Projection of the nasal tip is among the most important aspects of the nose. In this article, a wide spectrum of techniques are presented that allow the rhinoplasty surgeon to decrease, maintain, or increase nasal tip projection. Rhinoplasty surgeons must be adept with suture techniques, lower lateral cartilage overlay techniques, and structural grafting to be able to achieve excellent long-term results.
Key points
- •
Analyze the nose thoroughly to decide on the ideal projection of the nose.
- •
Discuss the alternatives of tip projection with the patient.
- •
If the patient’s tip projection is satisfactory, the surgeon must prevent postoperative loss of tip support by using columellar struts, or septocolumellar or tongue-in-groove sutures.
- •
For overprojected tips, the surgeon must determine whether the issue is resulting from to the nasal septum or the lower lateral cartilages.
- •
The surgeon should try to put all the surgical techniques in his or her armamentarium and choose the ones that will work in each selected case.
Introduction
There are 3 important parameters of the nose that the rhinoplasty surgeon and patients must take into account: nasal length, projection, and rotation of the tip ( Box 1 ). All of these parameters are closely linked to each other. During the preoperative consultation, the surgeon should examine and analyze the nose thoroughly and discuss the available solutions with the patient.
- 1.
Decreasing projection
- a.
Shortening the long medial crura
- i.
Septocolumellar or tongue-in-groove sutures
- ii.
Medial crural steal
- iii.
Footplate resection
- iv.
Lipsett
- v.
Medial crural overlay
- vi.
Vertical dome division
- vii.
Dome truncation
- i.
- b.
Shortening the long lateral crura
- i.
Lateral crural steal
- ii.
Lateral crural overlay
- iii.
Vertical dome division
- iv.
Dome truncation
- i.
- a.
- 2.
Keeping the projection
- a.
Septocolumellar or tongue-in-groove sutures
- b.
Columellar strut
- a.
- 3.
Increasing projection
- a.
Sutures
- i.
Lateral crural steal
- ii.
Vertical dome division
- iii.
Septocolumellar or tongue-in-groove sutures
- i.
- b.
Grafts
- i.
The grafts used to increase the dimensions, change the shape and strength of the caudal septum
- 1.
Columellar strut
- 2.
Caudal septal extension graft
- 3.
L-strut graft
- 4.
Subtotal septal reconstruction
- 1.
- ii.
The grafts used to support or replace the existing lower lateral cartilages
- iii.
The grafts used over the tip
- 1.
Shield graft
- 2.
Tip onlay graft
- 1.
- i.
- a.
In facial analysis, there are many methods to calculate the ideal projection of the nose. The simplest method, described by Simons, states that the length of the upper lip equals the length of the subnasale to the tip. In Goode’s formula, a line to the nasal tip drawn perpendicular to a line from the nasion through the alar–facial junction should be 55% to 60% of the dorsal nasal length from the nasion to the tip. Crumley and Lanser described the ideal nasal projection as a ratio equal to 0.2833 by comparing the length of the line from the nasion to the vermilion of the upper lip and the length of a perpendicular line to the tip defining point. Similarly, Powell described that a line drawn from nasion to subnasale is correlated with a perpendicular line reaching to the tip defining point and found it to be approximately 2.8. Byrd published in his research that tip projection should be approximately two-thirds (0.67) of the surgically planned or ideal nasal length ( Fig. 1 ).
Current concepts in tip support are based on Anderson’s tripod concept. He described the conjoined medial crura as 1 leg and each of the lateral crura as the other legs in the tripod that determines tip projection and rotation ( Fig. 2 ). The projection of the nasal tip can be changed by changing the length of these legs or the pedestal on which the tripod rests.
Introduction
There are 3 important parameters of the nose that the rhinoplasty surgeon and patients must take into account: nasal length, projection, and rotation of the tip ( Box 1 ). All of these parameters are closely linked to each other. During the preoperative consultation, the surgeon should examine and analyze the nose thoroughly and discuss the available solutions with the patient.
- 1.
Decreasing projection
- a.
Shortening the long medial crura
- i.
