Rami K. Batniji, M.D.*, Stephen W. Perkins, M.D.#

*Batniji Facial Plastic Surgery, 361 Hospital Road, Suite #329, Newport Beach, CA 92663
#Meridian Plastic Surgeons, Meridian Plastic Surgery Center, 170 W 106th Street, Indianapolis, IN 46290
*corresponding author: Rami K. Batniji, M.D., 949.650.8882/949.650.2293 (facsimile)

Acknowledgements
The authors would like to acknowledge Nancy A. Rothrock for her assistance in the preparation of digital images used in this manuscript.

Introduction
The key to successful nasal tip surgery is precise preoperative analysis, a thoughtful operative plan, and meticulous execution of that plan. To that end, an understanding of the anatomy of the nose, the pathology present, the desires of the patient and the maneuvers necessary to achieve the desired result are essential in nasal tip surgery. As well, an appreciation for the long-term effects of healing has resulted in an increased use of the external rhinoplasty and of grafting techniques to avoid long-term complications. While there are several facets to rhinoplasty, this chapter will focus specifically upon rhinoplasty of the nasal tip.

Anatomy
In order to embark upon surgery of the nose, the surgeon must be familiar with the anatomy of the nose, the abnormalities of the underlying bony-cartilaginous framework resulting in the nasal deformity, and the surgical maneuvers necessary to treat these deformities and achieve a satisfying aesthetic and functional result. By mastering the understanding of the anatomy of the nasal tip, the surgeon may predict the underlying structures of the tip via visualization and palpation. Structural support of the nasal tip is determined by 3 major and 6 minor tip support mechanisms. The major tip support mechanisms include: (1) the size, shape, and resilience of the lower lateral cartilages, (2) the medial crural footplate attachment to the caudal border of the quadrangular cartilage, and (3) the attachment of the caudal border of the upper lateral cartilages to the cephalic border of the lower lateral cartilages. The minor tip support mechanisms include: (1) the interdomal ligament, (2) the cartilaginous septal dorsum, (3) the sesamoid complex extending the support of the lateral crura of the lower lateral cartilages to the pyriform aperture, (4) the attachment of the lower lateral cartilages to the overlying skin and musculature, (5) the nasal spine, and (6) the membranous septum.
Dr. Anderson’s tripod theory is a helpful method of conceptualizing the nasal tip and the effects any change to one of the three limbs of the tripod will have upon the nasal tip. The tripod consists of each of the lateral crural legs of the lower lateral cartilages; the third limb of the tripod is the joined medial crural feet.
While both the internal and external valves are of great importance in maintaining proper aiflow through the nasal passageways, the external valve is of particular interest in tip rhinoplasty. The external valve is formed by the nasal alar sidewall laterally and the columella/medial crural footplate medially. Weakness of the lateral crus of the lower lateral cartilage results in dynamic collapsing of the nasal alar sidewall and, thus, external valve collapse.

