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Symmetric pocket formation and meticulous implant carving are the most critical parts of nasal dorsal augmentation using implants. Innovative three-dimensional printed nasal implants can exactly fit the nasal dorsal contour, decreasing the chance of deviation and malpositioning. Vertically oriented folded dermal graft technique can avoid the high resorption rate of conventional dermofat grafts. Multilayered costal cartilage graft technique for dorsal augmentation can minimize warping and difficulty in the graft carving. Derotation graft allows supple and movable nasal tip while enabling enough tip lengthening, even if the septal extension graft is the most commonly performed procedure for short nose correction.

The main objectives of rhinoplasty in African descendants are to improve the definition and projection of the nasal tip, augment the dorsum, and reduce the alar base. Open rhinoplasty using costal cartilage graft, with lateral crural tensioning and septal extension graft associated with en bloc dorsal augmentation is the workhorse. Cartilage resections should be minimal. Oral isotretinoin and triamcinolone injection may improve tip definition. Surgical success ultimately depends on the ability of the surgeon to accurately identify the anatomic variables and reconcile these anatomic realities with the patient's aesthetic expectations and his or her sense of ethnic identity.

"Subperichondrial-subperiosteal dissection technique (SSDT) decreases soft tissue injury to a minimum by protecting soft tissues from dissection and retraction traumas. The fact remains that dissecting the perichondrium of the nasal tip cartilages is not effortless. Cartilages may be harmed if dissection is not initiated at the right location. The aforementioned surgeons have routinely used the SSDT between the years 2008 and 2019 in more than 4000 rhinoplasties. The number of the surgeons making use of the SSDT will increase with the understanding of the key points in dissection, their ordering, and use of correct instrumentation."

The pinched nasal tip deformity often results as sequelae of prior nasal surgery. Conventional tip surgery techniques that overemphasize tip narrowing often deform the lateral crura and weaken support for the alar margin. The pinched nasal tip is characterized by the demarcation between the nasal tip and the alar lobule, isolating the tip from the surrounding nasal subunits. Lateral crural strut grafts with or without repositioning offer the surgeon a powerful maneuver that can help correct this functional and aesthetic deformity and restore a natural appearance to the nasal tip.

Nasal hump surgery is frequently regarded as a reduction surgery in most Western rhinoplasty textbooks and referred to as reduction rhinoplasty. Most Asian hump noses have a small hump frequently associated with a low nasal dorsum and underprojection of the nasal tip. Correcting a hump nose in Asians has distinct differences in concept and technique. A small hump and additional need for augmentation of the dorsum and the tip often minimizes the amount of hump removal or obviates resection itself. Characteristics of the Asian hump nose with emphasis on surgical techniques commonly used to obtain reliable results are presented.

Refinement of the wide, ptotic, under protected tip is one of the most difficult challenges in cosmetic nasal surgery yet also among the most common. Although excisional techniques can produce reductions in lobular width, long-term contour alterations are unpredictable and subject to stigmatic tip deformity. Preservation of natural tip support is a fundamental requirement of a successful rhinoplasty. The traditional lateral crural steal is a useful technique for tip refinement, but, when combined with a sturdy septal extension graft, the modified lateral crural steal (lateral crural tensioning) becomes a more potent and versatile rhinoplasty technique that can improve tip contour without jeopardizing function or structural stability.

Vertical arch division is a mainstay of tip surgery, and its applications are expanding. It allows deprojection of the overprojected tip, and modifies rotation, length, and lobule definition. These parameters can be altered in a controlled, predictable fashion when the alar cartilage is preserved and overlapped, maintaining its strength. Cartilage overlay techniques aim to preserve normal anatomy and establish support for the nasal framework. We discuss the uses of vertical arch division when applied to the M-arch model, an expansion of the nasal tip tripod concept, which provides for a utilitarian approach to surgical techniques for the nasal tip.

