Nasal Tip Surgery Research Articles

Clinical efficacy of M-shaped cartilage used in nasal tip cosmetic plasty

Objective To explore a new method of nasal tip plasty and its clinical effect, which is much accorded with biomechanical properties of the human body. Methods From June 2010 to March 2016, a total of 33 cases of nasal tip surgery, 6 males and 27 females, were performed. Ages ranged from 22 to 46 years in this group. Ear cartilage was trimmed into two strips and sutured them together in a M shape. When located to the original position of the nasal alar cartilage, the M shaped cartilage could be used in nasal tip; when fixing part of it on the nasal septum or lengthened nasal septal cartilage, the M shaped cartilage could be used in cosmetic surgery of nasal tip lengthening. Results The follow-up period was from one month to 60 months, with average 14 months. 29 patients (87.9%) were satisfied with the efficacy and 2 patients were suffered from infection (6.1%). Conclusions When the M-shaped cartilage is fixed with lengthened nasal septum, it can lengthen the nasal tip much more and the contouring and texture of nasal tip are better than that of using a shield or a cap cartilage graft. Key words: Nasal tip; Rhinoplasty; M-shaped cartilage

A Novel Method for Smooth Contouring of Nasal Tip: Camouflaging Alar Tip Graft.

The aim of this article is to define a tip graft that provides camouflage for a smoothly contoured, natural-looking tip and that prevents long-term graft visibility. When traditional grafts are used to substantially increase tip projection, there is a possibility for thinning of the skin and subsequent graft visibility. To avoid such unwanted results, the authors have developed a novel graft: the camouflaging alar tip (CAT) graft. In this study, the authors provide a retrospective analysis of the long-term follow-up of 742 patients from 2003 to 2013 in whom a CAT graft was placed. This article is a synopsis of the authors' 10 years experience in nasal tip surgery.

Cranial tip suture in nasal tip contouring.

The creation of both a functionally and aesthetically pleasing nasal tip contour is demanding and depends on various different parameters. Typically, procedures are performed with emphasis on narrowing the nasal tip structure. Excisional techniques alone inevitably lead to a reduction in skeletal support and are often prone to unpredictable deformities. But also long-term results of classical suture techniques have shown unfavorable outcomes. Particularly, pinching of the ala and a displacement of the caudal margin of the lateral crus below the cephalic margin belong to this category. A characteristic loss of structural continuity between the domes and the alar lobule and an undesirable shadowing occur. These effects lead to an unnatural appearance of the nasal tip and frequently to impaired nasal breathing. Stability and configuration of the alar cartilages alone do not allow for an adequate evaluation of the nasal tip contour. Rather a three-dimensional approach is required to describe all nasal tip structures. Especially, the rotational angle of the alar surface as well as the longitudinal axis of the lateral crus in relation to cranial septum should be considered in the three-dimensional analysis. Taking the various parameters into account, the authors present new aspects in nasal tip surgery which contribute to the creation of a functionally and aesthetically pleasing as well as durable nasal tip contour.

New aspects in surgery of the nasal tip

The creation of both a functionally and aesthetically pleasing nasal tip contour is demanding and depends on a variety of parameters. Typically, procedures are performed with emphasis on narrowing the nasal tip structure. Excisional techniques alone inevitably lead to reduction in skeletal support and are often prone to unpredictable deformities. But long-term results of classical suture techniques have also shown unfavorable outcomes. Particularly pinching of the alae and displacement of the caudal margin of the lateral crus below the cephalic margin belong in this category. A characteristic loss of structural continuity between the domes and the alar lobule and an undesirable shadowing occur. These effects lead to an unnatural appearance of the nasal tip and frequently to impaired nasal breathing. Stability and configuration of the alar cartilages alone do not allow for an adequate evaluation of the nasal tip contour. Rather a three-dimensional approach is required in order to describe all nasal tip structures. Especially the rotational angle of the alar surface as well as the position of the lateral crus in relation to the cranial septum should be considered in the three-dimensional analysis. Taking the various parameters into account the authors present new aspects in nasal tip surgery which contribute to the creation of a functionally and aesthetically pleasing as well as durable nasal tip contour.

