Supratip deformity: A closer look

Supratip deformity, a hallmark of a poorly executed rhinoplasty or an inaus picious healing, continues to plague the novice often and the experts on oc casion. A clinical and histopathologic study was conducted to search for th e surgical causes of this deformity and its histologic presentation. An org anized, logical management program was then developed. Clinically, supratip fullness was observed in bath primary (26 of 298 patie nts; 9 percent) and secondary (40 of 112 patients; 36 percent) rhinoplasty candidates. In primary patients, the deformity was the result of inadequate tip projection (pseudodeformity), an overprojected caudal dorsum, a combin ation of both, or cephalically oriented lower lateral cartilages. In second ary patients, the deformity was caused by an underresected or overresected caudal dorsum, overresected midvault, underprojected tip (pseudodeformity), or a combination of some of these factors. The histopathologic evaluation demonstrated significant fibrosis in the supratip soft tissue of 14 of 16 p atients undergoing secondary rhinoplasty without the injection of triamcino lone acetonide and in only 13 of 23 patients who underwent primary rhinopla sty (p < 0.05). A supratip deformity can be eschewed by proper resection of the caudal dors um, avoidance of dead space, restoration of adequate projection to the nasa l tip, and an approximation of the supratip subcutaneous tissue to the unde rlying cartilage using a supratip suture, hence eliminating the dead space. If the problem is noted shortly after surgery, in the presence of collapsib le consistency of the supratip tissue and adequate projection, the treatmen t is taping the supratip tissue as often as it is practical. If no favorabl e response is elicited in 6 to 8 weeks, the judicious injection of a small amount of triamcinolone acetonide (0.2 to 0.4 cc of 20 mg/cc) in the deep s ubcutaneous tissue (not in the dermis) is done. The injection is repeated i n 4-week intervals until the desired effect is achieved. If supratip fullne ss is the consequence of inadequate cartilage resection or inadequate tip p rojection, surgical correction is needed. The recalcitrant soft-tissue excess in the supratip area is resected, and t he subcutaneous soft tissue is approximated to the underlying cartilage. If the dorsum was previously overresected, a cartilage graft to the caudal do rsum or midvault will create an optimal dorsal frame and reduce the potenti al for a recurrent supratip deformity.