Nasal Tip Projection Rhinoplasty

As the central feature of the face, the nose has a profound effect on facial aesthetics. Therefore, nasal tip projection must be assessed not only in relation to the nasal dorsum but also in relation to overall facial proportions. Rhinoplasty maneuvers inevitably increase, preserve, or decrease nasal tip projection. The desired preservation or change in projection of the nasal tip should be assessed and surgical maneuvers chosen accordingly. Any changes in the nasal skeleton must be made with consideration of the overlying skin and soft tissue envelope and the resultant limitations on changes in the topography of the overlying skin. The complexity of nasal tip dynamics must also be carefully considered because alterations in nasal tip projection are intimately associated with alterations in tip rotation and nasal length.[1]

An image depicting tip grafting can be seen below.

The character of the nose is greatly defined by the contour of the nasal tip, and, as the central facial feature, the nose has a profound effect on facial aesthetics. Much of classic facial aesthetic analysis is based on a Greco-Roman ideal. Modern aesthetic values embrace the multiracial and multicultural nature of society and of beauty. Greater focus is placed on improving nasal and facial aesthetics while simultaneously preserving nasal and facial ethnicity. Similarly, modern aesthetic values embrace a more natural nasal appearance. In the past, reductive rhinoplasty techniques frequently focused on altering tip shape with techniques that ultimately weakened the structural integrity of the alar cartilages. A loss of tip support and projection was frequently inevitable. The modern trend is toward a stronger nasal profile and a more natural, unoperated look.

Nasal tip projection must be evaluated in relation to overall facial structure. The surgeon can then determine whether preservation, augmentation, or reduction of tip projection is desired.

Multiple methods can be used to assess tip projection in relation to various structures (eg, subnasale, alar-facial groove, a line from the nasion or glabella). One of the more useful methods of determining the degree of tip projection is the method described by Goode. A line drawn from the alar-facial groove to the nasal tip measures 0.55-0.60 of the distance from the nasion to the nasal tip in typical noses. If the distance from the alar-facial groove to the nasal tip is more than this, the tip is considered overprojected. If the distance is less than 0.55-0.60, the tip is considered underprojected.

Several other methods have been described. Crumley describes the nasal profile as a right triangle with vertices at the nasion, tip-defining point, and alar crease. The sides of the triangle have a 3:4:5 ratio, with a resultant nasofacial angle of 36°. Simons describes nasal tip projection, measured from the subnasale to the tip-defining point, as equaling the length of the upper lip, which is measured from the subnasale to the vermillion border. Byrd proposed that ideal nasal length is two thirds of the midfacial height, and that ideal tip projection is two thirds of the ideal nasal length. Baum proposed a 2:1 ratio between the vertical height (nasion to subnasale) and tip projection (line placed perpendicular to the first through the tip-defining point). Powell and Humphries (1984) modified this ratio to 2.8:1 (aesthetic triangle) to better approximate the ideal nasofacial angle of 36°.[2]

A final method to evaluate nasal projection is the amount of nasal projection in relation to the upper lip. Ideal nasal projection is present when 50-60% of the horizontal projection of the nose is anterior to the upper lip as measured by a horizontal line drawn from the alar-facial groove to the tip-defining point and a perpendicular line drawn vertically to the most anterior projection of the upper lip.

Each of these methods has potential drawbacks. Upper lip length or the length of the alar cartilages may vary significantly, which may affect the estimated projection. Frequently, the nasofacial angle may be used to indirectly evaluate tip projection. However, each of these methods provides an additional measure of tip projection beyond a single nasofacial angle.

A handful of properly used techniques can achieve deprojection of the overprojected nose. While controlling the level of rotation, these techniques offer sound functional approaches to effect deprojection. To help simplify the approach to deprojection, an algorithm can be used.

Frequency

Nasal tip surgery has become significantly more complex since the introduction of tip grafting and the many suture designs that followed the resurgence of open rhinoplasty. Independent of the surgeon's technical approach, however, is the need to identify the critical anatomical characteristics that make nasal tip surgery successful. Two nasal tip features require mandatory preoperative identification: (1) whether the tip is adequately projecting and (2) whether the alar cartilage lateral crura are orthotopic or if they are cephalically rotated (ie, malpositioned).

Only 33% of the patient population had adequate preoperative tip projection, and only 54% had orthotopic lateral crura (axes toward the lateral canthi). Forty-six percent of the patients had lateral crura that were cephalically rotated (axes toward the medial canthi). Both inadequate tip projection and convex lateral crura were more common among patients with malpositioned lateral crura than in patients with orthotopic lateral crura.

Tip projection can be reliably assessed based on the relationship of the tip lobule to the septal angle. Malposition is characterized by abnormal lateral crural axes, long alar creases that extend to the nostril rims, alar wall hollows, frequent nostril deformities, and associated external valvular incompetence. Surgeons treating the average spectrum of primary rhinoplasty patients see a majority (61%) who need increased tip support and a significant number (46%) with an anatomical variant (alar cartilage malposition) that places these patients at special risk for postoperative functional impairment.

Correction of external valvular incompetence doubles nasal airflow in most patients. As few as 23% of primary rhinoplasty patients (the number with orthotopic, projecting alar cartilages in one series) may be proper candidates for reduction-only tip procedures. When tip projection and lateral crural orientation are accurately determined before surgery, nasal tip surgery can proceed successfully, and secondary deformities can be avoided.

