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.
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