Over the past 35 years, aesthetic rhinoplasty has evolved from a generic, reductive operation to a highly individualized, problem-specific operation that often combines augmentation with reduction. The author's experience has been marked by the following conceptual and technical milestones that have contributed to an ongoing exploration and advancement of nasal surgery:(1) vestibular stenosis: diagnosis of a surgical consequence;(2) etiology and treatment of supratip deformity: the dynamic relationship of soft-tissue contour to skeleton;(3) etiology and treatment of the tip with inadequate projection: tip graft design;(4) practical aesthetics of balance: the augmentation-reduction approach to rhinoplasty;(5) support of the middle vault: functional and aesthetic effects;(6) malposition of the lateral crura: recognition and management; and (7) the significance of the middle crura: clinical and aesthetic considerations.

Submucosal placement of strips of cartilage along the anterior border of the septum--the spreader graft--has proved to be an effective method for reconstructing the roof of the middle vault. It is recommended in all primary rhinoplasty patients in whom resection of the roof of the upper cartilaginous vault is a necessary part of the surgical plan.

This paper chronicles a personal experience with nasal tip grafts over 20 years. In the first period (1968-1975), the original graft was designed for use in secondary rhinoplasty cases to obtain both projection of the tip and increased angulation at the columellar-lobular junction. The use was soon expanded to primary patients with inadequate tip projection. During the middle period (1975-1982), the applications for tip grafting were expanded to include many kinds of tip problems (both primary and secondary), cleft lip noses, and various ethnic noses, especially those with thick skin. The incidence of postoperative displacement and/or visibility of the graft was reduced as multiple grafts of solid, bruised, and crushed cartilage became routine. Ear cartilage was first used and ethmoid was abandoned as a primary graft. The incidence of infection was significantly reduced. The current period (1982-1991) is marked by refinements in technique and materials. Greater versatility with graft composition and materials makes possible a variety of tip configurations, custom-made for individual requirements.

Over the past 35 years, aesthetic rhinoplasty has evolved from a generic, reductive operation to a highly individualized, problem-specific operation that often combines augmentation with reduction. The author's experience has been marked by the following conceptual and technical milestones that have contributed to an ongoing exploration and advancement of nasal surgery:(1) vestibular stenosis: diagnosis of a surgical consequence;(2) etiology and treatment of supratip deformity: the dynamic relationship of soft-tissue contour to skeleton;(3) etiology and treatment of the tip with inadequate projection: tip graft design;(4) practical aesthetics of balance: the augmentation-reduction approach to rhinoplasty;(5) support of the middle vault: functional and aesthetic effects;(6) malposition of the lateral crura: recognition and management; and (7) the significance of the middle crura: clinical and aesthetic considerations.

Fixation of the orbicularis muscle to the levator muscle in an upper blepharoplasty can create a higher supratarsal fold in selected caucasians. The technique that I introduced two years ago has been refined to eliminate one of the major problems (postoperative morbidity).

We have developed software that employs interactive computer graphics to simulate the surgical experience of rhinoplasty by allowing the surgeon to experiment within a model of nasal behavior. For any of three preoperative noses, the surgeon can choose and see the effects of dorsal resection, modification of nasal spine or caudal septum, alar cartilage resection, osteotomy, alar wedge resection, and a variety of nasal grafts. The available choices and views total nearly 3000 images, or approximately 200 different surgical solutions. The surgeon can get textual analysis at any time or see accelerated healing to the projected nasal appearance at 1 year. We believe that the ability to experiment without risk, to safely learn the biological laws governing nasal behavior, should augment the development of surgical judgement in rhinoplasty.