Refining the nasal tip-an anatomical approach

Surgical strategies to refine the nasal tip should be conceived to address the lobule rather than just the domal extremity of this aesthetic region. The goal should be to create normal, stable anatomy. The anatomy of the tip cartilages is complex. Surgical strategies must consider the size, shape, position, and orientation of each crus including their relationships with the ipsilateral and contralateral crura of both lower lateral cartilage rings. Every surgical step has the potential for unintended as well as intended change. We favor as a first step fixation of the medial and lobular segments of the middle crura. The domes and lateral crura can then be addressed on a stable base. Suture placement must be precise with excess tightening avoided to prevent nonanatomical twists of the tip cartilage ring in part or whole. Consideration must be given to structural grafts to brace the crura and to correct convex lateral crura. These grafts should be incorporated within or deep to the tip cartilage framework to minimize visibility. It is the, contour, position, and orientation of the caudal margins of the middle and lateral crura which we think are a key component in achieving natural tip refinement.