Several interrelated anatomic features determine nasal projection. These anatomic elements, either individually or collectively, account for overprojection or underprojection of the nasal tip. These anatomic elements include the following:

• The character of the nasal tip skin

• The shape, size, and strength of the alar cartilages

• The length of the infratip lobule and medial crura

• The length of the columella

• The quadrangular cartilage (especially the anterior septal angle)

• The nasal spine

• The premaxilla

Etiologies of the overprojecting tip include the following (see Pathophysiology, Overprojection):

• Alar cartilage overdevelopment

• Nasal spine overdevelopment

• Caudal septal overdevelopment

• Dorsal septal overdevelopment

• Elongated columella and medial crura

• Combined overdevelopment abnormalities

• Iatrogenic overprojecting tip

Etiologies of the underprojecting tip include the following (see Pathophysiology, Underprojection):

• Small or hypoplastic alar cartilages

• Short columella

• Small nostrils

• Illusion of underprojection secondary to high radix (reduces nasofacial angle)

• Maxillary retrusion

Overprojection

Overprojection results from the overdevelopment of one or more of the anatomic components of the nasal tip.

A common etiology of overprojection is overdevelopment of the alar cartilages. This may result from either overdevelopment of the lateral, intermediate, or medial crus only or from overdevelopment of the entire alar cartilage. This deformity is commonly associated with thin skin. The nostrils are also frequently elongated. Tip overprojection may occur because of an elongated columella associated with excessively long medial crura. In this deformity, the infratip lobule is commonly insufficient, creating the effect of extremely large and disproportionate nostrils.

Over development of the caudal septum may result in an overprojecting nose, and hypertrophy of the nasal spine may exacerbate this deformity. This tension nose deformity frequently results from involvement of the anterior and posterior septal angles and the caudal aspect of the septum. The overdeveloped quadrangular cartilage creates a pedestal effect, spuriously pushing the lower lateral cartilages forward. The lower lateral cartilages may be normal in size, hypertrophied, or even underdeveloped. Similar findings are observed with the pedestal effect of an enlarged nasal spine. Minimal nasal spine enlargement may further augment the tension nose deformity caused by an overdeveloped quadrangular cartilage.

The pedestal effect of the overdeveloped septum usurps the role of the tip cartilages in tip projection and obliterates the normal supratip break. The resultant tension nose deformity tents the tip away from the face, tethers the upper lip, and blunts the nasolabial angle. This condition may also create abnormal exposure of the maxillary gingiva, particularly upon smiling. The forward projection of the nasal tip results in narrowing of the nostrils and flattening of the alar curvature. Overdevelopment of the caudal cartilage may also push the medial crura inferiorly, resulting in increased columellar visibility, especially with downward rotation of the tip with smiling.

Iatrogenic overprojection may occur from overaggressive attempts to increase tip projection and is often associated with overrotation. This is commonly the result of borrowing the lateral crura through an interrupted strip technique to enhance the central limb of the tripod (ie, Goldman technique). Healing may be unpredictable, particularly in thin-skinned patients, and significant asymmetries and distortions may result in addition to overprojection. Collapse of the alar sidewalls early or even late in the postoperative period may also occur.

Correction of iatrogenic overprojection focuses on exploration and accurate diagnosis of the precise deformity. Noniatrogenic overprojection usually results from various combinations of overdeveloped anatomic structures. Surgical correction generally focuses on weakening a combination of the major and minor tip support mechanisms to retrodisplace the tip. The overdeveloped anatomic components are also reduced in an incremental fashion in order to achieve the desired result.

Underprojection

Lack of nasal tip projection has certain common characteristics. The columella may be short, but frequently other deficiencies are present in the nasal tip. Short medial crura may curve into small lateral crura without a significant segment of intermediate crura to provide caudal angulation and projection for the tip. This abnormality typically results in an acute nasolabial angle. The illusion of lack of projection may be created by a high radix, and deepening the radix can restore apparent projection without directly addressing tip projection.

The tension nose deformity may produce the phenomenon of an overprojected nose and a tip with underprojected alar cartilages. The length and strength of the lower lateral cartilages do not determine tip projection in this deformity; instead, the height of the dorsal septum and anterior septal angle determine tip projection. The prominence of the pedestal can result in overprojection of alar cartilages that are actually deficient and may require reprojection of the tip after the pedestal is reduced.

Correction of the underprojected tip focuses on preserving and/or restoring major and minor tip supports, reorienting the alar cartilages, and augmenting with cartilage grafts.[3]

Nasal tip projection is evaluated with careful examination of the nasal profile. Various methods of assessing tip projection have been described, including those of Goode, Crumley, Simons, Byrd, and Baum (see Problem). Each of these methods has limitations but provides supplemental information to the indirect measurement of tip projection based on an ideal nasofacial angle.

The aesthetic triangle of Powell and Humphries (1984) is used to assess nasal tip projection in the context of multiple facial angles.[2] In their method, a vertical line is drawn from the glabella to the pogonion, which should make an angle of 80-95° with the Frankfort horizontal plane. A line tangent to the glabella through the nasion intersects a line tangent to the nasal dorsum, which defines the nasofrontal angle (the nasal dorsal line should transect any dorsal hump to prevent distortion of the angle).

The original vertical line and the line tangent to the nasal dorsum define the nasofacial angle. The nasomental line is drawn from the nasal tip to the pogonion, intersecting the nasal dorsal line and creating the nasomental angle. Intersecting the vertical line from glabella to the pogonion with a line from the cervical point tangent to the menton measures the mentocervical angle. The cervical point is the innermost point between the submental area and the neck. The ideal facial angles and ranges are as follows:

• Nasofacial angle - 36° (range, 30-40°)

• Nasofrontal angle - 120° (range, 115-130°)

• Nasomental angle - 130° (range, 120-132°)

• Mentocervical angle - 85° (range, 80-95°)

As the central feature of the face, the nose both affects and is affected by overall facial proportions. Therefore, the aesthetic triangle of Powell and Humphries best determines ideal nasal proportions.

