Indications and Techniques for Increasing and Decreasing Tip Projection in Closed Rhinoplasty

Barış Çakır

Mithat Akan

DEFINITION

One of the reference points in the face is the vertical line intersecting the pupil, or “midpupillary line.” The horizontal distance from the midpupillary line to the highest point of the tip is called the tip projection (TP).
The horizontal distance from the midpupillary line to the apex of the nostril is called the nostril apex projection (NAP).
The horizontal distance from the nostril apex to the tip’s highest point is called the lobule projection (LP).
The NAP together with the LP constitutes the TP (FIG 1).
Examining the nose in this manner, element by element, will assist with the treatment.

ANATOMY

The lower lateral cartilages consist of the footplate, the medial crus, the middle crus, the domes and the lateral crus.
The lower lateral cartilages rest on the lip, the septum and the upper lateral cartilages.
With its thickness of 2 to 4 mm, the Pitanguy midline ligament, which fills the space between the septal angle and the domes, ensures an elastic projection (FIG 2A,B).

PATHOGENESIS

Tip projection = nostril apex projection + lobule projection
- High NAP: Hypertrophic anterior and caudal septum, hypertrophic maxillary spine
- High LP: Long medial and middle crus
  
  FIG 1 • Tip projection (TP), lobule projection (LP), nostril apex projection (NAP).
- Low NAP: Hypoplastic maxilla, footplate sitting posteriorly, hypoplastic caudal septum, previous septoplasty surgery, aggressive resection of caudal septum
- Low LP: Short middle crus, short medial crus

PATIENT HISTORY AND PHYSICAL FINDINGS

If the premaxillary support is weak, the nasolabial angle will be narrow, and when pulling up the lips, one can see that the maxillary mucosa is deep.
Pressing on the nose tip will give us an idea about its support.
In patients with posteriorly located maxilla it is difficult to obtain enough nasal projection. Patients who do not want a LeFort osteotomy may require a tongue in groove, an aggressive augmentation in premaxilla, or a long, strong columellar strut graft.

FIG 2 • A,B. With its thickness of 2 to 4 mm, the Pitanguy midline ligament, which fills the space between the septal angle and the domes, ensures an elastic projection.

FIG 3 • One can easily plan changes to the TP, LP, and NAP by superimposing the newly planned nose over the old nose with a 50% contrast.
It is noteworthy that in patients with high projection, the caudal and dorsal septa are hypertrophic.
A hypertrophic septum can cause a hanging columella, tense lips and a wide footplate.
Because the septum pushes the footplates more anterior than normal, the depressors are extremely tense. For this reason, the nasal tip may be more active when speaking.
Skin thickness should be noted.

IMAGING

Front, base, top, lateral, and oblique photographs are standard. A lateral smiling photograph can give clues about the dynamics of the nose tip.
Imaging programs facilitate better analysis of the problems and planning of treatment.
One can easily plan changes to the TP, LP, and NAP by superimposing the newly planned nose over the old nose with a 50% contrast (FIG 3).

SURGICAL MANAGEMENT

The treatment needs to directly address the problem.

FIG 4 • Although a patient’s LP may be normal, the high TP can be linked to a high NAP. In this case, LP did not change; TP decreased by decreasing NAP. Three months post-op photo is similar with the simulation.

FIG 5 • A patient may have a normal TP, a high NAP, and a low LP. In order to protect the TP, one has to increase the LP in the same measure as one decreases the NAP.

Preoperative Planning

It is important to observe how much the nasal tip contributes to the patient’s facial expressions. One should observe the nose while the patient speaks. If the depressors are very active, this should be noted.
Although a patient’s LP may be normal, the high TP can be linked to a high NAP (FIG 4).
A patient may have a normal TP, a high NAP and a low LP. In order to protect the TP, one has to increase the LP in the same measure as one decreases the NAP (FIG 5).
A low TP may be linked to a low NAP as well as a low LP. Projection is the horizontal axis of the tip cartilage length. Rotation of the droopy tip also increases the projection (FIG 6).
In thick-skinned noses, the projection needs to receive stronger support.