La chirurgie de la pointe large

The multiple techniques, the accurate examination and the checking of the various anatomic components (skin, cartilage resistance) could explain the difficulty for the surgeon to choose a main line, achieving the purpose of perfect and permanent results. Facing this complexity, the goal of this study is to plan step by step, using a simple and original technique in order to correct a broad nose. The modification of the nasal tip includes resection techniques, currently the most used, the cartilaginous reshaping with sutures or onlay grafts and more recently the reinforcement structures approach by inlay grafts. Basically, there are 3 important stages in the performing of a new nose tip: projection and rotation control of the tip, nasal base stability and reshaping of the tip. The author reports an original technique for the control of the tip projection and reshaping the middle crus with two cartilaginous grafts disposed on the external side of the medial crus. These two grafts permit both improving naturally the support of the tip and stabilizing the columella, avoiding the classical median columellar strut. Through a ten-year experience with 203 cases, every patient result was analyzed and criticized. All the cases were reviewed after 2 years at least, and the unwanted effects were noted. Nineteen patients have had a secondary rhinoplasty (11%), 4 for a revision tip surgery (2%). There is no respiratory dysfunction and more than 90% of patients are satisfied for their aesthetic result. We think that the main problems as resection techniques with skin or mucosa retraction, unpredictable long-term effect on the tip, unknown future of the grafts, especially onlay grafts responsible sometimes for unpleasant irregularities, could be minimized with this procedure. The more the nasal tip is stabilized, the more the results are better and longer lasting. The surgery of the nose tip is focused not only with shaping procedures of the middle or lateral crus. The technique reported is very simple and safety for the nasal tip surgery through a modification and/or a reinforcement of the initial structure, maximizing the contact between skin and anatomical component and economizing the interposition of a cartilage graft as far as possible. It is a new concept including respect of the anatomy, and stability, which are the best guarantee for a durable result.

Hezarfen wings: a lower lateral cartilage-based cartilage suspension technique for the adjustment of nasal tip rotation and projection and the correction of supratip deformity.

Nasal tip surgery is one of the most important parts of rhinoplasty to achieve an attractive nose. There are numerous techniques focusing on the correction of nasal tip rotation and projection. In this article, a new cartilage support derived from the cephalic border of lower lateral cartilages is used for the adjustment of tip rotation and projection, whereas improving supratip fullness is presented. Bilaterally harvested cartilage extensions are resembled as bird's wings and dedicated to the wings that were created by the world's first scientist who flew from one continent to another: Hezarfen Ahmed Çelebi. Thirty-two patients who underwent open-approach rhinoplasty operation including the abovementioned method were evaluated retrospectively. After performing conventional steps of open approach rhinoplasty, a wing is created by making a cephalic incision parallel to the lateral crural axis leaving the medial attachment intact and then undermined. Then, the cartilage is turned over the midline bilaterally as it acts like a curb by pulling or releasing the wings to adjust to the desired tip rotation and projection and sutured to the repaired upper lateral cartilage roof. Other 2 types of using these wings were asymmetric suturing one of the wings to help in the redirection of deviated nasal tip (n = 12) and suturing each other at midline to support the overlying skin like a tent with supratip deficiency (n = 7). The authors presented here both esthetic and functional outcomes of Hezarfen wings' method that was used for both nasal tip adjustments and supratip support.

Use of nasal septal bone for septal extension graft after jaw surgery.

Background:After jaw surgery, there is often posterior caudal septal defect with dislocation of caudal septum from anterior nasal spine. In such patients, reconstruction of caudal septum is required during rhinoplasty. The authors used septal bone for nasal tip surgery reconstructing caudal septum in patients who have no desire to use autologous or homologous costal cartilage or foreign material.Methods:This study included 50 patients who underwent rhinoplasty using septal bone from November 2009 to September 2012. The subjective satisfaction of patients was evaluated 6 to 12 months after rhinoplasty with a questionnaire.Results:Mean follow-up was 9 months. Forty-three patients (86%) answered the questionnaire after the operation. Postoperative subjective satisfaction was excellent in 28 cases (65%), good in 9 cases (21%), fair in 4 cases (9%), no change in 1 case (2%), and poor or worse in 1 case (2%).Conclusions:Use of septal bone for septal extension graft may serve as a valuable option in septal cartilage–depleted patients. It gives a strong construct for tip surgery with patient satisfaction.

