Many of the common techniques employed in standard rhinoplasty have the effect of reducing tip support. The foundations of nasal tip support are the aponeurotic attachments between the upper and lower lateral cartilage, the interdomal ligaments of the lower lateral cartilages attaching to the superior septal angle, the attachment of the feet of the medial crura to the caudal septum, and the forward thrust of the lower lateral and sesamoid cartilages. The cartilage splitting and cartilage de-livery techniques, as well as cephalic trimming of the lower lateral cartilage, disrupt the attachments between the upper and lower lateral cartilages. Transfixion incisions interrupt the attachments between the domes of the lower lateral cartilage and the superior septal angle and, if carried low enough, will disrupt the attachment of the feet of the lower lateral cartilages to the septum. Lowering the cartilaginous dorsum, and shortening the caudal septum contribute to loss of tip support. Petroff et al' found that all of these maneuvers when performed in rhinoplasty led to a measurable loss of tip support. The only reliable method of increasing nasal tip projection was through support grafts. Rich et al' found similar results of loss in tip projection with cephalic cartilage trim and vertical dome division.

	Figure 1. A, Preoperative and B, postoperative views of a revision of a polly beak deformity corrected with a columella strut and extended shield graft.

Common postrhinoplasty complications of the nasal tip that surgeons see are the polly beak, the thickened and poorly defined tip, the overresected nasal tip, nasal tip bossae, the asymmetric tip, the excessively shortened nose, and the long dependent tip.

Polly beak results from three potential causes: inadequate supratip reduction, postoperative supratip thickening, or poor tip projection (Fig. 1).

In correcting a polly beak deformity, the critical aesthetic decision that must he made is whether there is adequate tip projection. If there is adequate projection, the mechanism of the polly beak is either inadequate supratip reduction or uncompensated thick skin. These problems can be addressed by lowering the anterior septum and upper lateral cartilages as necessary and thinning and removing supratip scar tissue. If tip projection is inadequate, it must be corrected through tip grafting.

	Figure 2. A, Preoperative and B, postoperative views of the revision of a poorly defined tip corrected with a columella strut.

The poorly defined tip can result from post-operative scar formation, inadequate trimming and narrowing of the alar cartilage, thick skin that was not adequately compensated for, or inadequate tip projection (Fig. 2).

Correction must address the cause and often will require tip grafting. The tip structures must be dissected and scar tissue removed, although this may reduce tip support further. Thick skin needs to be thinned, the interdomal fat pad, if present, is removed. To achieve tip definition in the thick-skinned patient, it may be necessary to increase tip projection significantly and create a tent pole effect. This increase in projected may lead to the need for dorsal augmentation to balance the new tip height.

The overressected tip usually results from excessive resection of the lower lateral cartilages (Fig. 3).

The hallmarks are alar pinching with excessive tip narrowing, bossa formation, and vestibular stenosis. Correction will require tip and alar grafting.

They usually occur after division of the lower lateral cartilage or with lower lateral cartilage collapse due to overresection. The most common finding at exploration is a domal asymmetry that has resulted from buckling of an overressected lower lateral cartilage on the side of the bossa, causing projection and pointing of the dome. Correction requires freeing the medial and lateral crura from the surrounding tissue and transaction and repositioning. If an alar deficit exists, it is reconstructed with an onlay graft. The tip usually will need to be restructured with tip grafts.

Nasal tip bossae are unsightly projections of cartilage (Figs. 3 and 4).

They usually occur after division of the lower lateral cartilage or with lower lateral cartilage collapse due to overresection. The most common finding at exploration is a domal asymmetry that has resulted from buckling of an overressected lower lateral cartilage on the side of the bossa, causing projection and pointing of the dome. Correction requires freeing the medial and lateral crura from the surrounding tissue and transaction and repositioning. If an alar deficit exists, it is reconstructed with an onlay graft. The tip usually will need to be restructured with tip grafts.

	Figure 5. A, Preoperative and B, postoperative views of the revision of an overshortened nose corrected with a caudal septal graft, columella strut, and double-layered buttress extended shield graft.

The overshortened nose most commonly results from excessive septal shortening of the caudal septum (Fig. 5).

Correction of this re-quires cartilage grafting to replace the shortened septum and mobilization of the nasal mucosa to accommodate lengthening. An external approach is used for the septum to elevate completely submucoperichondrial septal flaps. This dissection is extended to free the mucosa from under the upper lateral cartilages. A caudal septal graft is placed in a pocket at the leading edge of the existing caudal septum. Vertical mattress resorbable sutures are used to create a separate compartment for this graft and to maintain the nasal length it creates. A thick columella shield graft usually is placed, as the overshortened nose often will require tip restructuring.

	Figure 6. A, Preoperative and B, postoperative views of a long, dependent tip corrected with vertical dome division. lateral crura trimming, and an extended shield graft.

The long dependent tip as described by Anderson's tripod theory' is caused by strong downward-projecting lower lateral cartilages overpowering the medial crura complex (Fig. 6).

It also may be associated with a projecting caudal septum. Correction is through vertical dome division, lateral crural transection, cephalic and lateral trimming of the lower lateral cartilage, and caudal septal trim, if necessary. These patients often have weak medial crura and may require a columella strut to strengthen the medial component of the tripod.

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