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NASAL TIP
General Considerations
In the nasal tip, overreduction may violate critical tip sup-port mechanisms (Table 39–1) which can lead to complications such as tip ptosis and inadequate tip projection (see below).
| TABLE 39–1 Tip Support Mechanisms |
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Major tip support mechanisms
- Size, shape, and strength of lower lateral cartilages
- Medial crural footplate attachment to caudal septum
- Attachment of caudal border of upper lateral cartilages to cephalic border of lower lateral cartilages
[Nasal septum is also considered a major support mechanism of the nose.]
Minor tip support mechanisms
- Ligamentous sling spanning the domes of the lower lateral cartilages (i.e., interdomal ligament)
- Cartilaginous dorsal septum
- Sesamoid complex of lower lateral cartilages
- Attachment of lower lateral cartilages to overlying skin/soft tissue envelope
- Nasal spine
- Membranous septum
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Alternatively, overresection of the caudal septum can result in overrotation of the nasal tip with excessive shortening of the nose. Overresection may also contribute to other complications, such as bossae, alar retraction, and alar collapse.
Underreduction may simply be due to overcaution but may also be due to a failure to correctly assess preoperatively the anatomical situation. For example, failure to recognize an overprojected nose or to diagnose the steps required based on the patient's anatomy to adequately address this can lead to a persistent overprojected state. Failure to adequately resect cartilaginous dorsum may result in a pollybeak deformity.
Asymmetry of the nasal tip may be due to unequal reduction of the lower lateral cartilages or to asymmetrical application of dome-binding sutures. ' It may also be caused by unequal scarring that can occur during the natural healing process and may not be evident for months or even years after surgery. Asymmetry is often present preoperatively and should be recognized and pointed out to the patient prior to surgery.
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