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Randall et al. Plast Aesthet Res 2024;11:18 https://dx.doi.org/10.20517/2347-9264.2023.115 Page 9 of 13

The rainbow graft used by Bracaglia et al. in the correction of nasal tip asymmetry was also found to correct
[16]
alar retraction in 16 of 18 revision rhinoplasty patients in their case series . In patients with multiple tip
[17]
deformities, a rainbow graft could be considered a viable option for reconstruction . Comprehensive grafts
have been attempted with varying success, including the nasal tip tripod graft, which has been shown as a
useful technique in cases of severe tip deformity to reconstruct the entire nasal tip in one single structured
[54]
graft .
In the most severe cases of alar retraction, there may be a deficiency of nasal lining. In these cases,
composite grafting is a powerful technique that can replace the deficient soft tissue and cartilage with one
graft . Composite grafts for alar retraction are typically harvested from the cymba concha and placed into
[55]
the defect created by incising the vestibular skin to release it.

Adjuvant therapy for revision rhinoplasty to help treat scar contraction may also be helpful in the setting of
alar retraction. Ahn et al. demonstrated a cohort of 30 patients with nasal skin retraction who underwent
revision rhinoplasty and were treated with several sessions of pre- and postoperative
polydeoxyribonucleotide and invasive bipolar radiofrequency treatments. These treatments helped to
release the tightness of the scar tissue from previous surgery and made revision surgery more accessible,
with no patients suffering from persistent alar retraction or scar contracture following revision surgery .
[56]

DISCUSSION
In the words of Samuel Fomon MD, PhD, “He who masters the nasal tip, masters rhinoplasty.” The nasal
tip remains one of the most important subunits of the nose to address in rhinoplasty. Each of the common
nasal tip abnormalities and/or complications, tip asymmetries, bossae, and alar retraction, require deliberate
consideration to prevent, and careful planning when approaching correction with revision surgery. Care
should be taken during primary rhinoplasty to practice meticulous and deliberate surgical techniques to
prevent these complications by preserving or augmenting the native structural integrity of the lower lateral
cartilages. Repair is more difficult than prevention. While secondary rhinoplasty can present a surgical
challenge, appropriately addressing patient concerns with revision rhinoplasty has been shown to improve
health-related quality of life, which is rewarding for both the patient and the surgeon . To better visualize
[57]
the tip structure in vivo, revision rhinoplasty is often undertaken with an external approach [3,31,58] .

As trends in modern rhinoplasty shift toward emphasizing minimal intervention for maximal function and
aesthetic benefits, rhinoplasty surgeons must be familiar with minimally invasive approaches to nasal tip
refinement. The endonasal approach can offer many advantages that abide by these modern rhinoplasty
principles, as it offers preservation of nasal tip anatomy by minimizing external incisions and limiting direct
dissection of nasal tip structures [59-61] . The minimally invasive nature of this approach not only limits the
visibility of scars but also significantly reduces postoperative swelling and bruising, enhancing patient
recovery times [62,63] .

Additionally, preservation of the scroll area and Pitanguy’s ligament during endonasal rhinoplasty allows
the surgeon to maintain the nasal tip’s natural contour and function, enabling retention of its natural
dynamics and support . Furthermore, rhinoplasty literature has demonstrated that many of the
[43]
non-destructive techniques originally designed for open rhinoplasty have been successfully adapted for use
[60]
in the endonasal approach, including cepahlic trims, lateral crural steals, and various grafting techniques .