The boxy nasal tip, the ball tip, and alar cartilage malposition: variations on a theme--a study in 200 consecutive primary and secondary rhinoplasty patients.

BACKGROUND: Although "boxy" and "ball" nasal tips have received considerable attention in the rhinoplasty literature, their association with cephalic rotation of the alar cartilage lateral crura ("malposition") has not been emphasized. The thesis of this article is that most boxy and ball tips are not unique entities but rather constitute anatomical variants of alar cartilage malposition.

METHODS: Data were generated from a review of 100 consecutive primary and 100 consecutive secondary rhinoplasty patients on whom the author had operated before February of 1999.

RESULTS: The majority of the patients (68 percent of primary rhinoplasty patients and 87 percent of secondary patients) studied had alar cartilage malposition (axes toward the medial rather than the lateral canthi) (p < 0.001). Orthotopic lateral crura were significantly more common than malpositioned lateral crura among primary patients (p < 0.001); conversely, the frequency of malpositioned crura was significantly higher in secondary patients than in primary patients (p < 0.001). Most of the primary and secondary patients with malposition (74 percent and 72 percent, respectively) had boxy or ball tips. Among patients with alar cartilage malposition, ball tips were most common (31 percent of primary patients and 36 percent of secondary patients); boxy tips were second-most common (19 percent of primary patients and 27 percent of secondary patients); the remaining patients had lateral crura that were considered to be "flat" (18 percent and 24 percent, respectively). The most common configuration among primary patients was the malpositioned boxy or ball tip with inadequate projection (54 percent). All primary and secondary rhinoplasty patients with alar cartilage malposition, regardless of tip lobular configuration, had incompetence at their external nasal valves; valvular reconstruction at least doubled the geometric mean nasal airflow in most patients. In primary patients, treatment for each variant was identical: lateral crural resection, crushing, and replacement along the alar rim. Some secondary patients also required composite grafts.

CONCLUSIONS: The morphological and functional results of this study indicate that the surgeon seeing a patient with a boxy or ball tip can predict that the patient has seven times the likelihood of having malpositioned, rather than orthotopic, lateral crura. The importance of most boxy and ball tips is therefore not only the lobular deformity itself but also the functional deficit associated with it.