Major tip support mechanisms

1. Size, shape, and strength of lower lateral cartilages
2. Medial crural footplate attachment to caudal septum
3. 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

1. Ligamentous sling spanning the domes of the lower lateral cartilages (ie inter-domal ligament)
2. Cartilaginous dorsal septum
3. Sesamoid complex of lower lateral cartilages
4. Attachment of lower lateral cartilages to overlying skin-soft tissue envelope
5. Nasal spine
6. Membranous septum

Incisions – methods of gaining access

• Intercartilaginous
• Trans-cartilaginous
• Marginal (NOT to be confused with rim incision)
• Trans-columellar

Approaches – provide surgical exposure

• Cartilage-splitting
• Retrograde
• Delivery – Marginal + inter-cartilaginous incision
• External approach – marginal + trans-columellar incision

Sculpting techniques – surgical modifications

• Complete strip – ie cephalic resection, or volume reduction of lateral crura.
• Incomplete strip (Dome division).
• Transdomal/Domal sutures.
• Augmentation grafting.
• Tip graft.
• Other.

Indications for External Rhinoplasty Approach

• Asymmetric nasal tip
• Crooked nose deformity (lower two thirds of nose)
• Saddle nose deformity
• Cleft-lip nasal deformity
• Secondary rhinoplasty requiring complex structural grafting
• Septal perforation repair