Tip Refinement Case Study 4

Tip Refinement Case Study 4Video transcript: This is a case study of a patient who requires hump reduction, tip defining and tip rotation and in addition it is fairly complicated case in that she has fairly thick skin so there are some very specific techniques that are required to achieve this. On the front view what we are going to try to do is try to narrow a fairly boxy tip and also tilt it up I think on the front view you don't really see much of a hump so we will show you that on the side view. On the side view what you can see is that her bridge is a little bit too high and also the tip of her nose could also come upwards tilt up a little bit.Hump Reduction In terms of the hump reduction again and like we have done before taking down some of the cartilage and bone that are forming the hump achieves the hump reduction so that's simply removed because it develops a bit of a flattening I will often do osteotomies on the sides to narrow the nose bones so that's been done. Now with her nasal tip you have to think about this case a little different perhaps then some of the others because her skin is quite thick so the changes we want to make underneath are going to be fairly dramatic in order for us to see them otherwise the skin will camouflage just minor changes.Cephalic TrimIn her case the first thing I did was a cephalic trim so we remove the back end or the cephalic end of the tip cartilages to make them narrower, now in addition to that we also want that narrowed cartilage to have a better or sharper angle. Now in her case because her cartilages are fairly bulbous and strong and she also had thick skin I decided to use a technique called dome division and dome division means that I actually make a cut through the dome cartilage and separate the two ends completely and that allows them to lose all of their intrinsic spring and makes it possible for me to angle them in quite dramatically.Now that cut could be seen through the skin in someone with thin skin and someone with thick skin it's not seen so it's very appropriate for someone with thicker skin not appropriate for someone with thin skin. That allows me to reposition the cartilages and then secure them again in place with stitches, and that takes us from a broad and boxy shape to her nasal tip to a much more narrow and defined shape. Again keeping in mind that the over lying skin is fairly thick and does to a certain extent camouflage some of those changes.Tip Rotation & RefinementOnce that's all been done the other thing I did for her was I narrowed her tip and rotated it through the use of what are called cephalic margins and well in her case I pulled each of the individual cartilages up and in by suturing the cephalic edge, the part that had already been cut to the under lying cartilages above so that narrows and rotates her tip so that you get two benefits from that technique.This is her before and after and you can see the hump has been reduced, the position of her tip has been elevated and narrowed and on front view you will see that the broadness of her tip has been substantially decreased and she's got a much more narrow tip and aslo the tip has been tilted in an upward direction as well. This is her three quarter view again tip rotated up slightly and defined and in someone with fairly thick skin I think this is actually a fairly good result.