It is no longer sufficient to rely on the hope that a generous cephalic trim will be associated with an appropriate degree of constrictive fibrosis that will optimally pull the tip cartilages into a new shape. Fibrosis and healing is unpredictable and it is erroneous to think that one operation fits all given that there are such a wide variety of different tip cartilage morphologies. These differences are manifest not only in the shape of each strip or ring of cartilage but also in their relationship to each other and also in their orientation in both coronal, axial and sagittal plains.
In addressing the definition of the tip therefore I look particularly at the size of the nasal anatomy both in their vertical and horizontal dimensions, the degree of their curvature, their position with regard to the angle with the mid line and their rotation along both the transverse and vertical axes.
I take a step wise approach to surgery which begins first with trying to fix the medial crura in an optimal position so that surgical techniques whether with resection, grafting or suturing of the middle and lateral crura don’t result in unwanted torsion and unexpected movement.
Cephalic trim is usually confined to the paradomal area and is conservative. If more cephalic trim is performed then the lateral crural turnover flap may maintain strength and minimize the chances of buckling.
Excess convexity in the crura may be treated with sutures but careful note must be taken of any unwanted movement that could cause alar rim retraction or exacerbation of lateral crus recurvature particularly in the region of the accessory cartilages. Lateral crural convexity sutures when I use them are usually placed as multiple small bite sutures rather than one large bite suture which can cause rolling and tubing of the lateral crus.
Excess curvature I prefer to correct with underlay lateral crural strut grafts placed in a vestibular skin pocket.
The boxy tip in my experience is often associated with excess, vertical para mid line fullness as the lateral crura are occupying a more cephalic mid line position. This may be associated with notching of the alar rims which can be exacerbated by domal sutures. In these cases careful consideration must be given to the option of caudal transposition or repositioning of the lateral crura. This decision must not be taken lightly as the dissection can lead to fibrosis from the more extensive dissection which can offset any possible advantages of the new more anatomical position of the lateral crura. Repositioning of the lateral crura may also produce significant changes in the position of the middle crura affecting the infratip lobules, soft facets and alar rims.
As with all aspects of rhinoplasty and perhaps particularly in the tip the risk versus reward equation must be very carefully considered and maybe the KISS (keep it simple stupid) should be upper most in our minds! Our dilemma is that if we pioneer and push for better, more dramatic results we and our patients perhaps take greater risk but potentially achieve greater beauty.