Indications and Technique for Increasing and Decreasing Tip Projection in Open Rhinoplasty

David A. Sieber

C. Spencer Cochran

DEFINITION

Proper tip projection can be determined through multiple methods.
- The authors’ preferred method is to have a tip projection that is equal to the length of the upper lip as measured from the white roll to the base of the columella. This line should equal the distance from the base of the columella to the tip-defining point. This method assumes that the upper lip is of normal length and may not be applicable in all patients (FIG 1A).
- Another method places a line from the alar crease to the tip-defining points (lines A to B). A perpendicular line is then drawn from the upper lip through lines A to B. Ideal tip projection is when A, 50% to 60% of AB (FIG 1B).
- Goode method: a triangle is formed from a line drawn from the nasion through the alar crease (A). The other sides are composed of a line from the nasion to the tip-defining point (B) and another line from the alar crease to the tip-defining point (C). An ideal tip has a B:C ratio of 0.55 to 0.6 (FIG 1C).

ANATOMY

PATHOGENESIS

Overprojection of the tip may be the result of one or many abnormalities in nasal anatomy such as a prominent septal angle or excessively long and/or strong medial or lateral crura.¹
Likewise, underdevelopment or underprojection of the nasal tip may be due to a weak septal angle or short and weak medial or lateral crura.²
More commonly, underprojection is the result of a poorly planned primary rhinoplasty in which proper support either through the use of a columellar strut or tip suturing was not employed, resulting in loss of tip support as the soft tissue envelope contracts.³^,⁴

FIG 1 (Continued)
The tripod method for understanding tip projection is both relevant and important to comprehend (FIG 2). As each leg of the tripod is modified to re-establish proper tip projection, there is a resulting effect on tip rotation.
Proper support of each leg of the tripod is critical in maintaining tip projection over time through the use of:
- Columellar strut graft: forms foundation of the tip, maintains projection, and prevents distortion
- Extended alar contour grafts
- Dorsal spreader grafts

PATIENT HISTORY AND PHYSICAL FINDINGS

Patients presenting for primary rhinoplasty will complain of a nose that “sticks out too far” or will state that they do not like the appearance of their nose on profile view.

FIG 2 • Tip support is dependent on three independent structures much like the legs of a tripod. The paired lateral crura and the columella/medial crura form the three legs of support.
Secondary rhinoplasty patients may complain of a “short” nose, stating that their nose has become smaller over time.
Confirmation of nasal over- or underprojection should be confirmed using the aforementioned methods.

IMAGING

Imaging may be performed using Vectra (Canfield, Parsippany, NJ) or standard photographs and should be employed to establish preoperative anatomy as well as to help determine surgical goals with the patient.

NONOPERATIVE MANAGEMENT

Although soft tissue fillers such as hyaluronic acid are used by some surgeons as a nonsurgical option to change nasal contour, we do not advocate the use of fillers in the tip to increase tip projection; the risk of vascular occlusion or embolization that can result in injury to the remaining nasal vascular network may lead to irreversible skin loss.

SURGICAL MANAGEMENT

Surgical management of tip projection should follow an organized and incremental approach including the following:
- Determine the cause of tip over- or underprojection.
- Incrementally address each of the aforementioned factors.
- Reset the desired tip projection based on preoperative planning and intraoperative results.
- Re-establish proper support in each leg of the tripod.

Preoperative Planning

Preoperative imaging should be reviewed with the patient to ensure that the patient has realistic goals for surgery and that the desired surgical result can be achieved.

Positioning