fig2
Figure 2. (A) This patient had two prior rhinoplasties and was troubled by her tip bossae, asymmetry, irregularity, and alar retraction. She has bifidity of her tip with prominent domes. Note the pinching lateral to the domes that creates shadows between the tip and the alae. These areas should be supported by the caudal margins of the lateral crura. Operative notes indicated that a vertical dome division was performed at her initial surgery. No tip work was performed at her second surgery; (B) Note the structural void between the lower and upper lateral cartilages as a result of the cephalic trim. Approximately 8 mm of lateral crural width remained. There is buckling of the cartilage on each side lateral to the domes. Additionally, note the sagittal malpositioning of the shirt axes of the lateral crura. This not only narrows the external nasal valve but creates shadows lateral to the tip, making it look more bulbous. The right lateral crus was also cephalically malpositioned, contributing to her greater alar retraction on that side. The short and long axes are superimposed on the right lateral crus; (C) To correct these problems, the lateral crura were dissected from the vestibular skin and costal cartilage lateral crural strut grafts were placed. The long axes of the lateral crura were then repositioned more caudally to address the cephalic malpositioning; (D) Sutures were used to reorient the short axes of the lateral crura in order to correct the sagittal
