Objectives: 1, Understand the need for analysis and planning with tip aesthetics
2. review the graft material choices
3. understand the tetrapod concept

Introduction: Tip aesthetics are generated through a combination of analysis and planning coupled with flawless execution of the operative plan with the proper grafting materials.

Materials / method: analysis of cases of tip aesthetics will be presented and analyzed.

Results: support and aesthetic choices make the difference for tip aesthetic results

Conclusion: Tip aesthetic are key to successful rhinoplasty. Managing the support and shape of the tip is key to an acceptable aesthetic result.

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Objectives: The preservation rhinoplasty on the tip of the nose includes, closed approach, preservation of the nasal ligaments and preservation of the alar cartilage. Here we present the alternatives to resection and grafting the alar cartilages in order to achieve adequate results in the lower third of the nose.

Introduction: The shape of the nose depends on the size, shape and position of the alar cartilages. the classical resections and grafting may lead to lateral crura mispositioning, irregularities and weakness in the long term follow-up. Treating the nasal tip without any resections or graftings may help to prevent some of these problems.

Materials / method: We present series of patients treated with no resection of the lateral crura. The treatments used were abrasion, for shape changing and stitches for changing and stabilizing the position.

Results: the results were maintained in the long term follow-up

Conclusion: The shape of the tip can be altered changing the shape and position of the lateral crura. Almost no resections are needed. As there is no weakness spots created, no lateral grafts are needed also and there is no compromise of the external valve in using these preservations techniques.

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Objectives: Understanding and correcting primary and post-rhinoplasty aberrations of the alar-columellar relationship (ACR).

Introduction: The alar-columellar relationship (ACR) describes the anatomical relation between the superior border of the alar margin and the caudal border of the columella. The visible space in-between these 2 anatomical elements is defined columellar show (CS). Multiple anatomical factors may affect size, orientation and contour of the CS. ACR aberrations represent one of the most frequent post-rhinoplasty stigmata.

Materials / method: Standard pre- and post-operative frontal, lateral and ¾ views of a series of 20 consecutive rhinoplasty patients presenting with excessive CS (11 primary rhinoplasty patients, 9 revision rhinoplasty patient) were analyzed in order to evaluate the aesthetical outcome of three surgical techniques, used singularly or in combination: personal variation of tongue-in-groove suture (TIG), rim grafts and post-crural grafts.
All the patient were operated endonasally (closed approach) under general anaesthesia. The mean follow-up was 21 months.

Results: Personal variation of TIG combined with tailor-made trimming of the membranous septum resulted highly effective in treating the central (septal) component of the excess of columellar show.
Regarding the lateral (alar) component of the excessive columellar show, alar rim grafts showed a poor performance in elongating the nostril border whereas post-crural grafts resulted to be more effective in down-positioning the nostril border.
After surgery, 3 patients (2 primary patients, 1 revision patients) underwent minor touch-procedures for further improvement in a period between 8 and 15 months.

Conclusion: A thorough understanding of the multiple variables that result in aberrations of the ACR is the essential pre-requisite for a proper planning of the most suitable treatment options.
Significant improvements of the alar columellar relationship can be predictably achieved by relatively minimally-invasive endonasal surgery procedures. However, in most of the cases the surgeon must correct the whole tip-columella-lip complex in order to get superior aesthetic results.

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