Nasal Tip Surgery
Natural sculpturing of the nasal tip during rhinoplasty is the common goal of surgery. In the vast majority of patients undergoing primary rhinoplasty, it is important to preserve an intact caudal segment (complete strip) of alar cartilage, which extends from the medial crural footplate attachment to the caudal septum to the lateral crural attachment to the pyriform aperture. It is important, according to Dr. Sam Rizk, a New York facial plastic surgeon and rhinoplasty surgeon, to avoid the less predictable healing consequences of the various forms of vertical dome division interrupted strip. Symmetry is enhanced and a predictable less traumatic procedure is performed. There are very few surgical procedures that blend artistic and technical skills to the degree required in aesthetic rhinoplasty. Although it is one of the one of the more common operations performed, only a few surgeons ever master the subtleties and nuances of this procedure.
It is important for a successful rhinoplasty to carefully analyze the nose and its relationship to the face and chin. Careful analysis is important to a proper accurate surgical plan. A realistic estimate of surgical correction, based on the possibilities and limitations imposed by the characteristics of nasal tissue thickness, is important. Based on this accurate analysis, Dr. Sam Rizk composes an operation predicated on the anatomy and deformity encountered, orchestrating the operation to achieve the intended long-term stable result. Dr. Sam Rizk envisions the result before and during the operation. The goal of the surgery is to fashion a natural nose that is in harmony with its surrounding facial features, does not draw attention to itself, and results in a happy patient. This finesse rhinoplasty approach was refined by Dr. Sam Rizk and over many years to achieve the most natural outcome with a rapid recovery rhinoplasty.
Rhinoplasty remains the most challenging of all aesthetic operations, since no two procedures are ever quite the same. Each patient's unique nasal configuration and anatomic structure requires individual customized operative planning. Therefore, no single technique will be adequate for the varied anatomic patterns encountered. This is why Dr. Sam Rizk uses both the endoscopic and open approaches and does not limit himself to one approach, depending on the anatomic abnormality in the nose present and the necessary steps used to achieve the best surgical result, irrelevant of approach used. It is also important to be conservative in the surgical approach. Dr. Rizk states that repositioning the tip, sculpting the tip cartilages and resection of tissue must be made in a conservative manner. Far more problems and complications arise from overcorrection of nasal abnormalities than from conservative correction.
Tip sculpting techniques can be classified as those that preserve a complete strip of intact caudal alar cartilage and those that interrupt the caudal segment to produce an incomplete or interrupted strip. The concept of a systematic graduated anatomic approach implies the application of the most conservative and most predictable sculpturing operations and incisional approaches to the tips requiring minimal or subtle changes. As the anatomic deformity encountered becomes more severe, progressively less conservative approaches are utilized. Emphasis is always placed on conservation of nasal tip structures, replacing radical dissection with cartilage reorientation and repositioning whenever possible. The ultimate aim of all techniques is to produce a natural non-operated appearing tip that heals in a predictable fashion in concert with the remainder of the nasal superstructure. Tissue conservation facilitates a nonsurgical appearance.
When considering nasal tip surgery alternatives and variations, it is useful to differentiate among incisions, approaches, and techniques. These important distinctions have not always been noted in the literature, leading to confusion and misunderstanding about the indications for and long-term results of individual surgical approaches and techniques.
Incisions are in reality only methods to gain access to nasal tip structures and by themselves exert no major influence on the final tip contour and appearance. If the incision chosen weakens or divides one of the important fundamental tip support mechanisms, then by the dynamics change and the consequent loss of tip support may adversely affect healing and subsequent tip-supratip relationships. Approaches to the tip may be divided into delivery and non-delivery categories. Tip approaches provide exposure of the tip structures for analysis and modification. Relatively clear indications for each approach exist.
Techniques are those sculpturing modifications carried on the alar cartilages that effect a minor or major shape change, projection alteration, and possibly a dynamic cephalic rotation of the tip to enhance the nasal appearance. The technique chosen preoperatively often dictates the approach to be used, a decision made as a result of precise preoperative evaluation and diagnosis of the anatomy of the alar cartilages and the ultimate result desired.
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