The nasal base must also be evaluated carefully because its aesthetics affect and are affected by nasal tip projection. The alar base width should be 70% of the nasal length (as measured from the nasion to the nasal tip). The nasal base width also approximates the intercanthal distance or half of the interpupillary distance. The columella-to-lobule ratio should be approximately 2:1, and the width of the lobule should be 75% of the width of the nasal base. The long axis of the nares should be 45-60°, and the length of the nares should be approximately two thirds of the length of the columella.

On lateral view, the alar-to-lobule ratio should approximate 1:1, and 2-4 mm of columellar show is ideal. Ideally, a double break of the columella is present. The nasal tip is the leading point and curves into the columella. The first curve is convex and reflects the lobule, while the second curve reflects the columella. The nasal tip is elevated slightly above the cartilaginous dorsum by 1-2 mm, blending into the supratip. This supratip break should be more pronounced in the female nose than in the male nose, where a straighter dorsal profile is desired. The ideal nasolabial angle also differs with gender, with more tip rotation aesthetically desired in the female nose than in the male nose. The ideal nasolabial angle in men approximates 90°. In women, slight upward rotation with a nasolabial angle of 95-110° is desirable.

Preoperative assessment of nasal projection is not complete without evaluation of chin projection. Retrognathism may exaggerate the appearance of an overprojected nasal tip or give the false illusion of overprojection in a normally projected tip. Chin projection can be evaluated by dropping a vertical line from the vermilion cutaneous border of the lower lip perpendicular to the Frankfort horizontal plane. The pogonion should be in the same plane as the subnasale or vermilion border of the lower lip.

Other methods of assessing chin projection can also be used. The zero-meridian method of Gonzales-Ulloa drops a line that intersects the nasion perpendicular to the Frankfort horizontal plane. The chin should approximate this line. A line from the glabella to the subnasale and a line from the subnasale to the pogonion define the Legan angle (12° with a standard deviation of 4°). A line connecting the pogonion and the most anterior part of the lip to the Frankfort horizontal line forms the Merrifield Z angle (80° with a standard deviation of 5°). An additional technique for assessing chin projection involves drawing a line through the most projected portion of the upper and lower lip. Inferiorly, this line should touch the menton in men and be within 2-3 mm in females.

The nose should also be assessed in relation to the patient's overall facial structure and stature. As the central feature of the face, the nose should be proportionate to overall facial height and width. A nose with a high strong profile may complement a tall person better than a shorter individual, who may tolerate a shorter and overall smaller nose with good aesthetic results. The nose should fit both the face and the person.

In every rhinoplasty, tip projection must first be assessed as normal, excessive, or deficient. A variety of methods are available for assessment, but most commonly the Goode technique is used (see Problem). The surgical goal to preserve, to enhance, or to decrease tip projection can then be determined. Many of the standard rhinoplasty incisions and maneuvers weaken the tip support mechanisms, which must be considered in surgical planning. If retrodisplacement of the tip and loss of projection is undesirable, these tip support mechanisms must be reconstituted.

An important part of an aesthetically pleasing result is to ensure an adequate nasal tip positioned slightly higher than the proper dorsum, with the two tip-defining points in close proximity to each other, giving the nose a triangular shape from the caudal view.

Anatomy of the nasal tip

The term crural arch refers to the alar cartilage in its entirety. The components of the crural arch are the lateral crura and the medial crura. They are joined by a transitional segment of cartilage in the domal region, which is termed the intermediate crura. The tip-defining point refers to the highest point of the tip cartilages, which is usually the highest medial cephalic portion of the lower lateral crus. The tip should have 2 symmetric tip-defining points that are manifested externally by a light reflex.

The caudal border of the lower lateral crus roughly parallels the alar rim near the apex of the nostril. The border variably departs from the alar rim and proceeds superiorly and laterally. It then indirectly attaches to the pyriform aperture laterally via dense fibrous connective tissue, frequently incorporating sesamoid or minor alar cartilages. The ala itself is primarily a fibrofatty structure, with the lateral crus providing little shape and structure laterally because of the oblique orientation of the cartilage. Fibrous connective tissue also constitutes the connection between the upper lateral and lower lateral cartilages (scroll region), which serves as a major tip support.

Most commonly, the cephalic edge of the lower lateral crura overlaps the caudal margin of the upper lateral cartilage. The medial crura lie just below the columellar skin and are of variable convexity. They are connected by loose areolar connective tissue with variable divergence at the crural feet and toward the domes. The fibrous attachment of the medial crura to the caudal nasal septum serves as a major tip support.

The caudal portion of the quadrangular cartilage also contributes significantly to the anatomy of the nasal tip. The caudal septum has 3 distinct angulations: the anterior septal angle, the midseptal angle, and the posterior septal angle. Surgically, the anterior septal angle is the most important. The interdomal ligament is a fibrous sling between the domes that connects the domes to the anterior septal angle; it is a minor tip support mechanism. The posterior septal angle is located just above the articulation of the quadrangular cartilage and the nasal spine. The posterior septal angle supports the feet of the medial crura. The membranous septum consists of the vestibular skin between the caudal margin of the quadrangular cartilage and columella on either side, with an intervening layer of subcutaneous areolar tissue.

