Despite many wonderful tip graft techniques developed by other authors, I feel the more durable “pea-pod” graft has been an important addition to my armamentarium. When elevating and “tenting” the thickened nasal tip to increase projection and definition, this has been the most reliable graft in my hands. I found that mere “add-on” grafts without “tenting” effect from the base of the columella to the nasal tip usually added bulk, and not projection, to the tip.
Advancement techniques with nasal alar base reduction allow one to excise more alar soft tissue. Previous to the “pea-pod” tip graft, larger nasal base excisions resulted in a triangular spreading and flattening of the nose. When cheek skin is advanced medially, a more acute angle is developed and the normal curvature of the nostril is maintained.
The combination of “pea-pod” tip graft and alar base excision techniques has assisted tremendously in solving the problem of the thickened nasal tip, which normally cannot be removed without significant scarring. It is beneficial to excise the alar base to provide a semblance of nasal thinness.
The desired degree of augmentation in my patients has not been significant unless there is an imbalance between the dorsum and nasal tip. As years have gone by, more patients now desire a very slight convexity, instead of a perfectly straight nose. I mention to my patients that there are no straight lines in the human body and that slight curves, particularly in the facial area, are normal. While I am not in favor of “ski-slop” noses, one must be cautious when creating a large nose with a large tip—even if “balanced”, as such patients are frequently dissatisfied. Erring on the side of a smaller nose with a more concave dorsum typically results in greater patient satisfaction. Taking a convex bridge and narrowing the pyramid a moderate, but not substantial, degree provides more balance. This is particularly true when there is a significant width to the bony pyramid.
When dealing with difficult anatomical challenges, we all learn both from our patients’ preferences and surgical experience. I find it most rewarding to sit in the consultation room and present a mirror to my patients while sitting across from them and to ask them what bothers them about their nose.