Use of the “Septal T” as a Spacer and Conformer for a Properly Contoured Nasal Tip in Rhinoplasty

The complex issue of obtaining an aesthetically pleasing and structurally stable nasal tip brings into play a vast array of maneuvers and techniques, often performed through an open approach.1 Although these approaches are numerous and different, they all share the attainment of a stable tip cartilaginous structure, and then, if necessary, some sort of refinement or camouflage on top. An obvious situation in which such camouflage is unnecessary is the thick-skinned patient for whom sharp definition intrinsically may be welcome. As epitomized by Daniel,2,3 the ideal tip configuration will usually resemble a gently opened diamond. A similar concept is found, often with different suture terminology, in the work of other well-known surgeons.4,5 After appropriate repositioning, tensioning, or stiffening of the lateral crura as necessary, transdomal and interdomal sutures will be used to appropriately shape the domes and allow the gentle anterior domal divergence that will be stabilized by posterior dome equalization sutures. Some final camouflage may be necessary at this point. Various grafts are commonly utilized for this purpose, including segments from the cephalic trim, intercrural soft tissue, crushed cartilage, or even deep temporal fascia if harvested for other reasons.6,7 A specific drawback that will oftentimes detract somewhat from the result of an otherwise well-executed rhinoseptoplasty is a residual V-shaped infralobular cleft, extending from between the domes to the middle and medial crura. This is obviously more evident with thin skin and can be bothersome to the patient preoperatively. In such a patient, the surgeon must note the necessity of gently filling the gap between the new domes, as well as the indentation in continuity that flows below the columellar lobular angle and resides between the medial crural segments along the columella. Beginning in 2014, the senior author (E.R.) noticed …