Mestizo patients are the largest ethnic minority in the United States; the main facial plastic procedure they request is rhinoplasty. Mestizo noses are a challenge. It is common to find bulbous, undefined nasal tips sitting on a poorly structured osteocartilaginous framework. A structural approach is presented whereby support structures of the nose are strengthened and reinforced with structural grafts. A gradual approach to the nasal tip is presented whereby sutures and grafts are used to improve rotation and projection and create more definition. Cases showing long-term results are presented with discussion of the different surgical techniques used.

We are in the midst of truly changing times, as patients of African descent actively embrace facial cosmetic surgery. Gaining surgical consistency in patients of African descent has proven to be elusive and unpredictable for many rhinoplasty surgeons. Surgical success relies on the surgeon's ability precisely to identify anatomic variables and reconcile these anatomic realities with the patient's expectations for aesthetic improvement and ethnic identity. An appreciation for underlying heritage provides a link culturally to connect with prospective patients and serves as a tool for establishing realistic aesthetic goals. This article highlights the significance of exploring ancestry in the rhinoplasty consultation; identifies key anatomic variables in the nasal tip, dorsum, and alar base; and reviews surgical logic that has facilitated the achievement of consistent, balanced aesthetic outcomes.

Profile refinement is one of the most common reasons patients seek consultation for rhinoplasty. Emphasis on creating a natural-appearing nasal dorsum demands a methodic nasal and facial analysis. Areas of dorsal excess and deficiency are identified, quantitated, and considered when determining surgical goals. The radix is an essential component of the profile and is carefully assessed from the standpoint of projection and position. Height and contour are evaluated at the radix, rhinion, and nasal tip. Each component of the dorsal profile is individually classified as overprojected, underprojected, or of appropriate height. Case studies demonstrate the necessary surgical steps to create a more balanced profile.

In the patient who undergoes revision rhinoplasty, tip grafts are used often when overresection has resulted in structural deficit of deformity. As a result, the last 20 years have witnessed a progressive movement toward more conservative handling of the nasal tip. Still, as some surgeons have not adopted that philosophy and because many more surgeons have not adopted that philosophy and because many more surgeons now take on difficult primary tip problems because of the advent of the external approach, major tip problems continue to plague the final result. Despite these potential variables, when used correctly, the tip graft is critical in achieving the successful reconstruction of the nasal tip region. This article reviews the indications and techniques for tip grafts in revision rhinoplasty and explores how these indications and techniques for tip grafts in revision rhinoplasty and explores how these indications could be prevented in the primary setting.

The consistent ability to gain and maintain nasal tip projection in the under projected nose is the trump card of the successful facial plastic surgeon. The underprojected nose is the nemesis that causes most of the disappointment in rhinoplasty for the patient and the surgeon. It is imperative that the surgeon recognize the many variations that constitute the underprojected nose, and this recognition must be made long before it is encountered in the operating room. The diagnosis of under projecting nasal tip is made by observation and by palpation. Several broad categories of nasal tips can be thought of as the underprojecting nasal tip family.

An algorithm for an endonasal approach to most aesthetic problems of the nasal tip is presented. Endonasal surgery in this manner has been successful in the management of many thousands of cases through the years and effective for most variations of tip anatomy and appearance. Every attempt is made to maintain the pleasing, natural, and individual aesthetic elements of the tip while eliminating the offending features through minimally invasive techniques.

Reconstruction of nasal tip and columella defects is demanding area with a range of reconstructive options, varying in complexity depending on requirements from simple skin grafting to multiple stage reconstruction with regional flaps. A framework is suggested to aid the reader in choice of reconstruction by classifying the defect based on size and the requirements of one to three layer (full thickness) reconstruction.

