Nasal tip support and its surgical modification

As noted by Drs. Johnson and Toriumi, "The keyto successful rhinoplasty lies in the restructuring of the lower third of the nose. The modified skeletal elements must have both proper form and sufficient skeletal strength to give shape to the overlying skin-soft tissue envelope. A skeleton that lacks this load-bearing integrity becomes distorted or collapses under the weight of overlying tissues and the forces of scar contracture" [6]. All facial plastic surgeons have seen (or caused)a weakened nasal tip and have been frustrated at attempts to correct the resultant aesthetic and functional deformities. In a well-reasoned plea for surgical conservatism Dr. Tardy states that "Tip cartilage reorientation and repositioning often produce more favorable and predictable appearances. Notching, pinching, cephalicalar retraction, over-rotation, asymmetries, and tip support loss are all almost entirely eliminated in long-term healing when this conservative philosophy is embraced" [3]. Though conservation of surgical injury will certainly improve rhinoplasty results, a midline tensegrity rebuild using the time-honored surgical technique of layered wound closure will provide the maximum level of surgical control presently available overnasal tip modification. The basic knowledge of architecture and engineering presented here, along with the application of these concepts to nasal tip support,will benefit all of our patients through improvement of surgical results. As surgical architect/engineers we should all em-brace the concept that "The resistant virtue of the(nasal tip) structure that we seek depends on its (architectural) form; it is through its form that it is stable,not because of an awkward accumulation of material. There is nothing more noble and elegant from an intellectual viewpoint than this: to resist through form" [12].