CONCEPTS AND TECHNIQUES OF NASAL TIP SURGERY

Background: Rhinoplasty is one of the most challenging procedures in plastic surgery. It is technically demanding, and tip surgery is an art form. It requires an in-depth knowledge of the complex three-dimensional anatomy of the nose, a complete understanding of its physiology, familiarity with the described techniques of nasal tip surgery, and a well-developed sense of aesthetics. Aim of the work: This article will describe different techniques used to create a refined, aesthetically pleasing nasal tip. Patients and methods: The patients in this study were selected from of Dr John Hodges, M.D’ Office, Veterans Hospital, and Methodist hospital, USA, and Zagazig University hospital, Egypt. The study was carried out on 50 patients with different nasal tip deformities, who underwent rhinoplasty, they were 15 males and 35 females, their age ranging from 20 to 60 years old. Two approaches had been selected; an open approach had been done for 30% of our patients, and a closed approach had been done for 70% of our patients with different nasal tip techniques. Results: The results of this study for nasal tip refinement techniques demonstrated a decrease in reductive and irreversible techniques as cartilage transection, domal truncation , morselization, and scoring that had been done in 8% of our patients for each, with a concurrent increase in stabilizing, strengthening, and reorientation techniques as sutures and grafts techniques that had been done in 60% of our patients for each; so cartilage-dividing techniques and the vertical dome division are rarely necessary to reduce projection, broadness, and/or rotation of nasal tips, they have been used if suture and graft techniques do not achieve the adequate nasal tip definition. Conclusion: The simplest approach for refinement of nasal tip deformity that allows the planned surgical techniques to be performed without difficulty and cause the least disturbance to the tip’s support, should be selected. Thus, we recommend the reversible, non destructive techniques as sutures and tip grafts for remodeling the tip deformities, with closed approach once indicated. Keywords: Rhinoplasty, nasal tip refinement

Vertical Dome Division: A Quality‐of‐Life Outcome Study

To assess quality-of-life outcomes in patients undergoing nasal tip surgery with the vertical dome division technique using validated instruments (Rhinoplasty Outcome Evaluation [ROE] and Nasal Obstruction Symptom Evaluation [NOSE]). Case series with planned data collection. Tertiary university center. Patients undergoing primary cosmetic and functional rhinoseptoplasty using vertical dome division were consecutively evaluated. The ROE, NOSE, and 100-mm visual analog scale (VAS) were administered pre- and postoperatively. Forty-four patients were included and completed pre- and postoperative questionnaires. Their median age was 28 years, 27 (61%) were female, and the median duration of follow-up was 5 months (range, 3-9 months). Median postoperative ROE, NOSE, and VAS scores (79 [66; 87], 20 [15; 23], and 88 [61; 97], respectively) showed significant improvement compared with preoperative scores (29 [16; 41], 75 [60; 95], and 65 [46; 82], respectively; P < .001). The change in median ROE score was significantly greater in normal- and thin-skinned patients than in thick-skinned patients (54 vs 33; P = .033). Median changes in NOSE-p (-48.5 vs -68.0; P = .10) and VAS (69.0 vs 48.0; P =.083) scores did not differ between normal-/thin- and thick-skinned patients. Vertical dome division is a versatile technique for nasal tip refinement that resulted in significant improvement in quality-of-life outcomes related to rhinoplasty and nasal obstruction, as well as satisfaction with nasal appearance in a short-term follow-up period. The vertical dome division technique does not seem to be indicated only in patients with thick skin.

Erratum to: Primary Nasal Tip Surgery: A Conservative Approach

Erratum to: Primary Nasal Tip Surgery: A Conservative Approach

Nasal Tip Recontouring in Primary Rhinoplasty

Surgery of the nasal tip is a particular challenging aspect of rhinoplasty. We describe a surgical concept in nasal tip surgery that is novel in certain aspects. It combines maneuvers that are typically reserved for the open approach with the minimally invasive concept of endonasal rhinoplasty. Integral to the concept are the complete dissection and delivery of the lateral crus, repositioning of the dome, placement of alar strut grafts that extend far medially, and lateral advancement of the lateral crus. This concept of nasal tip recontouring through the endonasal complete release approach is illustrated in detail. Representative cases are displayed, and outcomes in a population of 100 consecutive young female primary rhinoplasty patients are presented. The concept allows for excellent cosmetic and functional outcomes through a minimally invasive approach with preservation of a naturally soft nasal tip. Patient comfort is maximized by reduced swelling, avoidance of nasal packing, and obviation of external incisions.

Nose tip refinement using interdomal suture in caucasian nose.

