In terms of rhinoplasty, it means factoring the problem of tip modification into its component parts:
- Aesthetic Ideal
- Patient Anatomy
- Restriction, Contingencies, and Potentialities
The Aesthetic Ideal
This ideal defines solid objectives for the tip modification. It is specific in its detail and consists of expertise in normal surface anatomy, ideal features and symmetry, and the patient elegance.
Patient Anatomy
Here, it is necessary to analyze which anatomical parts comprise the surface detail that is manifest using average nasal anatomy as a baseline. Minus this analysis, it is impossible for the surgeon to conclude which parts should be modified and which technique to employ. The following are the primary anatomical considerations:
- Skin thickness and subcutaneous tissue: it is pointless to perform technical sorcery on the alar cartilages in a fibro-fatty or overly thick tip. Such a procedure would fail to create surface definition and decrease support on an already bulky cover. Is it worthwhile to dissect and trim the cartilage only when confirmation is made, visually or by palpation, that the lateral crura are responsible for excessive width. Keeping in mind that skin thickens as it contracts, cartilage reduction in a thick-skinned nose will likely result in a poorly defined and rounded tip.
- The alar cartilage shape and structure: the structure of the alar cartilages can be pre-operatively estimated with proper anatomical landmarks. The medial crus, medial genu, middle crus, lateral genu, and lateral crus are the constituents of the alar cartilage that affect tip contour. Since each can be modified independently, these parts must be considered separately. An important to note to consider is the size and position of parts and their relational dynamic.
Restrictions, Contingencies, Potentialities
With the Aesthetic Ideal and Patient Anatomy in mind, the surgeon must now consider the technically feasible. In general, techniques that result in structural distortions will also distort surface anatomy. Before selecting a procedure, the preservation of surface landmarks—such as the columella-lobular angle and the three-point light reflex—must be considered. In addition, the suitability of a procedure for a specific nasal tip must also be considered. Clearly, an all-purpose one-size-fits-all technique would be inadequate. The eversion method, as an example, allows trimming the cephalic edge of the lateral crus but does not allow access to the dome and middle crus—critical for correction of the box tip. If, on the other hand, a radical all-purpose technique is employed, an over resection of the alar cartilages and all the untoward effects will inevitably result. Cartilage quality is also an element of concern. Soft, thin, or diminutive cartilage lacks structural potential and it can be counterproductive to reform. Tip modification by resection presumes well-structured alar cartilages. Therefore, both technique and anatomical limitation must be assessed.
Infra-cartilaginous Incision with Delivery of Cartilage
In many cases, infra-cartilaginous incisions with delivery of the cartilage is a preferred procedure because it provides a direct access to the cartilage and affords the surgeon full control of the resection, particularly in the dome region. This technique produces a symmetrical and non-surgical-appearing nasal tip. When a slight tip refinement is required, occurring in a small percentage of cases, the retrograde eversion or cartilage-splitting technique can be used.
