Nasal Tip Projection Rhinoplasty Treatment & Management

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.