The nasal tip is one of the most varied anatomic units in the human body. For that reason, multiple techniques in tip modification have been described throughout the history of rhinoplasty. Excision techniques were used primarily in the early procedures. In the more recent rhinoplasty literature, conservation techniques and the use of sutures has become the dominant theme.

Nasal tip width, contour, projection, and rotation are all elements that can be modified or enhanced by tip suture techniques. To accomplish this, narrowing sutures can be used to reduce the interdomal space which may also modify projection and rotation at the same time. The convexity of the lateral ala can be altered by the use of lateral crural convexity sutures.

The first published tip suture techniques were by Joseph who used direct interdomal sutures. This method was intended to stabilize the lower lateral cartilages after significant cephalic resection or cross-section. Goldman later used bilateral medial crural-vestibular flaps sutured to the caudal septum. This resulted in occasional extreme rotation, increased projection, and a signature appearance in which the cut ends of the domes became visible through the skin in later years. McCullough and English described the double-dome suture in 1985. This technique effectively narrows the interdomal space, but care must be taken to avoid medialization of the external valve. Kridel described a transdomal suture designed to recruit lateral crura to increase tip projection titled the “lateral crural steal.” Daniel and Tebbets later described intradomal dome-shaping sutures and several variations of tip sutures. Guyuron also described tip suture techniques to alter the domes and columella. Baker and Guyuron have summarized these techniques in review articles.

As with any surgical procedure, it is important to gather pertinent patient history. Prior surgical procedures, cosmetic and functional, must be considered in planning further surgery. Medical conditions such as diabetes, hypertension, and sleep apnea are important to consider and advise about risk. Psychiatric conditions and medications are equally important as physical findings, especially disorders such as body dysmorphic disorder. Surgeons must identify risk factors and use their best judgment in planning rhinoplasty surgical procedures.

All patients are evaluated at a formal consultation. At this time, patient motivation, physical traits, past history, and realistic expectations are evaluated. Photographs are taken and used for further evaluation before surgery. Computer imaging is offered to selected patients, especially if the surgeon feels the patient is not visualizing the same changes as the surgeon is describing.