Increasing and decreasing tip projection in rhinoplasty

Abstract

An understanding of the anatomic factors that contribute to nasal tip support is paramount to developing a logical surgical sequence for controlling tip projection. Increasing tip projection can be accomplished by using several surgical techniques in a graduated fashion. A columellar strut is combined with advancing the medial crura on the strut, supplemented with additional domal sutures to increased tip projection. These techniques are then supplemented with onlay tip grafts. In cases requiring significant increases in tip projection, such as secondary cases, autogenous costal cartilage grafts may be necessary. A similar graduate approach is used to decrease tip projection. Disrupting the attachments of the lateral crura to the upper lateral cartilages with intercartilaginous incisions or cephalic margin resections, combined with a complete transfixion incision will result in a decrease in tip projection. If additional tip projection is desired, the lateral crura are transected laterally, the ends of the cartilage are overlapped, and suture stabilized. This is followed by a similar procedure with the medial crura to obtain the desired amount of decreased tip projection. Following this algorithmic approach to increasing or decreasing tip projection provides the surgeon with a logical sequence for intraoperative decision-making.