Summary Introduction: Refinement of the nose tip can be accomplished by a variety of techniques, but currently, the use of sutures in the nasal tip with conservative resection of the alar cartilage is the most frequently recommended approach. Objective: To classify the nasal tip and to demonstrate the interdomal suture applied to nasal tip refinement in the Caucasian nose, as well as to provide a simple and practical presentation of the surgical steps. Method: Development of surgical algorithm for nasal tip surgery: 1. Interdomal suture (double binding suture), 2. Interdomal suture with alar cartilage weakening (cross-hatching), 3. Interdomal suture with cephalic removal of the alar cartilage (McIndoe technique) based on the nasal tip type classification. This classification assesses the interdomal distance (angle of domal divergence and intercrural distance), domal arch width, cartilage consistency, and skin type. Interdomal suture is performed through endonasal rhinoplasty by basic technique without delivery (Converse-Diamond technique) under local anesthesia. Conclusion: This classification is simple and facilitates the approach of surgical treatment of the nasal tip through interdomal suture, systematizing and standardizing surgical maneuvers for better refinement of the Caucasian nose.

Primary Nasal Tip Surgery: A Conservative Approach

Rhinoplasty and rhinoseptoplasty are very important and complex surgical procedures because the nose plays a pivotal aesthetic role in the face and an important functional role in breathing. Mild bulbous, plunging, undefined tips are very common, and tip refining and repositioning often are required surgical procedures. For 97 selected patients, the authors performed their personal technique consisting of a transcartilaginous approach, incomplete vertical interruption, and retrograde undermining of the lower lateral cartilages to improve tip projection and definition. The five aspects analyzed were nasal tip symmetry, nostril symmetry, tip projection, tip definition, and appearance of the nasal tip only. Each parameter was assessed using pre- and postoperative quantification according to a visual analog scale. Postoperative evaluation was performed during a mean follow-up period of 1 year. The results at 1 year showed high rates of improvement in tip definition (mean, 7.9±2.4) and nasal tip only evaluation (mean, 6.5±3.1). The patients reported an improvement in nasal tip symmetry (mean, 4.2±3.2), nostril symmetry (mean, 4.5±4.1), and tip projection (mean, 5.8±2.9). This simple, safe, and effective technique is proposed for mild bulbous, plunging, undefined, and hypoprojected tips.

Triple Cartilage Combining Suture Technique in Rhinoplasty

The nasal tip position and shape is critical to the overall view of the external nose and is significant in planning rhinoplasty procedures. This study was designed to review our experience in nasal tip surgery and to describe our own version of the suture technique in patients having endonasal rhinoplasty. The technique is typically used in combination with other septorhinoplasty maneuvers to achieve the desired functional and cosmetic result. A telephone survey is designed aiming to give general information about the technique's outcomes. Our technique reduces excess columellar show and provides adjustable controlled nasal tip rotation and projection. The survey conducted among patients followed >1 year revealed that most patients (84 of 96) were very to completely satisfied with the appearance and symmetry of their nose. Of these 84 patients, 48 were very satisfied and 36 were completely satisfied with the result. Two patients who required revision surgery were somewhat and moderately satisfied. We present this technique to share our experience in modifying the widely accepted "tongue-in-groove" technique in septorhinoplasty. The figure eight-shaped suture, which avoids making the nose too stiff, is the main difference of our method.

Supporting Strength of Septal Extension Grafts

The aim of this study was to measure the supporting strength of septal extension grafts according to the linking methods. Swine scapular cartilages were harvested, and these were cut into pieces measuring 10 × 20 × 2 mm. For the overlapping type, a 4-mm length of each cartilage was overlapped and fixed using 2 interrupted sutures. For the interdigitating type, 2 parallel incisions (5 mm in length) were made 3 mm apart on each cartilage. The tongue of 1 cartilage was slipped into the groove of the other cartilage, and 2 fixation sutures were made. One end of the connected cartilage was gripped with a vise, and a 3-0 silk was passed through the other tip. The degree of sagging of the connected cartilage was measured using micrometers according to the power of a force gauge. The contralateral bending force, the ipsilateral bending force, and the shearing force were measured. In each group, 8 assembled extension grafts were measured and then analyzed with independent sample t-tests.For the contralateral bending force, there was no significant difference between the overlapping type and the interdigitating type (P = 0.494 for 5-mm bending and 0.834 for 10-mm bending). For the ipsilateral bending force, there was also no significant difference between the overlapping type and the interdigitating type (P = 0.247 for 5-mm bending and 0.529 for 10-mm bending). For the shearing force, there was no significant difference between the overlapping type and the interdigitating type (P = 0.495 for 5-mm bending and 0.462 for 10-mm bending). When performing a septal extension graft, the overlapping type is thought to be technically easier than the interdigitating type. Because the bending force and the shearing force are similar for the 2 methods, the easier overlapping type extension graft might be preferred when performing nasal tip surgery.

