Tip Cartilage Sculpturing Principles
In order to alter the nasal tip, the rhinoplasty surgeon must bring all of his clinical diagnostic skills for an accurate diagnosis of the deformity. Inspection and palpation of the contour, thickness, bulk, resilience, strength and extent of alar (lower lateral cartilages) with their surrounding soft tisssues and bony relationships is important. Surgical decisions related to incisional approaches and alar sculpturiing techniques should depend principally on the anatomy of the tip dynamics. The technical steps in tip surgery should accomplish cartilage contouring by the most conservative manner possible, preserving or reorienting structures in preference to resection. In reduction rhinoplasty, reducing in volume or reorienting cartilage so that the final altered alar cartilages will retain their positive characteristics while removing the undesirable characteristics. Tip surgery is almost always a compromise or series of compromises, in which the surgeon and patient must pay a price for almost any surgical alteration in the form of support sacrifice so it is very important to support the tip with cartilage grafts if tip support is weakened in other ways. Several important principles are worthy of strong emphasis when considering alar cartilage or tip cartilage contouring. According to Dr. Sam Rizk, a New York facial plastic surgeon and rhinoplasty expert, these principles apply in the overwhelming majority of rhinoplasty patients he sees.
1. Almost all tip techniques share the principle of volume reduction of the alar or tip cartilages, except in revision rhinoplasty where too much was removed in the previous rhinoplasty. Usually the reduction is confined to the broad cephalic portions of the lateral crus and dome, with an occasional thinning resection of the medial crural contribution to the dome. This volume reduction may include a portion of the "scroll" formed by the upper lateral cartilage-alar cartilage relationship. Alar volume reduction creates a dead space that ultimately will be filled with scar tissue, undergoing contracture in a variable manner. This space may eventually be diminished by an upward rotation of the alar cartilage. To reduce scar formation and cephalic contraction, all underlying vestibular skin residual from alar resection should be preserved.
2. Preserving a complete caudal strip of intact cartilage, extending from the medial crura footplates to the lateral cephalic-most tip of the alar crus, is entirely possible and desirable in the majority of rhinoplasty patients. Tip support and projection is enhanced, irregularities in healing are minimized, symmetry is probable, and a relative resistance to cephalic tip rotation is retained. The more alar cartilage left undisturbed consistent with adequate aesthetic tip correction, the more predictable is the healing process.
3. The laterocephalic portion of the latral crus, attached by connective tissue to the bony pyriform margin should be left intact and not resected. Support for the lateral nasal side wall is preserved (avoiding potential inspiratory collapse or external nasal valve collapse), possible dimpling stigmata are avoided, and potential undesirable alar cephalic retraction is unlikely.
4. In the vast majority of rhinoplasties, the surgeon preserves or increases existing projection of the nasal tip; much less often is reduction in tip projection required. Therefore, identifying and preserving the tip defining point of the alar cartilage dome is mandatory for optimum tip definition and projection.
5. In patients in whom preservation of a complete strip of alar cartilage does not result in satisfactory definition and refinement of the nasal tip, a shape or position change may be induced in the residual intact alar cartilage strip with suture techniques without resorting to a vertical dome division or interruption of the complete strip.
6. If a decision is made to interrupt the complete strip to achieve an added narrowing refinement, which might rarely be necessary in very thick skinned rhinoplasty patients for definition or increased projection or additional rotation, the overlying skin envelope must be very thick to camouflage any irregularities or offsets that would otherwise become palpable and or visible in the long-term postoperative period in thin skin patients requesting rhinoplasty.