Septocolumellar or tongue-in-groove sutures
- ii.
Medial crural steal
- iii.
Footplate resection
- iv.
Lipsett
- v.
Medial crural overlay
- vi.
Vertical dome division
- vii.
Dome truncation
- i.
- b.
Shortening the long lateral crura
- i.
Lateral crural steal
- ii.
Lateral crural overlay
- iii.
Vertical dome division
- iv.
Dome truncation
- i.
- a.
- 2.
Keeping the projection
- a.
Septocolumellar or tongue-in-groove sutures
- b.
Columellar strut
- a.
- 3.
Increasing projection
- a.
Sutures
- i.
Lateral crural steal
- ii.
Vertical dome division
- iii.
Septocolumellar or tongue-in-groove sutures
- i.
- b.
Grafts
- i.
The grafts used to increase the dimensions, change the shape and strength of the caudal septum
- 1.
Columellar strut
- 2.
Caudal septal extension graft
- 3.
L-strut graft
- 4.
Subtotal septal reconstruction
- 1.
- ii.
The grafts used to support or replace the existing lower lateral cartilages
- iii.
The grafts used over the tip
- 1.
Shield graft
- 2.
Tip onlay graft
- 1.
- i.
- a.
In facial analysis, there are many methods to calculate the ideal projection of the nose. The simplest method, described by Simons, states that the length of the upper lip equals the length of the subnasale to the tip. In Goode’s formula, a line to the nasal tip drawn perpendicular to a line from the nasion through the alar–facial junction should be 55% to 60% of the dorsal nasal length from the nasion to the tip. Crumley and Lanser described the ideal nasal projection as a ratio equal to 0.2833 by comparing the length of the line from the nasion to the vermilion of the upper lip and the length of a perpendicular line to the tip defining point. Similarly, Powell described that a line drawn from nasion to subnasale is correlated with a perpendicular line reaching to the tip defining point and found it to be approximately 2.8. Byrd published in his research that tip projection should be approximately two-thirds (0.67) of the surgically planned or ideal nasal length ( Fig. 1 ).
Current concepts in tip support are based on Anderson’s tripod concept. He described the conjoined medial crura as 1 leg and each of the lateral crura as the other legs in the tripod that determines tip projection and rotation ( Fig. 2 ). The projection of the nasal tip can be changed by changing the length of these legs or the pedestal on which the tripod rests.
Treatment goals
When dealing with the projection of the tip, there are 3 options that must be considered while performing rhinoplasty: whether to maintain, decrease, or increase the projection. In cases where the tip is overprojected or poorly projected, the surgeon should explore the underlying etiology. The 2 main factors in an overprojected nose are the lower lateral cartilages and/or the nasal septum, which acts as an important pedestal for the tip. In accordance with the results of facial analysis and examination, the surgeon should discuss his or her findings with the patient and try to find the best way to fulfill the patient’s desires.
Preoperative planning and preparation
The patient should be supplied with the general information on rhinoplasty and goals pertaining to their case. In revision cases, there may be a need for harvesting cartilage from the ear or rib. Preoperative photos must always be obtained. The author uses a studio with 2 flashes and a full-frame SLR camera with 105 mm macro lens to take life size 1:1 pictures. This is ideal for accurate aesthetic and photometric analysis as well as for postoperative comparison. These pictures are transferred typically into Rhinobase, a special program used to store patient data and enabling the surgeon to use an automated facial analysis tool. The program is used to make 5 calculations relating to the patient’s tip projection in accordance to Simons, Goode, Crumley and Lancer, and Powell and Byrd ( Fig. 3 ). Morphing of the images is undertaken, taking into account the measurements but relying mostly on the aesthetic eye of the surgeon and desires of the patient. During the imaging session, the surgeon can modify the lateral and basal view to show the likely changes to the patient regarding their tip projection and rotation. Altering the basal view helps the patient to better understand how changes in the projection of the tip can alter the nasal tip and alar flaring. In this author’s opinion, it is important to show different options to the patient to understand what the patient really wants.