Preoperative Assessment
Is essential in determining the techniques that will be required to achieve the aesthetic and functional results. Consultation with the patient is essential to understand the aesthetic and functional goals the patient desires and whether these goals are realistic in nature. The onus is upon the surgeon to balance the patient’s desires with what is realistically possible given the anatomic limitations of each individual nose. The consultation process affords the opportunity for the surgeon to document a history of trauma to the nose or previous rhinoplasty performed.
Accurate diagnosis is essential in rhinoplasty. This necessitates a thorough preoperative assessment, including a complete facial analysis in addition to analysis of the nose (see Chapter 2). Specific examination of the nasal tip begins with evaluation of the overlying skin. Nasal skin that is thick and contains many sebaceous glands does not reveal subtle changes to the underlying framework. Failure of thick skin to contract favorably over time may lead to excess soft tissue scar, an amorphous nasal appearance, and the soft tissue pollybeak deformity. Thin skin may show minor deformities and irregularities, thus camouflaging techniques are more necessary in the thin-skinned patient.
Through palpation of the nasal tip, the surgeon will gain valuable insight into the nature of the intrinsic support of the nasal tip with special attention to the septum and septal angle. As well, palpation provides the surgeon with the opportunity to determine the nature, volume, strength, and resiliency of the lower lateral cartilages. It behooves the surgeon to evaluate the orientation of the lower lateral cartilages; if the lower lateral cartilages are cephalically malpositioned, then alar strut grafts may be necessary to prevent curvature of the alar sidewalls.
On frontal view, the brow-tip aesthetic line follows a gentle curve from the medial brow to the nasal tip with slight narrowing at the middle nasal vault and slight widening at the alar margins. The nasal tip defining points represent light reflection on the skin overlying the domes of the lower lateral cartilages. Asymmetries and/or width of these tip defining points should be noted. Also, facial asymmetries on frontal view should be documented and noted to the patient. On profile, nasal projection is evaluated using any one of a number of techniques; however, we find the Simons relation of the nasal projection to the upper lip length in a 1:1 ratio as a helpful and reliable method of evaluating projection. On profile, the nasal-chin relationship should be noted, as a patient with inadequate chin projection may perceive the nose to be overprojected when in reality the projection of the nose is adequate.The nasofrontal angle is typically 115-130 degrees. The nasolabial angle is typically 90-95 degrees in men and 95-115 degrees in women, depending upon the height of the patient. 2-4 mm of columellar show should be visible from the profile. A double break is noted between the columella and nasal tip; this double break is created by the intermediate crura of the lower lateral cartilages. Finally, on base view, the nose has the form of an equilateral triangle with the lobule representing one-third of the triangle. Weakness of the alar sidewall with inward curvature should be noted as this condition may require supporting of the sidewall with alar strut grafts.
Digital photography in the standard views for rhinoplasty with proper lighting and background are essential to a rhinoplasty practice and provides consistency in the photographs. Computer imaging facilitates the communication between patient and surgeon by providing a medium through which the surgeon can demonstrate to the patient realistic surgical outcomes and limitations that existing anatomy imposes. For example, a patient with inadequate chin projection may benefit from a chin implant. Computer imaging also allows the surgeon to learn of the patient’s desires, such as profile relationships, which may or may not mirror that of the surgeon’s preferences. It is important for the surgeon to be honest and accurate with respect to the corrections made on computer imaging. Finally, each patient is asked to sign a waiver stating they understand that computer imaging demonstrates a predictive illustration and is not a guarantee as to the exact replication of the aesthetic surgical result.

Surgical Technique
Tip rhinoplasty is performed under monitored anesthesia care or general endotracheal anesthesia. The patient is placed on Cephalexin 500 milligrams every 12 hours, starting the day before surgery. In the operating room, once an appropriate level of anesthesia is achieved, the nose is infiltrated with 2% lidocaine with epinephrine (1:50,000) and cottonoid pledgets soaked with 4% topical cocaine solution are placed in the nasal passageways. After an appropriate amount of time for the epinephrine and topical cocaine to take effect has passed, surgery is commenced.

Endonasal Rhinoplasty
Endonasal rhinoplasty is performed via the delivery approach. Access incisions for delivery of the lower lateral cartilages involve bilateral marginal and intercartilaginous incisions. The intercartilaginous incision at the limen vestibula is connected with a high septal transfixion incision. If necessary, deprojection of the nasal tip is achieved by extending the high septal transfixion incision inferiorly to release the medial crural feet from the septum; if this maneuver is performed, the medial crural feet are reconstituted to the septum with a 3-0 chromic gut suture on a Keith needle at the end of the surgery.
The septum is approached via the septal transfixion incision and septoplasty is performed as indicated. Septal cartilage is harvested for rhinoplasty while preserving 10 millimeters of dorsal and caudal septal cartilage, thus preserving support to the nasal tip and dorsum of the nose.
Once the bipedicled chondrocutaneous flaps are delivered, cephalic margin trim is performed as indicated to narrow and define the nasal tip; the cephalic margin trim is conservative so that 8-10 millimeters of lateral crus laterally and 5-7 millimeters of lateral crus medially are preserved. One should avoid cephalic trim of the lateral one-third of the lateral crus to avoid lateral wall collapse. With long-term follow up, weakened crura and nasal tip support are subject to contracture forces that cause distortions to the nasal tip. Therefore, there has been a progressive movement toward more conservative handling of the nasal tip.

External Rhinoplasty
The evolving need to achieve more refined results and prevent late complications has resulted in the increasing use of the external columellar approach. Indications for external rhinoplasty include: revision cases, marked asymmetry of the tip, significantly poor tip support, lower lateral cartilages that are weak, marked under projection, the foreshortened nose that requires lengthening and de-rotation with extended spreader grafts, need for spreader grafts to stabilize the middle nasal vault, and presence of cephalic malposition of the lower lateral cartilages that require alar strut grafts.