Topography of the nasal tip

The nose can be divided into subunits consisting of the nasal dorsum, nasal sidewalls, nasal tip, alar lobules, and the soft tissue triangles or facets. The supratip refers to the area superior to the cephalic border of the tip-defining point. The nasal tip subunit includes both the tip-defining points (externally indicated by a light reflex) and the infratip lobule and columella. The infratip is the area inferior to the caudal border of the tip-defining point and superior to the upper end of the columella. The columella-defining point is the most anterior point of the columella in a profile view, commonly referred to as the double break. The columella-defining points should also be symmetrical. The alar lobules form a portion of the lateral nasal sidewall and are composed of fibrofatty tissue and devoid of cartilage. The soft tissue triangle refers to the soft tissue facet forming the nostril rim immediately below the tip-defining point.

Tripod concept

The alar cartilages of the nasal tip may be considered a tripod. Each lateral crus composes one lateral leg of the tripod, and the paired medial crura constitute the central leg. Alterations in any of the tripod limbs change the spatial position of the nasal tip. Shortening of the lateral limbs of the tripod results in rotation and deprojection of the nasal tip. Similarly, augmentation of the central limb of the tripod may increase nasal tip projection and rotation. Shortening of all 3 limbs serves to retrodisplace the nasal tip. The tripod concept, although an oversimplification of nasal tip dynamics, highlights the intimate relationship between projection and rotation. The tripod concept also highlights the effect that maneuvers performed on one limb may have on the spatial position of the entire nasal tip.

Tip support mechanisms

Major nasal tip support mechanisms include the following:

• Size, shape, and resilience of medial and lateral crura

• Fibrous attachment of medial crura to the caudal border of the quadrangular cartilage (nasal septum)

• Fibrous attachment of the alar cartilages (cephalic border) to the upper lateral cartilages (caudal border)

Minor nasal support mechanisms include the following:

• Cartilaginous septal dorsum

• Fibrous sling spanning both domes and connecting them to the anterior septal angle (interdomal ligament)

• Membranous septum

• Nasal spine

• Sesamoid complex or minor alar cartilages of the lower lateral cartilages

• Attachments of the lower lateral cartilages to the overlying skin and soft tissue envelope

Successful rhinoplasty depends on nasal tip support and its influence on nasal tip projection. Most experts agree that the components of nasal tip support include the attachment between the upper and lower lateral cartilages, the attachment between the lateral crus of the lower lateral cartilage and the pyriform aperture, the attachment between the paired domes of the lower lateral cartilages, and the medial crural attachment to the caudal septum. In recent dissection evaluation, macroscopic study showed presence of dense fibrous tissue between the upper and lower lateral cartilages, dense fibrous tissue and sesamoid cartilages between the lateral crus and the pyriform aperture, and loose connective tissue between the paired domes of lower lateral cartilages, with no identified specific tissue between the medial crus and the caudal septum.

Microscopic investigation allowed a more detailed analysis of these structures. Between the upper and lower lateral cartilages, dense collagen fibers ran in one direction and anchored firmly to each cartilage; this meets the histologic criteria of a ligament. Between the lateral crus and the pyriform aperture, intermingled collagen fibers and muscular fibers were present; this meets the histologic criteria of fibromuscular tissue. Between the paired domes of lower lateral cartilages, few fibers with abundant amorphous ground substances were present; this meets the histologic criteria of loose connective tissue.

Based on the results, the authors recommend that the previously mentioned nasal tip supporting structures should be named intercartilaginous ligament, sesamoid fibromuscular tissue, and interdomal loose connective tissue, respectively. In addition, the authors feel that the loose connection between the domes of the middle crura and the absence of an attachment of the medial crura to the caudal septum may be one of the reasons the nasal tip of people of Asian descent is broad and unprojected with a wide base.

Because rhinoplasty is an elective procedure, significant medical problems that could potentially increase the surgical risk are a relative contraindication. Any history of significant bleeding problems or a family history of bleeding problems warrants a more extensive preoperative evaluation. Any patient on anticoagulants must be able to stop these medications during the preoperative and postoperative periods.

Methods to increase projection

See the list below:

• Lateral crural steal (also increases rotation)

• Tip graft

• Transdomal suture

• Plumping grafts

• Premaxillary graft

• Septocolumellar sutures (buried)

• Columellar strut (variable effect)[4, 5]

• Caudal extension graft[6]

• Dynamic adjustable rotational tip tensioning (DARTT)

• Illusion of projection by enhancing supratip break

Methods to decrease projection

See the list below:

• High partial or full transfixion incision

• Lateral crural overlay (also increases rotation)

• Nasal spine reduction

• Vertical dome division with excision of excess medial crura with suture reapproximation

Nasal tip dynamics

The complexity of nasal tip dynamics must be considered carefully as alterations in nasal tip projection are intimately associated with alterations in tip rotation and nasal length. Projection and rotation can be complementary to each other. Some tip rotation techniques may augment tip projection, but the converse does not always hold true. Drawing a distinction between actual tip rotation and the illusion of tip rotation (using placement of contouring grafts or reduction of the dorsal nasal profile) is also important.

Alterations in tip projection can be achieved by complete or interrupted strip techniques. Interrupted strip techniques can result in dramatic changes, but they diminish surgical control over healing and ultimately the final result. They are useful techniques depending on the patient's anatomy and surgical goals, but care should be exercised. Complete strip techniques, in general, are preferable because healing is more predictable.

