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Creating normal structure and shape to the nasal tip.
If rhinoplasty is the most difficult procedure in aesthetic plastic surgery, tip plasty is arguably the most difficult procedure in rhinoplasty. In our experience, the most frustrating problems have been a supratip deformity, a bulbous tip, and an ill-defined tip. Secondary surgery has been frustrating because scar tissue has made it difficult to control the shape of the tip cartilages. The importance of not overresecting, not damaging cartilage, and grafting to achieve a normal ideal framework were capped by an advancement in suture tip plasty. The ability of sutures to permanently bend cartilage has made it possible to shape the cartilages with absolute precision, even in the closed approach. The first case in the open approach was by Daniel, in which a suture was used to narrow an unwanted wide dome. From that point in time, a flurry of suture techniques was introduced that now make it possible for the surgeon to have full control of the surgical situation. Suture techniques are reversible and extraordinarily precise. A cephalic trim of the lateral crus is nearly always necessary in primary large tip cases. Suture techniques have varied over the years, but during the last decade a fairly stable algorithm has resulted. In our experience, only four suture techniques are needed in most cases, and even then, not all four are required. The original “transdomal suture” has largely been replaced with the “hemitransdomal” suture because it avoids iatrogenic inversion of the rim and removes lateral crus convexity. To stabilize the tip against the septum, the old columellar–septal suture has been replaced with the septal–crus suture. The technique has been reasonably stable since.
Almost every nose that is considered for primary or secondary rhinoplasty has some unaesthetic issue, and therefore, tip sutures are indicated to make these corrections. A broad, round or large tip is the most common indication. The suture techniques described herein require specific sized domes and lateral crurae before application. In the primary cases of broad, wide, round, ill-defined tips, the lateral crus is, therefore, first converted to one that is 6 mm wide. A cephalic trim of that cartilage invariably works. The dome is cut a bit narrower to 4 mm. Once the tip cartilages are of this size, the suture techniques we propose are indicated to provide a tip of normal proportion and angulation.
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