Use of 2‐Octylcyanoacrylate (Dermabond) Tissue Adhesive for Tip Graft Fixation in Open Rhinoplasty

To describe the use of 2-octylcyanoacrylate (2-OCA; Dermabond) for fixation of cartilage grafts in nasal tip surgery via an external approach in Asian patients. Case series with chart review. Academic tertiary care medical center. This retrospective study analyzed data from 33 Korean patients who underwent open rhinoplasty using 2-OCA tissue adhesive for fixation of cartilage grafts in tip surgery. Autologous septal, conchal, costal, or homologous costal cartilage was used as graft materials. Layers of cartilages were bonded using 2-OCA tissue adhesive, and care was taken to prevent the tissue adhesive from spilling and directly contacting surrounding soft tissues. Preoperative and postoperative photographs were reviewed for objective and subjective assessment of aesthetic outcomes. Postoperative aesthetic outcomes were graded as excellent in 51.5%, fair in 33.3%, and no change/worse in 15.2% of patients. Preoperative and postoperative anthropometric measurements showed that the nasal tip projection increased (0.53 ± 0.03 vs 0.57 ± 0.05; P < .05) and the nasolabial angle improved (92.54 ± 6.95 vs 96.12 ± 5.20; P < .05). The overall complication rate was 24.2%, and complications included erythema (9.1%), infection (12.1%), and aesthetic dissatisfaction (3.0%). Although using 2-OCA tissue adhesive for tip surgery simplifies the surgical procedures of fixating graft materials, the relatively high complication rate may preclude its use in nasal tip surgery via an external approach for Asian noses.

The “X-Graft” for Nasal Tip Surgery

Sir: Rhinoplasty in Asians requires augmentation, lengthening, and increased tip projection.1 Grafts commonly used in the tip such as extended spreader grafts, caudal septal extension grafts, and columellar struts require long, straight, flat segments of cartilage. With smaller, potentially weaker quadrangular cartilages,1 harvesting sufficient cartilage for tip work is particularly difficult in Asians. The authors present a new graft design for tip surgery that offers excellent stability and minimizes cartilage use. Open rhinoplasty is performed, the lower lateral cartilages are fully mobilized and separated in the midline, and septal harvest is performed, leaving a generous 1.5-cm caudal and dorsal strut. The upper lateral cartilage is separated from the dorsal septum unilaterally. An extended spreader graft is sutured between the septum and lower lateral cartilage using 5-0 polydioxanone. The extended spreader graft can be positioned diagonally to project above the dorsum of the nose for greater tip projection. A modified caudal septal extension graft is sutured onto the contralateral caudal inferior septum, projecting superoanteriorly to meet the extended spreader graft in the midline. The two grafts are sutured together (Figs. 1 and 2). The membranous septum is opposed to the construct.Fig. 1.: Schematic illustration of the procedure.Fig. 2.: Intraoperative photograph.The new construct is tested for stability. The lower lateral cartilages are pinned temporarily to the X-graft using a 26-gauge needle after determining appropriate tip projection, rotation, and dorsal lengthening. The lower lateral cartilages are then sutured to the X-graft. Interdomal sutures can be applied to narrow a bulbous tip. The caudal septal extension graft is sutured to the inferiormost portion of the caudal septum, and the angle between the grafts should be as close to 90 degrees as possible to maximize stability. Conchal cartilages can be used with their concave surfaces facing each other so that opposing warping forces allow the X-graft to lie in the midline. There are many advantages of the X-graft, including the following: economy and flexibility in the use of cartilage grafts; only two shorter, separate pieces of cartilage are required; conventional caudal septal extension grafts requires a larger contiguous piece of cartilage; and the combination of extended spreader graft and an extended columella strut requires longer cartilage. Curved conchal cartilage can be used. The bilateral graft design allows curved cartilage to be used to achieve a final straight construct. The X-graft provides a strong construct for tip surgery. The extended spreader graft and caudal septal extension graft of the X-graft emulate a pillar-and-beam construct. The caudal septal extension graft is anchored firmly to the caudal septum, lowering the chance of postoperative shortening. Deviations of the caudal septum must be addressed before the X-graft can be used. The caudal septal extension graft can be extended to the nasal floor/maxillary crest, and a columella strut can reinforce the X-graft if the caudal septum is weak. Severely deviated caudal septa will not be suitable candidates for the X-graft. The X-graft is an excellent choice for the Asian rhinoplasty patient in whom cartilage is scarce. It gives a strong construct for tip surgery and with economical use of cartilage. To date, the authors have used the X-graft for both primary and revision rhinoplasties, with excellent clinical results in over 115 patients. Dong Hak Jung, M.D., Ph.D. Ian Loh, M.B.B.S., M.Med. Shimmian Rhinoplasty Clinic Seoul, South Korea DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No outside funding was received.

