Despite many wonderful tip graft techniques developed by
other authors, I feel the more durable “pea-pod” graft has been an important
addition to my armamentarium. When elevating and “tenting” the thickened nasal
tip to increase projection and definition, this has been the most reliable
graft in my hands. I found that mere “add-on” grafts without “tenting” effect
from the base of the columella to the nasal tip usually added bulk, and not
projection, to the tip.
Advancement techniques with nasal alar base reduction allow
one to excise more alar soft tissue. Previous to the “pea-pod” tip graft,
larger nasal base excisions resulted in a triangular spreading and flattening
of the nose. When cheek skin is advanced medially, a more acute angle is
developed and the normal curvature of the nostril is maintained.
The combination of “pea-pod” tip graft and alar base
excision techniques has assisted tremendously in solving the problem of the
thickened nasal tip, which normally cannot be removed without significant scarring.
It is beneficial to excise the alar base to provide a semblance of nasal
thinness.
The desired degree of augmentation in my patients has not
been significant unless there is an imbalance between the dorsum and nasal tip.
As years have gone by, more patients now desire a very slight convexity,
instead of a perfectly straight nose. I mention to my patients that there are
no straight lines in the human body and that slight curves, particularly in the
facial area, are normal. While I am not in favor of “ski-slop” noses, one must
be cautious when creating a large nose with a large tip—even if “balanced”, as
such patients are frequently dissatisfied. Erring on the side of a smaller nose
with a more concave dorsum typically results in greater patient satisfaction.
Taking a convex bridge and narrowing the pyramid a moderate, but not
substantial, degree provides more balance. This is particularly true when there
is a significant width to the bony pyramid.
When dealing with difficult anatomical challenges, we all
learn both from our patients’ preferences and surgical experience. I find it
most rewarding to sit in the consultation room and present a mirror to my
patients while sitting across from them and to ask them what bothers them about
their nose.