In a study by Abbou et al of 55 patients who underwent open septorhinoplasty, the investigators determined through statistical analysis that, unlike the Réthi incision, a columella-transalar incision is likely to close the nasolabial angle and reduces the Goode ratio (projection/nasal length), while alar cartilage resection produces nasolabial angle closure and reduction of nasal projection. Projection was found to be increased, however, with the use of a columellar strut.[7]

Preoperative assessment involves not only visual inspection but also palpation. Intranasal inspection is performed to assess the nasal septum, inferior turbinates, and nasal valves. The nasal tip is visually inspected for contour, asymmetries, and skin quality. Tip recoil indicates the inherent strength and support of the nasal tip and is assessed by depressing the nasal tip toward the upper lip. Palpation and bimanual ballottement can ascertain the size, shape, and resilience of the alar cartilages; characterize the thickness of the overlying skin and soft tissue envelope; and assess for any asymmetries in the underlying nasal skeleton. Internally, palpation allows assessment of the width and length of the medial crura and columella and renders information concerning angulations of the caudal septum, the length of the quadrangular cartilage, and the prominence of the nasal spine. Assessment of any muscle tethering of the tip-lip complex can also be made.

A critical part of the preoperative evaluation is discerning what the patient wants and expects from the surgery, as the patient's goals may differ from the surgeon's goals. This can result in a dissatisfied patient postoperatively despite an excellent result in the opinion of the surgeon. This situation is best alleviated by a mutual preoperative understanding of common surgical goals and realistic patient expectations. The patient's expectations must be tempered by what can realistically be achieved, given the structure of the nasal skeleton and overlying skin. Preoperative photographs are essential in preoperative planning and for documentation and follow-up care. Photographs can also be a tool to educate the patient about what is possible and, perhaps more importantly, what is not possible.

Once the patient and surgeon come to a mutual understanding that corrective surgery is desirable and that realistic expectations can be met, the operation and potential complications are described. Specific details, including methods of anesthesia, financial aspects, timing and frequency of postoperative visits, and specific postoperative instructions are emphasized.

A suitable premedication may be administered the night before surgery and/or the morning of surgery to facilitate a state of relaxation. At the time of surgery, the nose is topically decongested with pledgets or ribbon gauze. If the surgery is to be performed with awake sedation, then topical anesthetic is also applied. Local anesthetic is injected sparingly into the proper surgical planes in the standard fashion for septoplasty and rhinoplasty. A large volume of anesthetic is avoided to prevent distortion of nasal contour. A total of no more than 7-8 mL of local anesthetic is sufficient to produce profound vasoconstriction and nasal anesthesia. Direct injection into the membranous septum is avoided because this may distort the columella. No anesthetic is injected along the nasal dorsum in order to prevent distortion.

The vast majority of patients requiring a significant reduction or increase in nasal projection require either a delivery approach (bilateral chondrocutaneous flap) or an open approach. Making bilateral intercartilaginous incisions, connecting the incisions over the anterior septal angle, and extending them into a high partial transfixion incision initiate the delivery approach. Marginal incisions are made along the caudal margin of the lateral crus. The lateral crus is then delivered into the nares, providing exposure for direct surgical modification.

In the external rhinoplasty approach, an inverted-V transcolumellar incision is made at the level of the midcolumella. In order to provide support to the scar, the incision is made overlying the caudal margin of the medial crura where it lies just beneath the skin. The transcolumellar incision is connected to bilateral marginal incisions via marginal columellar incisions placed approximately 1-2 mm behind the columellar rim. Care must be taken to make incisions perpendicular to the skin edge to avoid beveling, which may result in a trap door deformity. The transcolumellar flap is then elevated with scissors over the medial crura and the incision is completed. In this way, inadvertent damage to the medial crura is avoided.

Using Converse scissors and 3-point countertraction, the flap is elevated in an immediately supraperichondrial plane over the lower lateral crura, completing the marginal incisions. In the midline, the anterior septal angle is identified, and dissection is carried out again in a supraperichondrial plane over the middle nasal vault, exposing the upper lateral cartilages. Under direct vision using an Aufricht retractor, the periosteum of the nasal bones is incised and elevated to the nasion in the midline. Care is taken to not undermine the periosteum of the sidewalls of the bony nasal pyramid because this structure may provide support for osteotomies. With this exposure obtained, modification of the nasal tip, middle vault, and bony nasal pyramid can be achieved.

Correction of overprojection

Correction of an overprojecting nose involves the following surgical principles:

• Retroprojection via reduction of tip support mechanisms

• Reduction of overdeveloped anatomic structures

• Normalization of adjacent anatomic structures

Many of the incisions and maneuvers used in the standard surgical approaches weaken tip support mechanisms. The resultant retroprojection can be desirable in the overprojected nose and, in that case, can be viewed as an additional benefit of the surgical approach. A complete transfixion incision results in immediate retroposition of the nasal tip when incorporated into the surgical exposure. When the nasal tip is retroprojected, flaring of the alar sidewall and widening of the nasal base may result. Aware of this potential change, the surgeon can consider the need for alar base reduction procedures at the time of surgery.

In the tension nose deformity, reducing the anatomic component or the components causing the pedestal effect on the nasal tip corrects overprojection. Initially, a transfixion incision is performed, allowing inspection of the posterior septal angle and nasal spine. Through this incision, the posterior septal angle can be reduced directly. If the nasal spine is also overdeveloped, bone-biting rongeurs or an osteotome can be used to reduce the nasal spine and thereby reduce the posterior septal angle. This access also allows excision of caudal or membranous septum, if indicated.

