Aesthetic rhinoplasty is a popular procedure in the cosmetic surgery spectrum, often positively transforming facial balance and, with concomitant septal surgery, providing an opportunity to improve nasal airways. Dorsal hump reduction, correction of asymmetries and tip contouring are commonly undertaken. Rhinoplasty is usually performed as an isolated procedure, but can be combined with orthognathic surgery to enhance the overall result. However, more complicated deformities present the clinician with a greater challenge.

Hypoplasia and/or deviation of the nasal dorsum may be due to congenital deformities. However, trauma and iatrogenic surgery are by far the most common causes of distorted nasal contour and projection deformities due to direct disruption of support mechanisms involving the septum and associated osseo-cartilagenous framework. Prior to reconstruction of the collapsed and distorted nasal dorsum, it is important to ensure that the deformity is stable. Clinical assessment of the airways and valvular function must be undertaken together with palpation of support structures to define their integrity. Plain imaging is usually unhelpful, but CT scanning will help to disclose septal asymmetries and distortion of the bony pyramid.

Surgical strategies are aimed at rebuilding compromised nasal supports. Cartilage columella struts between the lower lateral cartilages help nasal tip projection but a more general collapse of the mid-dorsum and upper bony dorsum requires additional strength. A depressed naso-ethmoidal fracture may be a strong indication for primary onlay grafting to restore contour. Cases illustrating various techniques of projecting the nasal dorsum will be described together with the rationale for their choice.