Open Approach to the Underprojecting Tip

Chapter 23. Open Approach to the Underprojecting Tip

Diana C. Ponsky, MD; Bahman Guyuron, MD, FACS

INDICATIONS

Rhinoplasty is performed to correct displeasing disharmonies of the nose and incongruences with the rest of the facial features. Functional compromise and aesthetic anatomic flaws of the underprojected nasal tip is one of the most important nasal imperfections to correct. The underprojected nasal tip can result from loss of tip support, as in acquired tip ptosis, or from inadequate tip projection relative to the aesthetic ideal. Because nasal tip anatomy and facial features vary widely between patients, there is no single surgical technique that can be routinely applied in all patients to correct the underprojected tip.

It is essential that adequate preoperative facial analysis be performed, and the surgical plan formulated in the surgeon’s mind prior to surgery based on the nasal pathology and patient’s desires. Goals and limitations must be understood and discussed prior to surgery. At the time of surgery, once the soft-tissue envelope is elevated, adequate exposure of the intended nasal structures may modify the surgical plan to some degree.

An external or open rhinoplasty approach is often preferred as it provides maximal exposure of the lower lateral cartilages, upper lateral cartilages, middle nasal vault, and bony nasal vault. These structures can be manipulated in a more precise fashion, and cartilage grafts can be accurately sutured into place, which is of particular importance in increasing nasal tip projection.

Contraindications to aesthetic rhinoplasty exist in patients who have medical problems such as uncontrolled diabetes, coagulopathies, or other chronic medical conditions that render elective surgery and anesthesia unsafe.

PREOPERATIVE PREPARATION

Careful analysis and study of the patient’s facial features, with evaluation of standardized (frontal, base, lateral, oblique) photographs, or life-sized photographs, is crucial. Our preference is the use of life-sized photographs to perform frontal and profile view analysis. Complete nasal analysis, as well as its relationship to the chin, is also required. A thorough intranasal exam and digital palpation of the nose must be performed. The patient’s goals and realistic expectations are discussed in detail. The external columellar scar is discussed with the patient. Any alar or nasal base modifications and the scar are also discussed.

Obtaining a detailed and complete medical and surgical history is necessary to understanding a possible iatrogenic or acquired cause of the underprojected nose. Medical history, such as inflammatory disease and infections, should be explored. A detailed account of past rhinoplasties should be elucidated. Additionally important is the need to assess for substance abuse, especially cocaine. All aspirin and nonsteroidal antiinflammatory agents should be discontinued at least 2 weeks before surgery. Smoking and steroid use may retard the healing process and should be stopped prior to surgery. The diagnosis of nasal tip underprojection requires a precise assessment of the nasal proportions and angles. Several reports and formulas have been developed to define the ones that constitute the aesthetic ideal. Analysis of facial proportions and landmarks, including the radix, nasal dorsum, nasal length, tip rotation, and tip projection, are essential.

In general, one should start with noting the different zones of the face and whether the facial thirds are in equilibrium. The nasofrontal angle (radix) is evaluated. The apex of the radix should lie between the upper lid eyelashes and the supratarsal fold with the eyes in neutral gaze. This is typically 4 mm deep in men and 6 mm deep in women. The aesthetic nasal dorsum should lie approximately 2 mm behind and parallel to a line from the radix to the tip-defining points in women and 1 mm behind in men.

Tip rotation and projection are addressed in profile view. Rotation is determined by the nasolabial angle, and is ideally between 103 and 108 degrees in women and between 95 and 100 degrees in men. In determining projection, a line is drawn from the alar-cheek junction to the tip of the nose. Projection is ideal if 50% to 60% of the nasal tip lies anterior to a vertical line adjacent to the most projected part of the upper lip. Alternatively, the Byrd method can be used where the tip projection is two-thirds or 0.67 of the planned postoperative (or the ideal) nasal length. Ideal nasal length in this approach is 0.67 of the midfacial height. Other methods can be used, including Crumley’s 3-4-5 triangle.

The physical examination includes looking at both the external and internal nose. The external examination includes observation in the anterior, profile, oblique, and basal view, examining the nose for symmetry, proportionality, and flaws and deformity. The skin quality is noted: thin, medium, or thick. Thick skin can often drag down the nasal tip. Palpation of the nose can reveal the strength or weakness of the supporting skeletal framework as well as any irregularities of the firm radix or supple nasal tip. Understanding the patient history can help identify areas of scarring, contracture, resection, and previous grafting. The influence of the depressor septi muscle during animation on both frontal and profile views should be assessed.

The internal examination is important for evaluating the presence of any septal perforations and to assess the quality and quantity of the internal lining. Attention to the functional aspects of the nose should not be overlooked. Investigating for septal deviation, hypertrophic turbinates, and internal and external valve competence are part of a complete nasal examination. Any functional abnormalities should be addressed with the patient and included in the operative planning. If compromised nasal function is determined or suspected, or facial trauma has occurred, radiography and CT scans of the nose and paranasal sinuses should be obtained.

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