Tip Sculpting Techniques
A graduated approach is used when sculpting the nasal tip during rhinoplasty. First, a cephalic margin trim of the lateral crura of the lower lateral cartilages is performed as described previously. Second, individual treatment of a dome to narrow and gain definition is performed; this is achieved via pinching the dome with Griffith’s Brown forceps, beveling the cephalic edge of the dome unit, and suturing the single dome with a 5-0 Dexon suture in a mattress fashion. Prior to suturing the single dome, the vestibular skin on the undersurface of the alar dome is dissected free from the cartilage; this maneuver avoids the incorporation of the vestibular skin and mucosa with the mattress suture, thus allowing for better scarification and maintenance of the new desired narrow single dome. Third, double-dome unit suturing with 5-0 clear Prolene suture is performed in a mattress fashion so that the knot rests between the domal units. The combination of individual dome narrowing and double dome suturing techniques allow for individual dome treatment, which might be different for each dome or crus then it reconstitutes them into a single tip-lobular complex. Whereas these techniques will achieve definition and narrowing of a broad tip, a bulbous tip which has bulky cartilage may require scoring as well. A boxy nasal tip may require camouflaging in the infratip lobular area to fill in the residual bifidity. A bifid tip may require a full length shield graft.

Tip Grafts
While suturing techniques may provide increased tip definition and projection, there are times when these techniques fall short of the desired outcome. Therefore, tip grafts are utilized to provide enhanced shape to the poorly defined tip and increased projection. As well, tip grafts may provide improved definition of the infratip lobule. Finally, tip grafts may also be used for camouflaging of persistent asymmetries. The grafts should be shaped and beveled along its edges to integrate seamlessly with the surrounding cartilaginous architecture. The tip graft is placed after the columellar strut is positioned (Figure 1).
The types of tip grafts used include shield grafts, cap grafts, blocking grafts, blanket grafts, infratip lobular grafts, and Peck grafts. A cephalic transverse onlay (Peck) graft is placed on top of the nasal dome, thus providing more height and definition to the nasal tip. A cap graft is typically sutured to a shield graft in the infratip lobular region to give more infratip lobular length (Figure 2). A blocking graft is also used in conjunction with a shield graft and is sutured into position at the supratip region; the blocking graft prevents rotation of the shield graft and fills in supratip dead space (Figure 3).

Controlling Tip Projection
In order to control tip projection, the surgeon must be aware of the factors that influence tip projection. Those factors include: the length and strength of the lower lateral cartilages, the anterior septal angle, the suspensory ligament from the anterior septal angle to the lobule, the height of the anterior nasal spine, the attachments of the upper lateral cartilages to the lower lateral cartilages, and fibro-fatty attachments of the medial crural footplate of the lower lateral cartilages to the caudal septum. Maneuvers that manipulate any one of these factors will influence tip projection. For example, a columellar strut may lengthen and strengthen the medial crura of the lower lateral cartilages, thus providing modest increase in tip projection. As well, individual dome mattress suture and trans-domal mattress sutures both provide increased projection of approximately 1-2 mm.
The lateral crural steal technique with intact domes is used to recruit the lateral crura to increase the length of the medial crus at the expense of the lateral crus, thus elevating the tip as much as 2 mm. This provides not only increased projection, but also increased rotation as well. If more projection is required, then dome division lateral to the dome will further lengthen the lateral crura to increase the tip projection moreso; dome division is typically reserved for relatively thick-skinned individuals. Otherwise, an effective means of providing increased tip projection includes a shield graft.
If the tip is overly projected and required de-projection, a complete transfixion incision provides deprojection of the nasal tip by disrupting the attachment of the medial crural footplate to the caudal septum; once appropriate deprojection is achieved via the complete transfixion incision, the medial rural footplate is reconstituted to the caudal septum with 3-0 chromic gut suture. If further deprojection is required, the individual dome sutures are placed; then, the entire dome is truncated or excised with a #15 blade. Following this maneuver, the entire dome is reconstituted with the transdomal suture. A soft tissue onlay graft or morselized cartilage graft is then used to camouflage the tip.

