This patient of Russian and Slavic blood sought and expressly requested a custom design of her nasal tip; after thorough in person discussions and agreeing on graphic simulations about her dream nose it was pretty well understood all about her solid and well grounded wishes; she wanted a poorly defined, large, round, bulbous and pretty much Russian nasal tip; in her words she hated her sharp and pointy tip, furthermore she did not take the advice of going for a somehow round but more conservative tip, she really wished a very specific, clearly designed and psychologically integrated ethnic and explicit Russian tip with a clown's tip flavor.
Such a challenge is unique in a surgeon's career and not a technique that may be read in any book; in ethnic rhinoplasties it is quite studied and practiced the conversion from a deeply ethnic nose to a more canonically shaped and adapted to universal standards of beauty; therefore those aesthetic issues on the nose due to the ethnicity are addressed and corrected; in this case it is exactly the inverse way, a non ethnic tip is meant to be a fully ethnic one or even somehow hyperrealist among Russian or Slavic ethnicities.
For such purpose a surgical technique had to be, literally, invented; this consisted in a series of customized ear cartilage grafting, number of three, assembled like three petals in cocoon to shape a dome on top of the caudal septum and thus shaping the aimed bulbous and round tip; this structure fully replaced the lateral cruras, the tip and the infratip lobule like a cap in a clown's nose.
For the first time and unlikely ever again such a structure was designed and executed in a rhinoplasty, that's the reason why custom rhinoplasties are the most creative procedures few surgeons can be capable to perform with dignity and sufficient proximity to success.
Other difficult but more standard issues affected this nose, like the over projection and droopiness of the tip, the dorsal ridges and the rhomboid dorsum, the difficult shape of the dorsal hump and the sunken supratip depression; all those difficult problems were also successfully corrected, however their merit ended shadowed by the ordeal of customizing such a nose.
The final outcome could not be more successful and closer, almost identical, to the idealized tip the patient sought: all the structural issues perfectly addressed and the nasal tip built as a typically Russian bulbous and clown's tip nose.
The last of the images in this case shows the wish picture simulation supplied by the patient comparing her preoperative profile on the left image with the one she was aiming to in the central image, being the right image the final custom rhinoplasty result achieved, the closest and even improved one it could be.
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