Advances in surgery of the tip: intact rim cartilage techniques and the tip-columella-lip esthetic complex.

There is no one technique best for all noses. The sensitive, versatile, and experienced cosmetic surgeon should select from his choices the combination of modalities best tailored to the needs of each patient. Among these modalities should be cartilaginous septal transfixion combined with the three techniques for changing the quantity and shape of the tip cartilages. The most important factor in choosing from the three tip techniques is the decision as to where the rotation points and major thrusts should be. Then come the choices as to tip width and infratip lobule length and the fine points of cartilage incision levels and directions and cartilage excisions or morselization. The decision to detach or not detach the septal strut below the cartilaginous septal transfixion incision is predicated mainly on tip-columella-lip esthetic complex requirements. Proper selection of these methods and attention to the tip-columella-lip esthetic complex should allow the surgeon to construct pleasing, relatively natural looking profiles with fewer radical hump removals and nostril base resections and with rare complications from nostril notching or collapse. No magic is involved in rhinoplasty; the surgeon's incision, removals, and additions, plus scar formation and contraction, produce the results.