Techniques to Increase Tip Rotation
A graduated approach is used to provide rotation of the tip. Evaluation of the anterior septal angle is performed first. If this is not deficient, then one may excise the anterior septal angle with its corresponding vestibular skin to provide upward rotation of the nasal tip. Another method of providing modest upward rotation of the nasal tip as well as tip support is placement of the columellar strut. The columellar strut is routinely used to provide tip support and to restructure the medial crural component of the nasal tip tripod. The strut is positioned between the medial crura and extends from the anterior nasal spine to the junction of the medial crura with the intermediate crura. In order to avoid an unnatural flattening of the columella-lobular double break, one should avoid suturing the normally divergent intermediate crural caudal margins.
If more rotation is needed, a lateral crural flap is performed. First, the underlying vestibular skin is mobilized from the lateral crus. Then, the lateral crus is vertically divided approximately 10 mm lateral to the dome. The nasal tip is repositioned to achieve the necessary upward rotation and the overlapping margins of the lateral crus are then secured with two transcartilaginous horizontal mattress sutures using 5-0 polydiaxone (Figure 4).

Techniques to Decrease Rotation
If the nasal tip requires de-rotation, the posterior caudal septal angle can be excised. Otherwise, extended spreader grafts used as cantilevers will push the entire lobular complex more caudally, thus providing decreased rotation. Prior to placement of the extended spreader grafts, mucoperichondrial flaps are elevated between junction of the nasal septum and upper lateral cartilage, thus creating a pocket within which the spreader grafts are placed. The extended spreader grafts are then sutured to the upper lateral cartilage and septum in a horizontal mattress fashion with 5-0 polydiaxone.

Special Considerations
Cephalic Malposition of the Lower Lateral Cartilage
Cephalic malposition of the lower lateral cartilage may predispose the patient to inward collapse or recurvature; this may be a late consequence of surgery. In an attempt to avoid this late complication, alar strut grafts are placed. The alar strut graft is placed in a pocket between the lateral crura and the vestibular skin; is extends from the piriform aperture laterally to at least 2/3 of the length of the lateral crura. Though this graft may be placed via an endonasal rhinoplasty, an external rhinoplasty affords the surgeon the opportunity to develop the pocket from the cephalic margin of the lower lateral crus, thus making it easier. The graft is sutured directly to the lateral crus with 5-0 monocryl; then the vestibular skin is repositioned with 5-0 dexon (Figure 5).
External Valve Collapse
In a patient who demonstrates external valve collapse, an alar batten graft is sutured as an onlay to the weak lateral crura; a curved portion of the cymba concha is an ideal source for this graft. The graft is secured into position with non-absorbable suture in a mattress fashion through the graft, lateral crura, and vestibular skin (Figure 6).
Alar Rim Graft
Whereas significant alar retraction may require an auricular composite graft, mild alar retraction is effectively treated with an alar rim graft. This is placed at the end of the procedure through a small incision made slightly caudal to the caudal margin of the lower lateral cartilage. Then, a 2 mm pocket is created along the rim of the nostril and a linear piece of cartilage is placed in the pocket, thus adding strength to the slightly weakened or retracted alar rim (Figure 7).
If alar retraction is significant, then a composite graft from the anterior surface of the cymbum concha is required and sutured to the edges of the marginal incision.

Postoperative Care
The postoperative dressing is applied as follows: tan 0.5 inch Micropore tape (3M, USA) is used for the postoperative taping of the nose. The tape around the lobule is pinched slightly to maintain hemostasis in and around the lobule and supratip area. The small brown nasal splint (Integra, USA) is used to provide stabilization of the nasal pyramid and maintain the medial position of the nasal bones, if needed; the splint is trimmed to size and bent manually to accommodate the nasal bony pyramind (Figure 8). A small ball of Surgicel (Johnson & Johnson, USA) is placed under each dome to re-approximate the elevated vestibular skin and prevent small hematomas in this area. A short Telfa (Kendall, USA) dressing is placed at the aperture to collect expected nasal drainage. No packing is placed.
Cold compresses are placed over the eyes and dorsum of the nose for the first 36 hours. The patient follows up on the first postoperative day and the Telfa dressing is removed. Postoperative instructions include no heavy lifting, bending, straining, or nose blowing. The patient is to avoid hot, spicy foods for the first week after surgery as these foods may initiate vasodilatation and subsequent epistaxis. As well, the patient is to elevate the head of the bed to minimize not only postoperative edema but also epistaxis as well. The patient is to clean the nasal aperture with a cotton tipped applicator soaked with hydrogen peroxide followed by the application of a petroleum-based product four times a day. If an external rhinoplasty was performed, the patient is instructed to cleanse the nylon sutures on the columella with a cotton tipped applicator soaked with hydrogen peroxide followed by the application of a petroleum-based product four times a day. On the fourth postoperative day, the columellar sutures are removed. One week following surgery, the patient is evaluated in the office, the dorsal splint is removed, the nasal passageways suctioned, and the patient is provided with a copy of the preoperative photographs to reinforce the acquired changes through rhinoplasty.