Once full surgical exposure has been obtained, the anterior septal angle can be evaluated and reduced, completing deprojection of the pedestal. The alar cartilages may be normal, hypertrophied, or underdeveloped in the tension nose deformity. Therefore, reprojection of the nasal tip is usually required after deprojection of the pedestal. Placement of a columellar strut and tip grafting, if indicated, can be used to achieve reprojection.

Alar cartilage overdevelopment also results in overprojection. Addressing the hypertrophied component or the components of the alar cartilage (ie, the medial, lateral, or intermediate crus) corrects overprojection. Interrupted strip techniques with suture reconstitution may be required to reduce the overdeveloped component. Lateral crural overlay involves excision of a strip of lower lateral crus lateral to the domes. The vestibular mucosa must be elevated from the undersurface of the lower lateral crura and preserved. The medial portion of the lower lateral crus then overlaps and is sutured to the lateral aspect of the lower lateral cartilage. Care must be taken in performing this technique because symmetry is critical, and tip rotation is also achieved. Deprojection can be achieved and rotation maintained by using an equivalent medial crura overlay in conjunction with the lateral crural overlay described above.

Vertical dome division can also be used when deprojection is desirable. The dome is divided, and excess cartilage medial to this incision is removed. Elevating the vestibular skin from the undersurface of the cartilage preserves the skin. The cartilage may then be reconstituted with suture. This technique should be used with extreme caution in thin-skinned patients, and tip grafts are generally required for camouflage. Vertical dome division techniques can also result in iatrogenic overprojection. This generally occurs from overaggressive attempts at lateral crural steal using the Goldman technique and its variants. The overprojecting cartilage, which is usually the medial crura, is reduced, and appropriate projection is restored.

Correction of underprojection

Lengthening of the central limb of the tripod can be accomplished in a variety of ways. Domal binding sutures can be designed to incorporate a larger segment of lateral than medial crus. The result is a medial shift of a portion of the lateral crus. Lateral crural steal can also be accomplished by vertical dome division with suture reconstitution of the medial and lateral crura to preserve domal integrity. Placement of a columellar strut also strengthens the central limb of the tripod and augments nasal projection.

A columellar strut is placed by developing a pocket between the medial crura, placing the graft, and fixing it with suture. Ideally, septal cartilage is harvested, and the graft typically measures 8-12 mm long, 3-4 mm wide, and 1-2 mm thick. The columellar strut can also correct asymmetries caused by buckling of the medial or intermediate crura and can be used to augment columellar show. When developing the pocket between the medial crura, care must be taken to leave soft tissue between the graft and the nasal spine. This prevents the strut from shifting to one side of the spine, which can cause deviation of the tip. Soft tissue also prevents the strut from shifting back and forth over the spine, which may produce an annoying clicking sensation.

If significant divergence of the medial crural footplates is present, resecting intercrural soft tissue and suturing the medial crural footplates together can augment tip support. This technique converts some of the horizontal width to vertical height. Placement of septocolumellar sutures to affix the medial crural–columellar strut complex to the caudal septum reconstitutes this major tip support and can also provide some tip projection.

Transdomal suturing results in refinement of the nasal domes and may also augment projection slightly. Transdomal sutures can reorient the alar cartilages, preserve or augment tip support, and, depending on placement, can add 2-3 mm of stable projection to the tip. Individual horizontal mattress sutures can be placed in each dome to achieve narrowing, followed by an interdomal suture to set the width between the domes. Alternatively, a single transdomal suture incorporating a horizontal mattress stitch in each dome can be used. In either case, place the horizontal mattress suture through the dome so that a wider amount of cartilage is included on the caudal pass than on the cephalic pass. The result is that the caudal cartilage edge usually leads the cephalic edge when the suture is tightened. If the caudal edge does not lead the cephalic edge, excision of a small cephalic wedge with suture reapproximation is usually corrective.

When significant tip projection is needed, tip grafting techniques can be invaluable. Tip grafts can also serve to alter tip contour. Tip grafts are placed in carefully developed subcutaneous pockets in endonasal approaches and stabilized with sutures in open approaches. When placed endonasally, tip grafts (single or laminated) lie in intimate subcutaneous pockets. Exact sculpturing of their size and shape is mandatory. Bilateral marginal incisions beneath the anatomic dome area facilitate the careful pocket creation and render final positioning and stabilization of the graft easier than if only one incision is used.

Tip grafts are carved in triangular, trapezoidal, or shieldlike shapes with carefully beveled edges to avoid any contour irregularities. Grafts are placed to accentuate favorable tip-defining points and highlights, while imparting a more natural appearance to tips with congenital or postsurgical irregularities. Suture fixation of the graft may be necessary if undermining is developed widely in a primary delivery or open approach method.

In the open approach, all tip grafts are stabilized with suture fixation. When minimal additional projection is needed, a cap graft can be used. This trapezoidal piece of cartilage can be carved with carefully beveled edges and sutured in place overlying the domes. The cap graft also provides camouflage when vertical dome division has been performed in the thin-skinned patient. When significant projection is required, the sutured-in-place shield graft is needed. Typically harvested from septal cartilage, the shield graft is usually 8-15 mm long, 8-12 mm wide, and 1-3 mm thick.

When auricular cartilage is used, the graft should be double-layered to provide strength. The shield graft is thicker at the leading edge and thinner at the base. It is sutured to the caudal margins of the medial and intermediate crura and usually overrides the existing domes by 1 or 2 mm. If the tip graft is required to project a greater distance above the domes, a buttress graft is used to support the leading edge of the shield graft. The additional support from this technique may also be useful when the tip graft is harvested from auricular cartilage, which is more pliable, or when the patient has a very thick skin and soft tissue envelope. The buttress graft is a trapezoidal or rectangular piece of cartilage that is sutured to both the underlying domes and the shield graft.

