The tip — Resection, sutures and support, in that order

The skin modulates everything done beneath it

No less important than the anatomical diagnosis is the relationship between cartilage strength and skin thickness, because the response to any manoeuvre depends on it. A domal suture that elegantly defines the tip in thin skin does not show through thick skin at all and the patient sees no change. Conversely, a graft that adds definition in thick skin becomes visible at six months in thin skin as a discernible edge. In broad tips with thick skin, lipectomy of the subdermal fibrofatty tissue is often needed to thin it, or a graft that increases projection and by contrast produces a finer tip. That debulking has reasonable detractors: it generates more inflammation and more scarring in the tip, and with it a risk of supratip fullness. As with so much here there is no single answer; what does not work is doing it without deciding.

Cephalic resection: how much to leave

This is the near-routine manoeuvre of the tip, and also the one that has historically produced the most sequelae. The classic rule is to leave about 6 mm of the caudal portion of the alar cartilage, avoiding excessive excision of the dome that produces the collapsed tip. In current practice the figure has crept upward: it is usual to measure 8 mm at the point of maximum width and draw the resection line from there towards the dome, and some leave even more, resecting only enough to keep the lateral crus from contacting the upper lateral, on the grounds that resecting a lot leaves small, characterless noses. The prudent approach is a two-figure rule — of the order of 6 mm at the dome and 8 mm posteriorly — and not carrying the resection too far back along the alar. The resected fragment is not discarded: it is autologous cartilage, already shaped, perfect for tip grafts.

The four errors of the domal suture

This is the suture that gives the most result and also spoils the most, and its failures are four and easy to name. Too tight: a sharp, pinched tip with the operated look everyone recognises. Too loose: no definition, it achieved nothing. Too medial: no effect at all, because it is not over the real dome. Too lateral: it overprojects the tip. The interdomal fails in two directions the same way: too tight gives a pointed tip, too loose a wide one. Numbers help: the domal divergence angle should end up around 30°, and both domes should measure the same — of the order of 5-6 mm — something worth checking with callipers rather than by eye. And one global proportion that orders the whole: tip width should be 1:1 or at most 1:1.2 relative to the dorsum, the tip always slightly wider.

Columellar strut and septal extension are not interchangeable

The columellar strut is a cartilage fragment — of the order of 30 × 3 mm, from septum or resected dorsum — housed between the medial crura and fixed only to them, never to the septum or the nasal spine. It unifies the tip complex, shapes and symmetrises the columella and adds stiffness. What it does not do, and this is the point: it does not guarantee projection or rotation. The study that examined it in a controlled way found that placing it may alter neither, and can even derotate the tip. The caudal septal extension graft is a different thing: it is sutured in continuity with the septum, which in turn rests on the nasal spine, so it inherits that support and does control projection and rotation stably. The mental rule is simple: if real, durable support is the aim, the graft must reach the septum.

The tip in secondary rhinoplasty

In an already operated nose, removing fibrosis is a fundamental step, not a formality. Fibrosis is always present, but sometimes it is so marked that it gives not only exaggerated bulk but true deformity, especially in the tip and supratip. At the same time it pays to open with realistic expectations: at best that fibrosis will be found along with remnants of previous grafts that may be useful for reconstruction; at worst, solid or injectable non-resorbable implants that have destroyed the tissues. It is worth telling the patient beforehand, because it changes the plan and sometimes the number of stages. And one rule that avoids regret with refinement grafts: if after placing it doubts remain about its final effect, it is better to remove it.