The standard rule of keeping the apex or genu of the lower lateral cartilages 6 mm above the dorsum does not account for the resilience or springiness of the cartilage. There is a certain percentage of patients’ lower lateral cartilages that have an excellent static appearance, but not enough resilience to withstand the downward force of the skin envelope leading to inadequate tip projection. As I became more experienced with rhinoplasty surgeries, I began to realize several important factors that have allowed me to obtain consistently superb results. The first is that the nose, after infiltration of local anesthesia and surgical trauma, is swollen and more stiff, therefore the lower lateral cartilage is supported leading to a false impression that there is adequate projection. The second is that there is a great variation as to the stiffness or “springiness” of the lower lateral cartilages. Some lower lateral cartilages have such exceptional spring that they overproject even at 6 mm above the dorsum and require segmental excision, and some are so floppy that even at 8 mm above the dorsum, there is inadequate projection. In these cases, I place columellar strut grafts and tip grafts quite liberally. This is important to evaluate in the pre-operative setting, so you can anticipate whether or not you will need to support the tip. The third factor is to realize that the nasal skin has a tendency to retain its shape. This is especially true with thick nasal skin. In those patients with thick nasal tips, I conservatively defat the nasal skin at the supratip area. This tends to release some of the structure of the nasal skin so it will better adapt to the underlying cartilage framework. The last important factor is a realistic assessment of how the nose will appear post-operatively. This requires evaluating the “spring” of the lower lateral cartilages intra-operatively and performing the appropriate modifications to either increase tip support or decrease projection. This can be performed equally easily with both open and closed techniques by simple ballotment with the index finger and should be performed after any modification of the tip. Prior to closing the incisions, it is important to squeeze out the tissue edema, redrape the nasal tip skin and firmly push the tip in, then evaluate the nose in a lateral view to assess the projection. The nasal tip should be firm and well supported. If the nasal tip collapses or the projection is inadequate, increased support is performed with a columellar strut graft and/or a tip graft. If you’re happy with shape and projection after pressing in the tip on the table, you will be happy post-operatively.

    12 patients From May of 1997 until February of 2002 underwent rhinoplasty utilizing a Medpore columellar strut graft. 4 of the 12 were revisionary rhinoplasties. In all cases there have been no infections, extrusions, or any other complication. Although this is a small sample size, the use of Medpore has been extremely helpful, especially in those patients who have had their septum previously harvested.