Complications
Immediate complications following rhinoplasty include epistaxis and septal hematoma. In the event of epistaxis, the patient is instructed to use oxymetazoline nasal spray to minimize the epistaxis. Indeed, if the epistaxis persists despite conservative measures, the patient will need to be seen by the surgeon, the patient evaluated for hypertension, and light packing performed so as to control the hemorrhage and minimize trauma to the freshly operated nose at the same time. If septal hematoma is identified, then incision and drainage with subsequent splinting with silicone septal splints may be required. Of note, mattress suture technique of the septal flaps with 4-0 plain gut on a short keith needle has significantly reduced the incidence of postoperative septal hematoma and obviated the need for aggressive nasal packing.
Late complications due to the scar contracture that shrinks the skin envelope over the modified tip structure may result in a pinching appearance to the nasal tip. This undesirable result can be avoided by refinement techniques and the use of alar strut grafts. For example, the thin-skinned patient undergoing rhinoplasty would benefit from the use of camouflaging of the nasal tip with a soft tissue graft overlaying the tip-lobular complex. If the lower lateral cartilages are in the cephalic position and/or there is inherent weakness to the lateral crura, then placement of alar strut grafts may prevent the inward curvature of the alar sidewalls.
Supratip fullness can be treated with intralesional steroids. Intralesional steroids are helpful in selected cases of thick skin or revision cases where robust scar tissue is found in the supratip region. Intralesional steroids are started 2 weeks postoperatively and repeated once or at most twice in the first 3 month postoperative period. Subdermal injection (0.1-0.2 mL) of triamcinolone acetonide (10mg/mL).

Acknowledgements
The authors would like to acknowledge Nancy A. Rothrock for her assistance in the preparation of the digital images used in this article.

Table 1. Treatment Options

Advantages
Disadvantages

1. Endonasal Rhinoplasty

Advantages
Disadvantages

2. External Rhinoplasty

Table 2. Key instrumentation and materials

#15 Bard Parker

Bipolar cautery

McCollough Elevator (Storz N2341)

Jovanovic Bone Plugger (Hu-Friedy PLGO/4)

Joseph Single Hook (Storz N4720)

Osteome #2 (Storz N4302)

Osteome #3 (Storz N4303)

Osteome #4 (Storz N4304)

Curved 6 mm Cottle Osteotome (Storz N4345)

Neivert Osteotome (Storz N4362)

Cinelli Osteotome #10 (Storz N4380)

#12 (Storz N4382)
#14 (Storz N4384)
#16 (Storz N4386)

Glabella Rasp (Storz P3000)
#1 Push-Pull Rasp (Snowden Pencer LO1996)
#2 Push-Pull Rasp (Snowden Pencer LO1997)
#3 Push-Pull Rasp (Snowden Pencer LO1998)
#4 Push-Pull Rasp (Snowden Pencer LO1999)
Cutting Block (Sowden Pencer 88-7724)
Boise Nasal Elevator (Storz N4655)
#3 Knife Handle (Storz N1710)
Nasal Mucosa Bayonet (Storz P0525)
Wright-Rubin Septum Morselizer (Storz N5345)
Forceps Guard (Storz N5345G)
Converse Nasal Retractor (Storz N4882)
Ferris Smith Forceps (Storz N5485)
Takahashi Nasal Forceps (Storz N2995)
Septum Speculum (Storz N2181)
Cottle Septum Speculum (Storz N2200)
Ferguson Frazier #9 (Storz N1379)
Cottle Crusher (Snowden Pencer 88-7227)
Caplan Shears (Storz N5295)
Gorney Shears (Storz N5296)
Castroviejo Flat Handle (Snowden Pencer 32-0440)
Adson Forceps (Snowden Pencer 32-0500)
Gerald Forceps (Snowden Pencer 32-0510)
Storz Eye Scissors, curved (Storz E3426)
Crile Hemostatic Forceps (Storz N5520)
Par Needle Holder (Storz P0404)
Lead-filled Mallet (Storz N1782)
5 mm Curved Mets Scissors (Storz E5284)
½ inch Micropore tape, tan (3M)
Small Brown Nasal Splint without extension (Integra P363)
4-0 plain gut on short keith needle
5-0 plain gut
5-0 clear prolene
5-0 clear polydiaxone
6-0 polydiaxone
3-0 chromic gut
5-0 polyglygolic acid

