
Lateral Crus
Medial Crus
2
1
2

Internal
Nasal Valve 1
Lateral
10 mm Crus
Figure 4. The dome is delivered with a hook.
2

B Precartilaginous Incision A Mediocephalic Resection of the Lower Lateral Cartilage

Level of Level of
Original Dome New Dome
Area of Resection

Lateral Crus 5 mm
Lateral Crus
1 7 mm
1
Medial Crus

Internal B Transdomal Sutures

New Domes
Nasal Valve
Lateral 2-3 mm
Crus 2-3 mm

C Both Incisions Used for the New Domes Technique

C Interdomal Sutures

2-3 mm
Lateral Crus
Lateral Crus
6-8 mm 6-8 mm
Medial Crus
Copyright 2002 Cassio Lynm.
Copyright 2002 Cassio Lynm.

Internal
Nasal Valve
Lateral
Crus
Figure 5. The new domes technique. A, Mediocephalic excision of the lower
lateral cartilage; B, the transdomal sutures creating new domes more lateral,
projected, and narrowed; C, the interdomal sutures achieve the aesthetic
Figure 3. Incisions for the nasal tip surgery. A, The postcartilaginous triangle.
incision; B, the precartilaginous or marginal incision; and C, illustration
of the 2 incisions.

ficient cartilage to ensure tip support and avoids late post-

conservative cephalic excision of the additional carti- operative complications such as bossae.
lage, leaving at least 5 mm width at this new dome level.
The vestibular skin is not excised. We continue this ce- Transdomal Sutures. With the cephalic cartilage resec-
phalic excision laterally, leaving the lateral crus with a tion completed, we measure the distance between the new
width of 7 mm at its medial half, without extending the dome and the patient’s own dome, which corresponds
excision to the distal posterior half of the lateral crus to the amount of lateralization required. Using polyglac-
(Figure 5A). This conservative procedure preserves suf- tin 5-0 suture (Vicryl; Ethicon, Somerville, NJ), we place

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 A Caudal Septum Shortening B Vestibular Skin Reduction

Postcartilaginous
Incision

Postcartilaginous
Excess Area Incision Edge

Internal
Nasal Valve New Edge Created
by Excision
Area of Resection

C Columellar Strut Placement and Fixation D Columellar-Septal Fixation

LEVEL OF CROSS-SECTION VIEW CROSS-SECTION, SUPERIOR VIEW

4 mm Caudal Septum
Postcartilaginous Septal Cartilage
2 mm Lower Lateral
15-20 mm Incision
Cartilages Columellar Strut

2
Columellar Strut 1
Obtained From
Septum
Columellar Strut
Copyright 2002 Cassio Lynm.

Precartilaginous
Nasal Spine Incision

Columella

Figure 6. The complementary techniques. A, Caudal septum shortening; B, vestibular skin reduction; C, columellar strut placement and fixation; and D,
columellar-septal fixation. Note the tip projection achieved.

a double transfixion suture 2 or 3 mm from the level of to strengthen the medial crura to support the nasal tip,
the new dome (Figure 5B). From the medial toward the is described later in greater detail.
lateral face, we pass the needle through the new dome,
returning to the same level but with a 2- or 3-mm sepa- Interdomal Sutures. With the cartilage delivery ap-
ration from the lateral to the medial side, knotting and proach for cartilage release, the dissection between the
taking another suture, to make it double. The tension of domes and the medial crura interrupts the ligaments be-
the transfixion sutures must be controlled without tight- tween them. These supports must be reconstructed us-
ening the suture so much that the lateral and the medial ing sutures between the domes and the medial crura to
sides of the domal cartilage come together. This main- secure their structural integrity and overall tip symme-
tains the natural arch of the cartilage at the level of the try. We use polyglactin 5-0 sutures, beginning with a su-
new dome. We perform this procedure with the right alar ture between the cephalic edges of the medial crura 2 mm
cartilage first and then the left. from the domes, followed by a suture between the caudal
The cartilages are replaced from both sides into the edges of those crura 6 or 8 mm from the domes (Figure
nasal cavities at their original positions to check the re- 5C). These interdomal sutures I described in 1981.11 In
sults obtained. Specifically, the new position of the na- this way, we reconstruct the cartilage in its ideal ana-
sal tip and its degree of rotation, shape, and symmetry tomic position and create a triangle formed by the caudal
are assessed. If the new domes are not located at the same edges of the new domes separated from each other by 6
level, one of them must be corrected. The initial trans- or 8 mm, and the caudal edges of the medial crura are con-
fixion suture is removed and relocated. This correction nected to each other 6 or 8 mm below the new domes. This
is performed as many times as necessary until the new is how the aesthetic triangle described by Sheen10 is
domes are symmetrical and in the desired position. An achieved, and it provides the corresponding external high-
additional transfixion suture of polypropylene 6-0 lights that give the tip a natural appearance.
(Prolene; Ethicon) ensures the stability of the new domes. We replace the cartilage into the nasal vestibule and
We next insert the cartilage strut, obtained from the reconfirm the position and symmetry of the nasal tip. The
patient’s nasal septum, between the medial crura, fixing marginal incision is closed with polyglactin 5-0 sutures.
it with polyglactin sutures at the caudal edges of the me- The nasal tip is now cephalically rotated, more pro-
dial crura. This complementary technique, which is meant jected, and narrowed.