Analysis of the Midface, Focusing on the Nose

Improvements in both living standards and incomes have meant that many more people are now able to undergo elective plastic surgery for facial improvement. The nose and midface are the most frequent surgical target in Korea. However, the lack of reliable and precise anthropological data is a hindrance for effective surgical applications in this area. In the current study, 21 different lengths and angles of the midface and nose were measured in 2065 volunteers. The data were analyzed to establish sex and racial differences. Most of the measurements obtained from male volunteers were 5% to 10% greater than for the females, exceptions being the nasofrontal, nasolabial, and nasal tip angles. The biggest sex difference was found for depth of pupil, and the smallest difference was for intercanthal distance. For each measurement, the ratio of proportional differences was similar to that for whites. Many Koreans exhibited a columella protrusion of 4 to 5 mm; that parameter measures 2 to 3 mm in whites. The prevention of a hanging columella is important in nasal tip surgery. The intercanthal distance was also relatively large compared with the facial width. In females, the intercanthal distance was similar to the length of the nasal dorsum and the width of the nose. Surgeons may find this analysis useful for surgical planning. The present study provides basic clues for planning and practice in reconstructive and aesthetic facial surgery.

The Onlay Folded Flap (OFF): A New Technique for Nasal Tip Surgery

In this article the onlay folded flap (OFF) is introduced as a new technique for reshaping, refining, supporting, and projecting the nasal tip by remodeling the cephalic portions of the lateral crura rather than canceling them. The surgical technique and the long-term outcomes are described. The indications, contraindications, advantages, and disadvantages are defined. Forty patients were operated on for hypoprojected nasal tips. They had been followed for from 6 to 35months (average=13months). None of the patients had thin skin, and none of them had previously undergone a rhinoplasty. Two symmetric lateral flaps are taken from the cephalic portions of the lateral crura and attached to the domal segments. The flaps' internal edges are carefully sutured together to form one flap. This is then rotated anteriorly over the original domes and fixed to them, before its distal portion is turned posteriorly over the first layer and fixed to it. The nasal tip projection was calculated for all patients before and 6months after surgery using a personal method as a means of evaluating the gain in nasal tip projection in the postoperative period. Revision was necessary in only one patient to fix an unpleasant columellar scar. The average nasal tip projection gain 6months after surgery was approximately 4mm (range=3-5mm). The nasal tips were fine and stable in all patients. The OFF technique is recommended in primary rhinoplasty for reshaping, refining, and supporting the nasal tip and for increasing nasal tip projection (from 3 to 5mm maximum) but only for people with normal or thick skin. It has many advantages and good postoperative results.

Modified vertical dome division technique for rhinoplasty in Asian patients

Vertical dome division (VDD) is a useful nasal tip surgery technique. However, it is associated with postoperative complications and has never been studied in Asian patients. This study examined results following application of our modified VDD approach in Asian patients requiring nasal tip surgery. A retrospective clinical chart review. We retrospectively studied 37 patients who underwent rhinoplasty using our modified VDD procedure. The indications were thick tip skin and relatively strong and well-developed lower lateral cartilages. Outcome measurements were made using preoperative and postoperative photographs. Doctors and patients separately indicated satisfaction using a visual analogue scale (from 1 = satisfied, to 4 = dissatisfied). Following surgery, the mean tip projection increment across the population was 15.8%, and the nasofrontal and nasolabial angle increments were 1.4 degrees and 5.5 degrees, respectively. Doctor and patient satisfaction scores were 1.54 +/- 0.76 and 1.61 +/- 0.81, respectively. Most patients showed prominent tip projection and good cosmetic results. Two patients (5.4%) were dissatisfied, one due to a narrow tip and the other due to nostril asymmetry. The modified VDD was an effective method for nasal tip projection and rotation in selected Asian patients.