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PRINCIPLES OF TIP SURGERY

It is to be understood that tip surgery is the base stone and the key for a successful rhinoplasty. Master rhinoplasty surgeons are those who deal confidently with the tip. The classic endonasal Joseph rhinoplasty has ended with many unpleasant results of dropped tip, pollybeak, hanging columella and wider nostrils. The reason is that tip supportive means were not considered, in order to compensate for the loss of tip support, that is caused by our incisions and excisions. These divide the anatomical factors maintaining the tip support.

The first attempts to improve tip projection were made by Irving Goldman. The Goldman's tip was based on cutting the angle between the medial and lateral crura and suturing the medial crura together. Safian (Joseph student) had vertically cut the dome, but Goldman's concept was that the more lateral cut would augment the medial crura and thus improve tip projection. Although Goldman's tip was a creative technique, in time, surgeons realized its problems of pinching, notching, retraction, asymmetry and pointed tip. The concept of Goldman's tip has been, over the years modified and developed further by master rhinoplasty surgeons of the past twenty years (Sheen, Simon, McCollough, M.E. Tardy and Peck) who developed the technique of new dome creation, scoring, suture fixation, columellar strut and tip graft. This approach preserved the lateral crus and established a strong tripod structure of conjoined lateral to medial crura supported by columella and dome grafts. Our objective is to obtain a clearly defined and properly projecting tip that appears symmetrical, triangular on basal view and that flows and blends well with the rest of the nose. In the author's series of over 3,000 rhinoplasties performed on people from the Middle East, Europeans, Indians, Chinese and Africans, it has been found that the manoeuvres of new dome creation, scoring, suture fixation, columellar and tip grafts are the key to a successful rhinoplasty. These manoeuvres achieve adequate tip projection, elevation, definition, rotation and symmetry with the least and most easily managed postoperative problems. The author has also developed a new technique which is largely based on the Goldman's Tip and I-beam of medial crura but without delivery of the lateral crus. This is in order to keep an intact rim and avoid any problems along the alar rim such as notching, retraction, collapse or asymmetry and dimpling of the alar side wall. The author has been applying this method for the last two years. In his opinion this technique is proving to be safe and useful in achieving tip projection, definition, rotation and refinement in selective situations. The new concept of rhinoplasty is balanced manoeuvres of reduction and augmentation. Therefore, rhinoplasty is transforming from an exercise in reduction to an operation of reorientation and preservation of structure.

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