A study by Persichetti et al indicated that onlay tip cartilage grafts provide stable enhancement of nasal tip projection. In the study, the investigators compared photographs of 28 patients taken at 6 months and 18 months following an onlay graft with septal cartilage; a mean reduction in tip projection of just 0.06 mm, or 0.19%, was found in the later images.[8]

In revision rhinoplasty, a weakened and overly resected cartilage framework may be encountered. The resultant deprojection and superior rotation can be addressed through structural grafting techniques such as the dynamic adjustable rotation tip (DART) or the caudal extension graft. The DART technique is performed through an open rhinoplasty approach, and grafts are ideally harvested from septal cartilage. Two septocolumellar interpositional grafts (SCIGs) are placed between the septum and upper lateral cartilages and are similar to long spreader grafts.

A columellar strut is sutured between the medial crura and also sutured to the SCIGs. Sliding the SCIGs along the quadrangular cartilage in an anterior-posterior fashion determines the final position of the tip complex. Sutures are then used to affix the tip complex in the desired position. This maneuver allows the surgeon to position the tip complex in the sagittal plane and to select the desired inferior tip rotation and resultant tip projection.

A caudal extension graft can be used to correct a variety of deformities, including a retracted columella, a short nose, and an overrotated tip. This graft can also increase tip support and projection. The graft is usually harvested from septal cartilage and is sutured to the caudal margin of the nasal septum. It is then secured between the medial crura, achieving desired tip projection. The key to the caudal extension graft is precise midline placement.

Plumping grafts can be used to address a variety of deformities. When placed overlying the nasal spine in the lower columella, plumping grafts may improve the appearance of a retracted columella and open up an acute nasolabial angle. This result is accomplished either by developing a midcolumellar pocket in the open rhinoplasty approach or by making a low lateral columellar incision in endonasal approaches. Multiple pieces of septal or auricular cartilage are placed for augmentation. Nasal base support is increased when grafts are placed below the medial crural footplates.

A retrospective study by Marianetti et al indicated that a procedure called the caudal septum pivot technique can also be used to effectively increase nasal tip projection. In this, a graft is inserted into the dorsal septum following division, with the caudal portion used as a pivot and with attachment to the anterior nasal spine preserved. At 12-month follow-up, the nasal length, tip projection, and nasolabial angle were found to be improved in patients who underwent the surgery.[3]

Enhancing the supratip break can achieve the illusion of projection. The cartilaginous dorsum can be reduced incrementally to redefine the relationship of the supratip to the tip, thereby allowing the tip to project 2-3 mm above the supratip region. If preoperative tip projection is inadequate, however, attempts to overreduce the supratip cartilaginous dorsum in order to produce pseudoprojection of the tip are inadvisable.

Maintenance of projection

If the preoperative projection of the tip is normal and adequate, lowering the cartilaginous dorsum into proper alignment achieves a satisfactory aesthetic appearance, provided that no loss of tip support occurs during the operative or postoperative period. Preserving the major and minor tip support structures decreases this likelihood, whereas their sacrifice, without compensatory reestablishment of support, inevitably leads to eventual tip ptosis.

The care of the patient is directed toward comfort, reduction of swelling and edema, patency of the nasal airway, and compression stabilization of the nose. Topical adhesive is applied and tape or Steri-Strips placed in graduated strips. In this manner, slight compression of the skin and soft tissue envelope onto the underlying nasal skeleton is achieved. A long strip of tape or Steri-Strip is then placed underneath the nasal tip to provide support and is carried onto the nasal sidewalls. The tape is then pinched on both sides to produce compression of the nasal tip. The final step is application of a nasal splint covering only the area between the lateral osteotomies. The splint can be made of plaster, aluminum, or thermoplast. Casting is important for reducing edema and to allow final moulding of the nasal bones.

The patient is instructed to keep the head elevated and avoid any lifting or strenuous activity. Oral glucocorticoids are given to reduce edema. Oral decongestant therapy may be helpful. Nasal saline is used to irrigate the nose and prevent dryness and crusting. A detailed list of instructions is provided to the patient, and the important aspects of care are emphasized. Prevention of trauma to the nose is the most important consideration.

A follow-up visit is scheduled 5-7 days postoperatively, during which the cast and intranasal splints are removed and nasal secretions are suctioned. If permanent transcolumellar sutures are used, these are removed at 3-5 days postoperatively. An important consideration is gentle removal of the tape and splint. Blunt dissection of the nasal skin from the overlying splint is performed with a dull instrument or cotton applicator to avoid disturbing or tenting up the healing skin.

Failure to follow this policy may lead to disturbance of the newly forming subcutaneous fibroblastic layer over the nasal dorsum, with additional unwanted scarring and even abrupt hematoma. The nose is then retaped to facilitate compression and redrapage of the skin and soft tissue envelope to the underlying nasal skeleton. This taping is continued for at least 2 weeks postoperatively but can be extended depending on the amount of residual edema. The next visit is approximately 3 weeks postoperatively, and another visit is scheduled approximately 3-4 weeks later. Initial postoperative photographs can be taken if desired.

When prolonged tip edema is present, injection of small volumes of triamcinolone acetonide (Kenalog, 10 mg/mL) into the region of the supratip may be beneficial. Use this treatment very conservatively to avoid atrophy of the tissue, particularly because the supratip edema usually resolves given additional time. A tuberculin syringe with a 30-gauge needle is used to inject generally less than 0.2 mL into the subdermal plane. The patient should be monitored periodically for at least one year to document the procedure, to monitor the healing process, and to detect impending complications for intervention.

