New concepts in nasal tip contouring.

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.