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 A B C D

E F G H

Figure 7. A, C, E, and G, Preoperative photographs of a 18-year-old woman with wide and drooped nose tip. B, D, F, and H, Postoperative views after the new
domes technique for the nasal tip, caudal septum, and vestibular skin reduction and columellar strut and columellar-septal fixation. The patient has also had hump
removal and alar reduction.

Complementary Techniques rior edges. The cartilage strut is placed inside the tunnel
so that its distal end does not extend beyond the distal me-
Based on the new position of the nasal tip and the colu- dial crura, and the convex edge of the strut is placed at
mella, we analyze the caudal septum and the membra- the same level as the anterior edges of the medial crura.
nous septum for redundancy. If redundancy is present, re- The anterior end of the cartilage strut is located 6 or 8 mm
section is performed to secure the new nasal tip position from the domes. It is fixed with polyglactin 5-0 sutures
and the proper degree of columellar show (4 mm). To pro- between the medial crura (Figure 6C). The length and
vide greater strength to the medial crura and nasal tip, we strength of the medial crura dictate the length and width
place a cartilaginous strut between the medial crura. We of the columellar strut—the weaker the medial crura are,
also place columellar-septal fixation sutures to at least main- the larger and stronger the columellar strut should be.
tain, or possibly increase, nasal tip projection.
Columellar-Septal Fixation. This suture was described
Caudal Septum Shortening.1,2 Pushing the columella up- by Fomon1 and Berman.7 Our technique is as follows: With
wards into the desired position with a finger, we ob- polypropylene 5-0, we place 2 sutures (Figure 6D). The
serve whether the caudal septum is long. If so, we resect first is placed at the posterior end of the medial crura.
the excess caudal septum so that it has an anatomically The suture is begun through the skin from the right side
normal curvature (Figure 6A). The ideal amount of colu- superiorly to inferiorly, and from inside to outside. The
mellar show is usually about 4 mm from the alar margin needle is reintroduced through the same point of exit and
to the inferior columella. transfixes the skin from right to left, passing through the
right skin, right crus, columellar strut, the left crus, and
Vestibular Skin Reduction.1 Pushing the columella into the left skin so that it comes out at the same level as its
the desired position with a finger replaces the vestibular entry. Once again, the suture is placed through the same
skin to its original position, and we can observe the amount point of exit, passing through the left skin from outside
of excess skin. This is excised in a triangular shape, usu- to inside and from inferiorly to superiorly, with the knot
ally 2 or 3 mm, or wider for very long drooped noses (Fig- being made behind the columella.
ure 6B). The second suture is placed at the middle of the colu-
mella in the same manner and, after knotting it without
Columellar Strut Placement and Fixation. The impor- cutting, the suture is passed through the caudal septal edge
tance of the cartilaginous strut for tip support was de- 3 mm or more anteriorly, where it is knotted so that the
scribed by Fomon1 and emphasized by Anderson.2 We use columella slides anteriorly over the caudal septum. This
an autologous graft from septal cartilage about 2 mm thick, increases projection and fixation of the medial crura and
4 mm wide, and 15 to 20 mm long. It is molded with an the nasal tip, as desired. It is important to bear in mind that
anterior convex curvature and is inserted as follows: Dis- nasal tip projection decreases postoperatively by 2 or 3 mm
section is performed through the precartilaginous (mar- as edema resolves. Therefore, the intrasurgical position of
ginal) incision of the columella to form a tunnel between the nasal tip must be projected 2 or 3 mm more than the
the medial crura without separating them at their poste- planned position for the nasal tip.

