Shaping and positioning the nasal tip without structural disruption: a new, systematic approach.

This paper presents a new, comprehensive, and systematic approach to analysis, planning, and techniques of primary nasal tip rhinoplasty, emphasizing techniques that limit uncontrollable variables before proceeding to techniques which increase uncontrollable variables and risk secondary deformity, including (1) maintenance of structural integrity of the alar rim strips, limiting use of scoring or morselization techniques which reduce support and introduce potential secondary deformities, (2) shaping and positioning the lateral and medial crura in a reversible, nondestructive manner using permanent suture and nonvisible control graft techniques, (3) minimizing uncontrollable postoperative variables by decreasing the need for visible grafts to shape the tip complex in primary rhinoplasty, achieving the same results with existing alar structural elements, (4) integrating these concepts with specific sequences of surgical techniques--bilateral alar arch components individually positioned, then shaped and unified for symmetry, and finally positioned for rotation and projection--and (5) introducing an integrated set of surgical techniques and sequencing of tip surgery to achieve the objectives listed above in most primary and some secondary rhinoplasties. The concepts and techniques of this approach are based on the principle that preservation of structural integrity of alar complex elements (medial and lateral crural arch elements) preserves support and reduces the incidence of secondary deformities (kinking, buckling, discontinuity) that can result from shaping techniques which disrupt that integrity. If shaping and positioning of the tip can be achieved with reversible, nondestructive techniques, the need for placement of visible grafts (with their additional variables) is greatly reduced. Shaping and positioning can be performed incrementally and reversibly without jeopardizing structural integrity and support in the surgical process. Ten fresh cadaver dissections were utilized in the development of the surgical techniques. A total of 233 rhinoplasties (220 primary and 13 secondary) with 1 to 9 years of follow-up have been performed using this approach. Only two secondary procedures for tip deformity have been performed.