Rhinoplasty is the most technically challenging procedure in facial plastic surgery. Successful rhinoplasty incorporates a delicate balance of cartilage resection and preservation. Although alterations in the nasal skeleton can be controlled surgically, anatomic variations in the nasal cartilages, skin, and subcutaneous tissues can sometimes render healing variable and unpredictable. The final result depends not only on the structural alterations but also on how the skin or soft tissue envelope is redraped and on the contractural forces of healing. Therefore, the final result is actually a gradual metamorphosis that lasts months to years.

Minimizing complications involves careful patient selection, proper diagnosis, good surgical technique, and attentive postoperative care. Because most of the complications in rhinoplasty stem from errors of surgical omission or commission, the rhinoplasty surgeon should be conservative, as errors of omission are easier to correct. Because healing after rhinoplasty is a gradual metamorphosis, a general recommendation is that revision rhinoplasty be delayed for at least a year postoperatively to allow the nuances of healing and scar formation to be revealed.

Early postoperative complications include hemorrhage, hematoma, infection, edema, and ecchymosis. Epistaxis usually occurs in the first 48 hours or 10-14 days postoperatively as eschars separate. Prevention is the best management, and patients should be instructed to stop taking any medications that affect coagulation for 2 weeks prior to surgery. Hematomas may occur in the septum and must be evacuated to prevent the sequela of septal perforation. A hematoma may also occur under the dorsal skin flap if the external splint is not applied adequately. Fortunately, infection is rare and is usually associated with hematoma formation; areas of retained bone dust; or loose, bony fragments.

Ecchymosis usually resolves in 2-4 weeks but can be prolonged for months with dark circles remaining beneath the eyes. This effect is predominantly observed in patients of Mediterranean heritage. Increased pigmentation of the lower lids and a tendency toward prolonged ecchymosis should be recognized and discussed with the patient preoperatively. Edema commonly takes 6-12 months to resolve completely but can be prolonged as long as 2 years postoperatively in some patients.

Tape reactions, skin pustules, and telangiectasias are minor skin complications. Fortunately, skin necrosis and skin loss are rare, but they can be disastrous. Flap loss usually results from hematoma formation, infection, or excessively tight taping. If dissection is performed too superficially, or if aggressive resection of soft tissue occurs from the undersurface of the flap, damage to the dermal vasculature may result. Therefore, dissection in the appropriate plane is paramount in preventing flap complications. Avoiding excess pressure from the splint or tape is critical, and relaxation of the splint or tape should occur if any signs of ischemia are noted.

Aesthetic complications of this procedure include bossa formation, saddle-nose deformity, alar retraction, and polly beak formation. Bossae are knoblike protuberances in the domal region. Development of bossae may not be observed until 1-2 years postoperatively as edema resolves and scarring evolves. Thin skin, thick cartilage, and intralobular bifidity predispose the patient to this deformity. Bossae most often result from vertical dome division or aggressive cartilage excision, which can result in buckling, irregularities, and sharp contours that develop or become more pronounced with time.

Saddle-nose deformity results from overaggressive dorsal resection. If preoperative tip projection is inadequate, avoid attempts to overreduce the supratip cartilaginous dorsum in order to produce pseudoprojection of the tip. Polly beak deformities (supratip fullness) can result from both undercorrection and overcorrection. Undercorrection involves inadequate lowering of the septal angle, inadequate excision of upper or lower lateral cartilages, or failure to achieve adequate tip projection. Overcorrection generally results from excessive bony hump removal. Tip ptosis or the formation of scar tissue in the supratip can exacerbate polly beak deformity. Supratip scar formation results from a failure of the skin or soft tissue envelope to adequately redrape and is more likely to occur in individuals who have thick skin. Finally, alar retraction is generally the result of excessive excision of cartilage and vestibular skin combined with scar contracture.

Additional concerns with external rhinoplasty approaches include prolonged supratip edema, visible midcolumellar scar, and flap necrosis. The transcolumellar scar, when meticulously executed and closed, is well camouflaged and rarely of concern to the patient. As previously noted, flap necrosis is extremely rare and generally related to hematoma formation, infection, or excessively tight taping. Prolonged supratip edema is well known as a sequela of the external rhinoplasty approach; however, this problem resolves with time. The unparalleled exposure and access afforded by this technique allows direct diagnosis and correction of deformities. This technique also provides the ability to suture secure grafts in position and suture reconstitute tip support mechanisms.

Rhinoplasty remains the most technically challenging procedure in facial plastic surgery. Although alterations in the nasal skeleton can be controlled surgically, anatomic variations in the nasal cartilages, skin, and subcutaneous tissues can sometimes render healing variable and unpredictable. The final result is a gradual metamorphosis for a period of years as edema resolves and scarring evolves.

Revision rates of rhinoplasty vary in the literature, but rates are generally accepted to be 5-10%. Only consider revision after a period of time has elapsed, with a year usually considered adequate. This allows time for the subtle changes that occur with fibrosis and scarring to be revealed. However, the forces of healing continue to subtly transform the final result for a period of years.

Fortunately, most patients are satisfied with the surgical improvement achieved if properly counseled regarding appropriate expectations and realistic surgical and aesthetic goals. Constant critical analysis of results provides an appreciation for the effects of time, technique, and healing. This invaluable information allows for technical modification and innovation, which serves as the scientific basis for the ever-evolving art of rhinoplasty.