Figure Legends

Figure 1. Figure 1a demonstrates a tip graft sutured into position with several 6-0 dermalon sutures. Alternatively, 6-0 PDS suture may be used to anchor the tip graft to the underlying lower lateral cartilages. Note that the edges of the tip graft are shaped and beveled along its edges to integrate seamlessly. Figure 1b is a preoperative photograph of a patient seeking, among other changes, an improvement in the tip definition. A tip graft was used to obtain the desired aesthetic result achieved in Figure 1c.

Figure 2. Figure 2a demonstrates a cap graft sutured to a shield graft in the infratip lobular region to give more infratip lobular length. Figure 2b is a preoperative photograph which demonstrates, among other findings, a deficiency in the infratip lobular length. Of interest, note the increased length of the infratip lobule achieved with the cap graft.

Figure 3. A blocking graft is also used in conjunction with a shield graft and is sutured into position at the supratip region; the blocking graft prevents rotation of the shield graft and fills in supratip dead space.

Figure 4. Lateral crural flap technique. After separating the lateral crus from the vestibular skin, the lateral crus is vertically divided approximately 10 mm from the dome. Then, the tip is rotated upward to the proper position; the overlapping segments of the lateral crura are then sutured in a mattress fashion with 5-0 polydiaxone (Figures 4a and 4b). Figure 4c demonstrates a patient who would benefit from increased rotation. Figure 4e demonstrates the maneuvers performed during rhinoplasty, including lateral crural flap for increased rotation and Figure 4d shows proper rotation as the postoperative result.

Figure 5. Alar strut grafts are used to address the consequences of cephalically malpositioned lateral crura of the lower lateral cartilage, as shown. A pocket is created between the lateral crus and vestibular skin (Figure 5a). The alar strut graft is then placed in the pocket and sutured into position in a mattress fashion (Figures 5b and 5c). Preoperative (Figure 5d) base view demonstrating cephalic malposition of the lower lateral cartilage, a schematic drawing of alar strut (Figure 5f), and postoperative base view demonstrating benefit of alar strut placement (Figure 5e).

Figure 6. Placement of alar batten graft in an individual with external valve collapse. The alar batten graft is sutured into position as an onlay graft in a mattress fashion.

Figure 7. Preoperative patient demonstrates weakness of the alar rim (Figure 7a). Following placement of bilateral alar rim grafts to address the weakness of the alar rims (Figure 7c), there is marked improvement upon the alar rims as seen in the postoperative photograph (Figure 7b).

Figures 8. Tan, 0.5 inch Micropore tape (3M, USA) is used for the postoperative taping of the nose. The tape around the lobule is pinched slightly to maintain hemostasis in and around the lobule and supratip area (Figure 8a). The small brown nasal splint (Integra, USA) is used to provide stabilization of the nasal pyramid and maintain the medial position of the nasal bones, if needed; the splint is trimmed to size and bent manually to accommodate the nasal bony pyramind (Figure 8b and 8c). A small ball of Surgicel (Johnson & Johnson, USA) is placed under each dome to re-approximate the elevated vestibular skin and prevent small hematomas in this area. A short Telfa (Kendall, USA) dressing is placed at the aperture to collect expected nasal drainage.

References

Konior RJ: The droopy nasal tip. Facial Plast Surg Clin N Am 14:291-299, 2006

Peck GC: The onlay graft for nasal tip projection. Plast Reconstr Surg 71:27-37, 1983.

Toriumi DM: New concepts in nasal contouring. Arch Facial Plast Surg 8:156-185, 2006.

Perkins SW: The evolution of the combined use of endonasal and external columellar approaches to rhinoplasty. Facial Plast Surg Clin N Am 12:35-50, 2004.

Dyer WK: Nasal tip support and its surgical modification. Facial Plast Surg Clin N Am 12:1-13, 2004.

Tardy Jr ME, Dayan S, Heck D: Preoperative rhinoplasty: evaluation and analysis. Otolaryngol Clin Am 35:1-27, 2002.

Perkins SW, Tardy Jr ME: External columellar incisional approach to revision of the lower third of the nose. Facial Plast Surg Clin N Am 1:79-94, 1993.

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