The ethnic appearance of the Middle Eastern nose is defined by several unique visual features, particularly a high radix, wide overprojecting dorsum, and an amorphous hanging nasal tip. These external characteristics reflect distinct structural properties of the osseo-cartilaginous nasal framework and skin-soft tissue envelope in patients of Middle Eastern extraction. The goal, and the ultimate challenge, of rhinoplasty on Middle Eastern patients is to achieve balanced aesthetic refinement, while avoiding surgical westernization. Detailed understanding of the ethnic visual harmony in a Middle Eastern nose greatly assists in preserving native nasal-facial relationships during rhinoplasty on Middle Eastern patients. Esthetic alteration of a Middle Eastern nose follows a different set of goals and principles compared with rhinoplasties on white or other ethnic patients. This article highlights the inherent nasal features of the Middle Eastern nose and reviews pertinent concepts of rhinoplasty on Middle Eastern patients. Essential considerations in the process spanning the consultation and surgery are reviewed. Reliable operative techniques that achieve a successful aesthetic outcome are discussed in detail.

In rhinoplasty, the nasal tip remains the most challenging anatomic region to diagnose and treat. This article presents a new concept, the M-arch model, to better understand the functional and aesthetic anatomy of the tip. This M-arch can be lengthened or shortened, or left as is, to establish the basis of ideal nasal length, projection, and rotation. Additional suture, incisional, excisional, and grafting maneuvers can be performed in a graduated fashion to further refine the M-arch, including the lobule and soft tissue of the nasal base. A full description of the M-arch model and its application is presented, and representative results are illustrated.

The authors introduce the concept of favorable shadowing of the nasal tip surface. Contouring the nasal tip is an advanced concept in rhinoplasty. Several tip altering techniques exist, but proper selection of an appropriate technique or combination of techniques first requires understanding of the impact of manipulating underlying tip structure on nasal surface topography. Frequently, maneuvers that narrow the domes, inappropriately create a pinched or unnatural-appearing nasal tip. Many of these tip-narrowing techniques act to lower the caudal margin of the lateral crura below the cephalic margin and decrease support along the junction between the tip and alar lobule. The nasal tip skin can then collapse on this structure, creating a visible line of demarcation between the tip and alar lobule. Patients will describe their operated nasal tip as having the appearance of a round ball or bulbous tip, even thought their nasal tip may be narrow. This pinched appearance is due to the shadowing that isolates the nasal tip, creating a bulbous or pinched look to the nasal tip. Maneuvers such as dome sutures, lateral crural strut grafts, repositioning of the lateral crura, and alar rim grafts can create a favorable tip structure to support the underlying skin envelope. Using the methods described will enable the surgeon to focus less on narrowing the nasal tip and more on creating favorable shadowing of the nasal tip.

Suture modification techniques have long served as reliable methods to surgically improve nasal tip contour by allowing control of width, projection, and rotation during rhinoplasty. Tip abnormalities characterized by a wide or broad shape are particularly amenable to such techniques. In the senior author's hands (SWP), the endonasal double-dome tip-sculpting technique has become a workhorse for the correction of the wide tip complex. When combined with additional techniques, the double-dome technique allows for the correction of various abnormalities falling under the umbrella of a broad tip (ie, boxy, bifid, bulbous, trapezoid, amorphous), while still adhering to the tenets of modern rhinoplasty philosophy. The authors present a paradigm for surgical planning, along with a series of case studies highlighting the capabilities of various suture techniques performed with the endonasal approach.

Nasal tip drooping following primary rhinoplasty often results secondary to disruption of nasal tip support. Predictable correction of this problem requires restoration of support within the destabilized nasal tip. This article highlights the use of structural augmentation and precise suture stabilization methods via the open rhinoplasty approach for repairing the postrhinoplasty droopy nasal tip.

Because of the complexity and variety of tip deformities encountered by the rhinoplasty surgeon,no single stylized approach or technique will suffice to satisfactorily correct the myriad anatomic configurations that present [21]. Thus, a graduated anatomic approach to nasal tip surgery is recommended, which equips the surgeon to correct more modest deformities with conservative approaches and techniques,reserving more aggressive approaches and techniques for more profoundly abnormal tip deformities. Pre-serving an undivided, complete residual strip in the majority of patients is entirely possible and eminently desirable for the control of long-term healing. Mastering a wide variety of tip sculpture techniques,employed as dictated by the presenting anatomy [22],equips the surgeon with the tools to correct the astonishing variety of nasal tip deformities encountered.