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 RESULTS tain a nasal tip that is more projected, cephalically ro-
tated, and narrowed through the use of a suture tech-
We have used the new domes technique on more than nique that preserves the integrity and continuity of the
3000 patients over 20 years and found it a reliable method lower lateral cartilage. This creates a tip that is natural
to precisely achieve increased projection and cephalic ro- in appearance with no risk of cartilage pinching or re-
tation of the nasal tip (Figure 7). Our results have been traction, the telltale signs of aesthetically undesirable ad-
predictable and stable over this long follow-up period. verse effects of surgery.
Patient satisfaction has been almost 100% in terms of na-
sal tip placement and in maintaining a natural appear- Accepted for publication June 11, 2002.
ance. We believe this is due to our ability to precisely set This procedural description was presented at the Third
the tip position and to maintain its stability by maintain- World Congress of the International Society of Aesthetic Sur-
ing crural continuity. gery, Tokyo, Japan, April 10, 2000; the Seventh Rhino-
The symmetrical and exact positioning of the new plasty and Facial Plastic Surgery Course, Barcelona, Spain,
domes is of prime importance to achieve the exact ce- May 11, 2000; the 103rd Annual Meeting of the Trilogical
phalic rotation desired and to avoid deviation or asym- Society, Orlando, Fla, May 15, 2000; the 30th Colombian
metry of the nasal tip. If we are not satisfied after using Otorhinolaryngology–Head and Neck Surgery Meeting, San
the technique, we replace the transdomal and inter- Andres, Colombia, June 3, 2000; the First Congress of the
domal sutures until we are fully satisfied. It is important International Federation of Facial Plastic Surgery Soci-
to maintain a calm demeanor since this surgical proce- eties, Cancun, Mexico, June 16, 2000; and the First Chil-
dure is not simple, and it is preferable to obtain the nec- ean Rhinology Meeting, San Pedro de Atacama, Chile, Au-
essary corrections during the initial surgery rather than gust 26, 2000.
be faced with revision surgery. Corresponding author and reprints: Fernando Pe-
It is also crucial to analyze each patient accurately droza, MD, Carrera 16, No. 82-95 Cons 301, Bogotá, DC
to determine the need for the complementary tech- Colombia (e-mail: fpedroza@cable.net.co).
niques that stabilize the surgical results. Resection of the
caudal septum and vestibular skin may be necessary to REFERENCES
improve a hanging columella. A columellar strut can im-
prove the strength and length of the patient’s medial crura, 1. Fomon S. Cosmetic Surgery, Principles and Practice. Philadelphia, Pa: JB Lip-
pincott Co; 1960.
and the columellar-septal fixation sutures can help to sus- 2. Anderson JR. New approach to rhinoplasty. Arch Otolaryngol. 1971;93:284-
tain or increase nasal tip projection. 291.
We keep in mind that the intrasurgical estimate of 3. Pedroza F. Choosing the most suitable surgical technique for the nasal tip. Pre-
nasal tip projection should be about 2 or 3 mm greater sented at: the American Academy of Facial Plastic and Reconstructive Surgery
Fall Meeting; September 1985; Atlanta, Ga.
than the final planned projection, since tip projection di-
4. Webster RC, Davidson TM, Smith RC. External marking in rhinoplasty planning.
minishes postoperatively by approximately that amount. Laryngoscope. 1977;87:126-133.
Through our postcartilaginous incision, we have not seen 5. Pedroza F. An integrated technique for septal rhinoplasty. Presented at: the 16th
any valvular disturbance or any obstructive scarring at Pan-American Otorhinolaryngology Meeting; May 1978; Acapulco, Mexico.
the nasal valve level. Using the new domes technique, 6. Hinderer KH. Fundamentals of Anatomy and Surgery of the Nose. Phoenix, Ariz:
Aesculapius; 1971.
we have not found any alar retraction or pinching, nor 7. Berman WE. Surgery of the nasal tip. Otolaryngol Clin North Am. 1975;8:563-
has there been alar inspiratory collapse because we pre- 574.
serve the continuity and resistance of the alar cartilage. 8. Bernstein L. A basic technique for surgery of the nasal lobule. Otolaryngol Clin
In conclusion, drooped nasal tips pose a challenge North Am. 1975;8:599-613.
to the surgeon, requiring accurate preoperative analysis 9. Webster RC. Advances in surgery of the tip. Otolaryngol Clin North Am. 1975;
8:615-644.
and precise surgical techniques to achieve nasal tip po- 10. Sheen JH. Aesthetic Rhinoplasty. St Louis, Mo: Mosby; 1978.
sitioning in the desired and appropriate position for each 11. Pedroza F. Nasal tip surgery. Presented at: the 21st Colombian Otorhinolaryn-
patient’s face. The new domes technique allows us to ob- gology Meeting; October 1981; Pasto, Colombia.

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