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While there are many potential adverse aesthetic issues that can occur after a rhinoplasty surgery, the pollybeak deformity is one of the most common. This refers to excessive fullness in the supratip area. This results in an upleasant roundness about the point of peak tip projection and disrupts a desired smooth dorsal line. It can occur due to inadequate resection of the caudal end of the dorsum or a residual high septal angle, inadequate tip projection, and excessive supratip scarring. While the thick-skinned patient is at a higher risk of developing a  pollybeak deformity, it can occur in any skin type.

Strategies during a primary rhinoplasty to prevent postoperative supratip fullness include an adequate cartilage resection of the septum angle/nasal dorsum. In looking at the dorsum and tip relationship in surgery it is important to be aware that any skin coverage will camouflage the transition. As a result I have learned that the dorsal-tip relationship must look a bit exaggerated, particularly in females patients, to avoid the problem of residual supra tip fullness.

In the June 2019 issue of the journal Plastic and Reconstructive Surgery an article was published entitled ‘How to Reduce the Probability of a Pollybeak Deformity after Primary Rhinoplasty: A Single-Center Experience’.  In this paper the authors discuss two intraoperative maneuvers in high risk patients, supratip suturing and supratip skin excision. The authors review their experience in 74 patients with the supratip suture technique and 21 patients treated by supratip skin excision. They use a 5-0 Vicryl placed using a cannula technique to sew down the dermis of the skin to the cartilage in the depth of the supratip area. When supratip skin seems excessive after closure an elliptical skin excision is performed in the midline just behind the tip-defining point.

Their results in the 74 cases of supratip suturing showed improvement in every patient with two actually having an overcorrection effect. Of the 21 patients who had supratip skin excision, 2 (10%) had adverse scarring which required secondary scar treatments.

Supratip suturing has proven to be an effective technique in my experience to reduce dead space between the skin and the cartilage in the thick-skinned patient. It offers an extra level of prevention of supratip fullness that has no downsides to doing so. I have never done supratip skin excision although its beneficial effects are easy to understand  if the surgeon and patient have the scar tolerance for it.

Dr. Barry Eppley

Indianapolis, Indiana

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